International Journal of Pediatric Otorhinolaryngology (2008) 72, 1345—1351

www.elsevier.com/locate/ijporl

Epiglottic suture for treatment of laryngomalacia

Igor Fajdiga a,*, Andreja Borinc Beden b, Uroš Krivec b, Črt Iglič a

a
University Department for Otorhinolaryngology and Cervicofacial Surgery,
Zaloška cesta 2, SI 1525 Ljubljana, Slovenia
b
University Children’s Hospital, Department of Pulmology, Vrazov trg 1,
SI 1525 Ljubljana, Slovenia

Received 25 March 2008; received in revised form 18 May 2008; accepted 19 May 2008
Available online 7 July 2008

KEYWORDS Summary
Laryngomalacia;
Objectives: To present a technique for surgical management of laryngomalacia
Classification;
directed against the basic abnormality of the disease. Considering the cause—con-
Stridor;
sequence relations of the abnormalities, we can distinguish two types of laryngoma-
Respiratory system;
lacia. In the first, the basic abnormality is the pathological shape of the epiglottis: the
Abnormalities;
epiglottis, which normally stands in an upright position, is characteristically exces-
Epiglottis;
sively folded, restricting the supraglottic space directly as well as indirectly due to
Suture techniques
the proximity of the aryepiglottic folds that are attached to its lateral edges. In the
second type the abnormality is the backward displacement ( ptosis) of a normally
shaped epiglottis. All other abnormalities are the consequences of these basic
abnormalities. We present a new procedure, the epiglottic suture, to correct the
pathological shape of the epiglottis. It is a suture placed transversely on the lingual
surface of the epiglottis that unfolds the folded epiglottis and shifts apart the
adjacent aryepiglottic folds.
Patients and methods: Prospective non-randomized study performed on eight
severely distressed patients with laryngomalacia at the University Department for
Otorhinolaryngology and Cervicofacial Surgery, Ljubljana, Slovenia.
Results and conclusion: The epiglottic suture enabled normal breathing in all treated
children without compromising the airway-protection function of the epiglottis. After
an average follow up time of 19.12 months (minimum 7 months and maximum 27
months), we have not noticed any complications or deteriorations of breathing.
# 2008 Elsevier Ireland Ltd. All rights reserved.

* Corresponding author. Tel.: +386 41662683;
fax: +386 15224815.
E-mail address: igor.fajdiga@guest.arnes.si (I. Fajdiga).
1. Introduction
Laryngomalacia is the most common cause of stridor
in children. About 50—60% of congenital laryngeal
anomalies that occur with stridor are due to laryn-
gomalacia. In most cases, the disease follows

0165-5876/$ — see front matter # 2008 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ijporl.2008.05.009
1346
Table 1 Abnormal anatomical and physiological find-
ings in laryngomalacia
Tubulated or folded epiglottis
Backward displacement of the epiglottis
Short aryepiglottic folds
Excessive mucosa on the aryepiglottic folds
(supraglottis)
Bulky arytenoids
Inward collapse of the aryepiglottic folds
Inward collapse of the excessive supraglottic mucosa
Inward collapse of the epiglottis
a benign course, but the prognosis is less favourable
in 10—15% of cases. These patients may require
surgical intervention [1].
The cause of the disease may result from a varia-
tion in the anatomy of the supraglottic area, of the
tissue, and/or of the neurological function [2].
Typical findings in severe laryngomalacia are pre-
sented in Table 1. The leading symptom in any type
of laryngomalacia is stridor, which typically
becomes more pronounced with any kind of activity,
emotional agitation, or food intake. In rare cases,
children are exposed to life-threatening situations
such as phases of apnea, right-heart failure resulting
from pulmonary hypertension, and a general physi-
cal deterioration [2].
Apart from tracheotomy, which cannot be con-
sidered a successful treatment, a number of surgical
approaches are described to resolve laryngomala-
cia. Using various tools (laser, microdebrider, clas-
sical surgical instruments), most of them are
directed against short aryepiglotic folds and excess
supraglottic mucosa [3].
We would like to introduce a new procedure, the
epiglottic suture that corrects the pathological
epiglottis shape, one of the basic problems in lar-
yngomalacia.
2. Methods
In the period from January 2006 to August 2007, the
epiglottic suture was performed at the University
Department for Otorhinolaryngology and Cervicofa-
cial Surgery, Ljubljana, Slovenia, in eight children
with laryngomalacia. Prior to the procedure they
were admitted to the University Children’s Hospital
in Ljubljana, which is a laryngomalacia referral
center for the entire country (Slovenia: 2,000,000
inhabitants, 9.05 live births per 1000 population and
fertility rate 1.47 averages for the 2000—2006 per-
iod). The criterion for the epiglottic suture proce-
dure was laryngomalacia with severe stridor, a
stridor accompanied by suprasternal and sternal
inspiratory retractions while awake and sleeping.
I. Fajdiga et al.
In 2006, the six children treated were selected from
15 children registered with laryngomalacia, and in
2007, the two treated were chosen from five with
the same diagnosis. The decision to perform the
epiglottic suture in these children was taken in
cooperation with the Ethics Committee. The
patients are presented in Table 2.
In all children with typical signs and symptoms of
laryngomalacia, the diagnosis was confirmed with
fiber optic endoscopy during spontaneous breath-
ing. The endoscopy revealed that in seven children
the epiglottis was pathologically folded (‘U’ shaped,
type 1 according to Shah’s classification [4]), while
in one it was tubulated (‘‘C’’ shaped, type 2 accord-
ing to Shah’s classification [4], Fig. 1, left). All of the
epiglottises were standing upright, the aryepiglottic
folds were short with excessive mucosa, and the
arytenoids appeared bulky. In the course of inspira-
tion, the abundant mucosa of the aryepiglottic folds
was fluttering and was sucked into the jar-like space
between the aryepiglotic folds. This space was in
fact more or less the only opening available for
inspiration in all the children observed. We esti-
mated the distance between the epiglottises’ lat-
eral edges (with the insertions of aryepiglotic folds)
to be from 2 mm (the tubulated epiglottis with
overlapping edges) to a maximum of 2 mm in the
least folded epiglottis.
An epiglottic suture was performed in all the
children. In one child (9 months old with tubulated
epiglottis) the procedure was repeated after 3
weeks due to recurrent stridor. In this child the
endotracheal tube was removed immediately after
both procedures while in the others it was removed
after 8 h (one child), 16 h (one child), and 24 h
(three children). In one boy the tube was left for
4 days and in one for 6 days due to tracheal infec-
tions that developed after the procedure. Post-
operative antibiotic prophylaxis was prescribed
for six children (including the two with the infec-
tion) while in two cases it was not considered
necessary. Oral feeding with sterile liquid food
was allowed immediately after the procedure
(one child, after both procedures) or after the
removal of the tubes (seven children).
Fiber optic endoscopy control examinations were
performed in all children 4—6 weeks after the pro-
cedures (see Section 4).
Fig. 1 shows fiber optic view of the epiglottis in
laryngomalacia before (left) and immediately after
the treatment (right).
2.1. Epiglottic suture
The procedure was performed under general endo-
tracheal anesthesia using microsurgical instruments.
 Epiglottic suture for treatment of laryngomalacia
Table 2 Patients treated with epiglottic suture
Patient’s number
1 2 3 4 5 6 7 8
Gender F F M M F M M M
Gestational 39 40 40 40 40 40 40 39
age (weeks)
Airway obstruction Stridor when Stridor when Stridor when Stridor when Stridor when Stridor when Stridor when Stridor when
awake and awake and awake and awake and awake and awake and awake and awake and
sleeping, life sleeping sleeping sleeping sleeping sleeping sleeping sleeping
threatening
during feeding
Suprasternal and Yes for all Yes Yes Yes Yes Yes Yes Yes
sternal retraction
Oxygen required Yes Yes No No Yes No Yes No
Failure to thrive Yes Yes No No — Yes Yes Yes
Recurrent respiratory Yes No Yes No No No Yes No
infections
Alimentation Aspiration at Aspiration at Occasional No Aspiration No Occasional No
disorders feeding or feeding or aspiration at feeding aspiration
drinking, drinking, at feeding or drinking, at feeding
nasogastric nasogastric or drinking nasogastric or drinking
tube needed tube needed tube needed
Gastroesophageal Confirmed with Confirmed Symptomatic No No No Symptomatic Symptomatic
reflux pH-metry with pH-metry
Diagnosis Symptoms and
fiber optic
endoscopy during
spontaneous
breathing
Age at procedure 6 months 2 weeks 9 months 4 months 3 days 1 month 3 months 2 months
Description of Folded Folded Tubulated Folded Folded Folded Folded Folded
epiglottis shape (‘‘U’’ shape) (‘‘U’’ shape) (‘‘C’’ shape) (‘‘U’’ shape) (‘‘U’’ shape) (‘‘U’’ shape) (‘‘U’’ shape) (‘‘U’’ shape)
Aryepiglottic folds Close and short Close and short Close and Close Close and Close and Close and Close and
with prolapsing with prolapsing short and short short with short short with short with
mucosa mucosa prolapsing prolapsing prolapsing

1347
mucosa mucosa mucosa
 1348
Table 2 (Continued )
Patient’s number
1 2 3 4 5 6 7 8

Epiglottis position Upward (normal)

Shah’s classification Type 1 Type 1 Type 2 Type 1 Type 1 Type 1 Type 1 Type 1
Distance between 1 2 2 (overlapping) 3 1 2 2 2
lateral edges
of epiglottis (mm)
Therapeutic procedure Epiglottic suture Epiglottic Epiglottic suture Epiglottic Epiglottic Epiglottic Epiglottic Epiglottic
suture (2 in 3 weeks suture suture suture suture suture
time)
Removal of the After 16 h After 8 h Immediately After 24 h After 4 days After 24 h After 6 days After 24 h
breathing tube after both (respiratory (respiratory
(reason) procedures infection) infection)
Immediate results Effortless breathing, Normal Normal breathing Normal Normal Normal Effortless Normal
normal feeding, breathing and feeding breathing breathing breathing breathing, breathing
occasional breathing and feeding (both procedures) and feeding and feeding and feeding normal and feeding
sound at effort/sleep occasional feeding,
first 3 months breathing sound occasional
at effort breathing
sound
at effort/
sleep first
3 months
Distance between 4 4 2 5 3 4 4 4
epiglottis’ lateral
edges at the control
endoscopy (mm)
Follow—up period 27 26 23 22 19 17 12 7
(months)
Status at last visit Normal breathing, Normal Normal breathing, Normal Normal Normal Normal Normal
feeding, growth breathing, feeding, growth breathing, breathing, breathing, breathing, breathing,

I. Fajdiga et al.
feeding, light stridor feeding, feeding, feeding, feeding, feeding,
growth occasionally growth growth growth growth growth
during effort
Epiglottic suture for treatment of laryngomalacia 1349

Fig. 1 Fiber optic endoscopy view of the epiglottis in laryngomalacia patient before (left) and after the placing of
epiglottic suture (right).

After the epiglottis was exposed by retracting the
tongue root with a flat retractor attached to an
exterior holder, a narrow saddle-like strip (5 10—
15 mm) of mucosa was removed transversely from
the epiglottic lingual convexity. A resorbable suture
(0—4, braided) was then placed over the exposed
site. At both ends the suture was driven through the
lateral edges of excised mucosa and attached to the
cartilage without touching its laryngeal lining (Fig. 2,
left). As the epiglottis was already spread by the
inserted endotracheal tube, the tying of the suture
fixed the epiglottis in that position or, with tighter
tying, unfolded it further to the desired shape (Fig. 2,
right).
3. Results
In all cases, the final effect of the laryngomalacia
treatment with the epiglottic suture was smooth
breathing and normal feeding. Although in some of
the children a light stridor (without any breathing
effort) was still heard sporadically during physical
exertion or respiratory infection, we consider them

Fig. 2 Left: the placing of epiglottic suture. Right: epiglottic suture tied. Note: epiglottic suture opens up the
obstructed laryngeal entrance; unfolds the excessively folded epiglottis, and spreads apart and lengthens the adjacent
and short aryepiglottic folds.
1350
all to be successfully treated. The average follow up
time was 19.12 months (minimum 7 months and
maximum 27 months).
4. Discussion
In general, an effective therapeutic approach
should be directed against the cause of a disease.
As the etiology of laryngomalacia is not clear [5],
treatment should be directed against the problem
that is most responsible for its occurrence. In the
literature, the anatomical abnormalities found with
laryngomalacia are presented in a descriptive man-
ner (Table 1) with no mention of any possible causal
relation between them. Presuming that they are
related, we tried to identify the primary abnorm-
ality that could be the cause of all the others.
With this cause—effect relationship approach, we
can distinguish two groups of laryngomalacia. In the
first, the basic abnormality is the pathological shape
of the epiglottis. The epiglottis, which (most often)
stands in a normal upright position, is characteris-
tically excessively folded and holds the (probably
normal) aryepiglottic folds that are attached to its
lateral edges in close proximity and moves them
backward against the arytenoids. Consequently, the
folds become flaccid, they seem shorter, and the
mucosa on them becomes excessive and makes the
arytenoids appear bulky. With the resulting constric-
tion of the laryngeal entrance, the negative pres-
sure of streaming inspiratory air (according to
Bernoulli’s principle) can cause further retraction
and an inward collapse of the aryepiglottic folds and
their mucosa as well as of the epiglottis itself in
severe cases.
The pathological shapes of the epiglottises in this
group of laryngomalacia are difficult to describe for
a useful classification. They are usually illustrated
by the letters ‘‘U’’ (folded) or ‘‘C’’ and ‘‘V’’ (tubu-
lated) or as posterior and postero-lateral collapses
[4], respectively.
However, there is a characteristic feature in all
these epiglottises that defines the degree of con-
striction and that can be measured: the distance
between the lateral epiglottic edges (to which the
aryepiglottic folds are attached) that determines
the space at the laryngeal entrance confined by the
epiglottis and the aryepiglotic folds.
In the second group of laryngomalacia, the
breathing is impaired by the pathological position
of the epiglottis. The epiglottis, which is (most
often) normally shaped, leans backwards ( ptosis)
and closes the laryngeal entrance. Although the
attachments of the aryepiglottic folds in this case
are normally apart, they are shifted backward
I. Fajdiga et al.
toward the arytenoids, which makes them short
and the mucosa on them excessive.
In the first group the narrowing lies in a sagittal
plane, while in the second it is transverse. The two
groups could be referred as types 1 and 2 (first
group) and type 3 (second group) according to Shah’s
classification [4] or types 1—3 (first group) and types
4 and 6 (second group) according to Holinger [6].
Understanding laryngomalacia as described, we
can conclude that its basic problems are the abnor-
mal shape and/or position of the epiglottis while all
other abnormal manifestations are simply their con-
sequences. This conclusion offers a clear direction
for laryngomalacia treatment. In the first group it is
necessary to correct the shape of the epiglottis,
while in the second the epiglottis should be ele-
vated.
All our patients were from the first group and
therefore the procedure we are introducing applies
only to this type of abnormality. To correct the
pathological shape of epiglottis we chose the sim-
plest surgical tool, a suture.
The epiglottic suture is a suture placed transver-
sely on the lingual surface of the epiglottis. The
tension of the suture spreads the epiglottis, pulls its
lateral edges apart and consequently the aryepiglot-
tic folds away from each other, and opens up the
laryngeal entrance for normal breathing. In this new
(normal) position, the aryepiglottic folds gain ten-
sion so they become longer and the excess mucosa
on them stretches to cover the folds normally.
The tension applied on a child’s soft epiglottic
cartilage by the suture is sufficient to remold its
improper shape. The excision of mucosa prior to
placing the suture is important to prevent the devel-
opment of edema and for the formation of the scar
tissue that preserves the shape of the epiglottis
after the resorption of the suture.
As the suture is placed only on the lingual side of
the epiglottis, its movements are not impaired and
its airway protection function is not affected. Post-
operatively there were no signs in the children
treated of aspiration during feeding or drinking that
could present a postoperative complication.
In seven children the treatment resulted in
immediate and lasting success. Aside from the occa-
sional light breathing sound at effort or/and sleeping
up to 3 months after the procedure in two children,
breathing became silent and effortless. Further-
more, the accompanying problems——aspiration of
food and liquids, aspiration pneumonias, alimenta-
tion disorders, gastroesophageal reflux, and thriving
problems——disappeared promptly after the treat-
ment.
In one case, however, it was necessary to repeat
the procedure. In this case the initial relief from
Epiglottic suture for treatment of laryngomalacia
stridor lasted for 6 days but then the stridor gradu-
ally returned over the following 2 weeks. During the
fiber optic endoscopy examination 6 weeks after the
operation, the epiglottis shape was found to be
similar to that before the procedure. The resorbable
suture had disappeared, and there was a thin scar on
the lingual side of the epiglottis that was evidently
not strong enough to preserve its new shape. We
repeated the procedure and subsequently the
breathing became silent and effortless. Although
a light stridor can be still heard occasionally during
physical exertion, we consider the child cured.
The reason for the failure of the first procedure in
the third child was most probably the tubular ‘‘C’’-
shaped epiglottis with overlapping lateral edges.
Compared to the less folded ‘‘U’’-shaped epiglot-
tises in the other children, it required considerably
stronger traction to successfully maintain the new
shape.
The fiber optic endoscopy control examinations
performed 4—6 weeks after the procedures (the
second for the third child) confirmed that the arye-
piglottic folds were spread apart and straightened.
The distances between the insertions of aryepiglot-
tic folds were increased from 2 mm to 4 mm
(Table 1). Though the increase may not seem impor-
tant, it was sufficient to enable normal breathing in
all cases. The scars holding the epiglottis in the new
shape were smooth and confined to its lingual side.
The epiglottic suture is a causal treatment of
laryngomalacia as it treats one of its basic causes,
the pathological shape of the epiglottis. In this sense
it can be compared (but not equated) with epiglot-
topexy [2], which corrects a pathological position of
the epiglottis, another possible cause of laryngoma-
lacia.
The causal approach makes the epiglottic suture
different from established laryngomalacia treat-
ments such as the excision of hyperplastic supra-
glottic mucosal formations [1,6], epiglottoplasty
[6,7], supraglottoplasty [3,6], and supraglottic trim-
ming [2]. These procedures could be described as
‘‘symptomatic’’ as they are all directed against the
short aryepiglottic folds and their excessive mucosa,
which in our opinion are clearly the consequences of
the basic causes for the disease.
Available online at www.sciencedirect.com
1351
5. Conclusion
The epiglottic suture is a simple and well-tolerated
procedure that relieves stridor in laryngomalacia
patients immediately without compromising the air-
way protection function of the epiglottis. No com-
plications have been observed in eight treated
children, and no recurrent breathing problems have
been noticed after 153 months (total for all chil-
dren) of follow-up.
Appendix A. Supplementary data
Supplementary data associated with this article
can be found, in the online version, at doi:10.1016/
j.ijporl.2008.05.009.
Conflict of interest
All authors declare that no financial or other pot-
ential conflicts of interest exist. No funds were
received.
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