Med Lasers 2024; 13(3): 123-127  https://doi.org/10.25289/ML.24.017
The role of CO2 laser surgery in the management of severe laryngomalacia: efficacy, safety, and future directions
Yeon Soo Kim, Kwang Yoon Jung, Seung-Kuk Baek
Department of Otorhinolaryngology-Head and Neck Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
Correspondence to: Seung-Kuk Baek
E-mail: mdbsk@korea.ac.kr
ORCID: https://orcid.org/0000-0002-4751-0337
Received: June 17, 2024; Accepted: July 15, 2024; Published online: August 1, 2024.
© Korean Society for Laser Medicine and Surgery. All rights reserved.

This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Laryngomalacia is the most common cause of stridor in infants and often resolves spontaneously by 18-24 months of age. However, severe cases necessitate medical intervention due to significant respiratory distress and feeding difficulties. Laser surgery, using carbon dioxide (CO2) lasers, has emerged as a pivotal therapeutic approach for severe laryngomalacia. This review examines the efficacy, safety, and long-term outcomes of CO2 laser surgery for laryngomalacia. CO2 lasers offer precise tissue vaporization, minimizing collateral damage and enhancing recovery. Numerous studies have reported high success rates, with significant symptomatic improvement and a reduction in the need for more invasive procedures like tracheostomy. Complications such as intraoperative bleeding and postoperative edema may occur. However, they are generally manageable. Long-term outcomes indicate normal growth and development with minimal impact on voice quality and swallowing function. Advancements in laser technology and ongoing research are expected to further improve the efficacy and safety of laser surgery for laryngomalacia.
Keywords: Laryngomalacia; Lasers, gas; Laser therapy; Supralaryngoplasty; Pediatric
INTRODUCTION

Laryngomalacia is the most common congenital laryngeal anomaly, accounting for 60%-75% of all congenital laryngeal abnormalities and a prevalent cause of stridor in neonates and infants [1]. The condition is characterized by the collapse of supraglottic structures during inspiration, which leads to intermittent airway obstruction. This collapse is usually due to a combination of factors, including immature laryngeal cartilage, redundant mucosa, and potential neuromuscular incoordination. The majority of infants with laryngomalacia exhibit mild symptoms that improve without intervention by the age of 18 to 24 months. However, approximately 10%-20% of cases are severe, necessitating surgical intervention due to significant respiratory distress, feeding difficulties, failure to thrive, and life-threatening events like apnea and cyanosis [2].

Severe laryngomalacia, which often presents with pronounced inspiratory stridor, feeding difficulties, and poor weight gain, requires timely and effective management to prevent complications and improve quality of life. Historically, various surgical techniques have been employed to manage severe laryngomalacia, including tracheostomy and aryepiglottoplasty using cold instruments [3]. However, these methods can be associated with significant morbidity and prolonged recovery times. The advent of laser technology has revolutionized the approach to treating this condition, providing a minimally invasive and highly precise surgical option [4].

Carbon dioxide (CO2) laser surgery has emerged as a preferred modality for treating severe laryngomalacia due to its precision, minimal thermal damage to surrounding tissues, and efficacy in relieving airway obstruction. The CO2 laser, which operates at a wavelength of 10.6 micrometers, is well absorbed by water-containing tissues, making it an ideal tool for cutting and ablation. This characteristic allows surgeons to perform delicate procedures with high accuracy, reducing the risk of complications and promoting faster recovery.

The efficacy of CO2 laser surgery in managing severe laryngomalacia has been well-documented in the literature, with numerous studies reporting significant improvements in airway patency, reduction in stridor, and enhanced feeding outcomes post-surgery. Additionally, the safety profile of CO2 laser surgery is favorable, with a low incidence of intraoperative and postoperative complications [5-7]. Despite these positive outcomes, continuous advancements in laser technology and surgical techniques are essential to further enhance the safety and efficacy of this treatment.

This review aims to provide a comprehensive overview of the role of CO2 laser surgery in the management of severe laryngomalacia. We will explore the pathophysiology of laryngomalacia, the mechanisms and techniques of laser surgery, and recent advancements in laser technology. Furthermore, we will evaluate the efficacy, safety, and long-term outcomes of CO2 laser surgery, and discuss future directions in this field. By consolidating current knowledge and identifying areas for future research, this review seeks to contribute to the optimization of care for infants with severe laryngomalacia.

PATHOPHYSIOLOGY OF LARYNGOMALACIA

Laryngomalacia is a condition where the supraglottic structures of the larynx collapse during inspiration, leading to intermittent airway obstruction and stridor in infants. This condition is multifactorial, involving structural, neuromuscular, and possibly genetic factors. The primary structural issue is immature or soft laryngeal cartilage, particularly the epiglottis and arytenoids, which lack the rigidity needed to keep the airway open. Redundant mucosal tissue around the aryepiglottic folds and an omega-shaped epiglottis also contribute to airway collapse (Fig. 1). Neuromuscular incoordination, where the neural control of laryngeal muscles is immature or dysfunctional, exacerbates the collapse. There is also a significant association with gastroesophageal reflux disease (GERD), where reflux can cause inflammation and edema of the laryngeal tissues, weakening them and leading to further collapse. Some cases may have a genetic component, with familial occurrences and associations with genetic syndromes. Premature birth and low birth weight are risk factors, as they can result in underdeveloped laryngeal structures and neuromuscular systems. The primary symptom is inspiratory stridor, which worsens with feeding, crying, or lying down. Severe cases can lead to feeding difficulties, poor weight gain, failure to thrive, and life-threatening episodes of apnea and cyanosis. Laryngomalacia is primarily diagnosed through clinical observation and flexible laryngoscopy, which visualizes the dynamic collapse of the laryngeal structures. The condition typically presents within the first few weeks of life.

Figure 1. Structural characteristics of laryngomalacia: Omega-shaped epiglottis with collapse into airway during inspiration, short aryepiglottic fold, redundant arytenoid mucosa, floppy supraglottic structure.
LASER LARYNGEAL SURGERY

Laser surgery for laryngomalacia primarily involves the use of CO2 lasers, which offer precise tissue vaporization with minimal thermal damage to surrounding structures. The procedure typically targets the redundant arytenoid mucosa, aryepiglottic folds, and the lateral edges of the epiglottis to alleviate the obstruction (Fig. 2).

Figure 2. Laser supralaryngoplasty to improve airway patency by removing excess or floppy tissues in the supraglottic area using a laser.

CO2 lasers are a pivotal tool in the surgical management of severe laryngomalacia due to their precision and efficiency. These lasers operate at a wavelength of 10.6 micrometers, which is highly absorbed by water-containing tissues. This property makes CO2 lasers ideal for cutting and ablation in soft tissues with minimal thermal damage to surrounding structures.

When the CO2 laser beam is directed at the targeted tissue, the absorbed energy causes rapid heating and vaporization of the water within the cells, leading to the precise removal of the tissue. The focused nature of the laser allows for high precision in delicate areas such as the larynx, reducing the risk of collateral damage and postoperative complications. The use of a micromanipulator and microlaryngoscope further enhances the surgeon’s ability to target specific areas accurately.

SURGICAL TECHNIQUES

CO2 laser supraglottoplasty is the standard surgical procedure for severe laryngomalacia. The primary goal of this surgery is to remove or reduce the redundant tissue causing airway obstruction and to stabilize the supraglottic structures.

The procedure is performed under general anesthesia. The patient is positioned to optimize access to the larynx, typically in a supine position with the neck slightly extended. A microlaryngoscope is used to provide a clear view of the laryngeal structures. The scope is carefully positioned to avoid trauma to the surrounding tissues. The CO2 laser is used to excise the redundant aryepiglottic folds, trim the arytenoid cartilages, and, if necessary, partially resect the epiglottis.

The surgical procedure involved endoscopic vaporization of various supraglottic tissues using a CO2 laser set at 5-8 W with 100-200 ms pulse sequences, adapted for use with microscope micromanipulator. Supraglottoplasty encompasses any surgical intervention where supraglottic laryngeal tissues are excised. In this series, the procedures were classified according to the targeted region: the lingual mucosal surface of the epiglottis (epiglottopexy), the posterior edges of the epiglottis (epiglottoplasty), the mucosa of the aryepiglottic fold (aryepiglottoplasty), and the suprarytenoidal mucosa (arytenoidoplasty). The laser’s high precision allows the surgeon to carefully remove the obstructive tissues while preserving the integrity of the vital structures. The laser also coagulates blood vessels as it cuts, reducing intraoperative bleeding and improving visibility during the procedure. After the surgery, the patient is monitored for airway stability. Corticosteroids and anti-reflux medications may be administered to reduce inflammation and promote healing.

ADVANCES IN LASER TECHNOLOGY

Recent advancements in laser technology, such as pulsed and super-pulsed CO2 lasers, have further enhanced the precision and safety of laryngeal surgeries. These technologies allow for controlled depth of penetration and reduced thermal damage, leading to better clinical outcomes and faster recovery times.

Microspot and ultrapulse lasers

These advanced systems allow for even greater precision and control. The microspot laser produces a smaller focal point, reducing collateral thermal damage. The ultrapulse laser delivers high-energy pulses in very short bursts, minimizing heat diffusion and allowing for more precise tissue ablation.

Enhanced visualization tools

High-definition imaging and enhanced micromanipulators have improved the surgeon’s ability to target and treat specific areas with greater accuracy.

Robotic assistance

Emerging robotic technologies are beginning to be integrated into CO2 laser surgeries, providing even greater precision and reducing surgeon fatigue.

The use of CO2 lasers in the surgical management of severe laryngomalacia offers a highly effective and precise method for relieving airway obstruction. Advances in laser technology continue to enhance the safety and efficacy of these procedures, making CO2 laser supraglottoplasty the preferred treatment for severe cases.

Numerous studies have reported high success rates for laser surgery in managing severe laryngomalacia. A systematic review by Richter et al. [8] found that approximately 90% of patients experienced significant symptomatic improvement following laser surgery, with reduced stridor and improved feeding. Similarly, studies have demonstrated that laser surgery effectively decreases the need for tracheostomy, a more invasive procedure associated with higher morbidity and mortality.

A study by Senders and Navarrete [9] reported that laser supraglottoplasty resulted in symptom resolution in 78% of the cases, with notable improvements in breathing and feeding. The authors emphasized the importance of addressing both the anatomic and functional aspects of the airway during surgery.

While laser surgery is generally considered safe, it is not without risks. Potential complications include intraoperative bleeding, postoperative laryngeal edema, granulation tissue formation, and, rarely, airway stenosis. However, with meticulous surgical technique and appropriate postoperative care, the incidence of these complications can be minimized.

A retrospective study by Olney et al. [10] evaluated the safety of laser surgery in 59 infants with severe laryngomalacia. The study reported a complication rate of 5%, primarily consisting of minor intraoperative bleeding and transient postoperative laryngeal edema, both of which were managed conservatively.

Long-term follow-up studies indicate that the benefits of laser surgery for laryngomalacia extend beyond immediate symptomatic relief. According to a longitudinal study by Thompson [11], children who underwent laser surgery for severe laryngomalacia exhibited normal growth and development patterns comparable to their healthy peers. Additionally, the study highlighted the minimal impact on voice quality and swallowing function, underscoring the procedure’s efficacy in preserving essential laryngeal functions.

FUTURE DIRECTIONS

The future of laser surgery for laryngomalacia looks promising with ongoing research and technological advancements. Some areas of potential development include.

Enhanced imaging and navigation

Improved imaging techniques, such as three-dimensional endoscopy and real-time imaging, can provide better visualization of the laryngeal structures, allowing for more precise surgical interventions.

Minimally invasive techniques

Advances in minimally invasive surgical techniques and equipment can further reduce the risk of complications and improve recovery times.

Robotic surgery

The integration of robotic technology in laryngeal surgeries can enhance precision, reduce human error, and improve overall surgical outcomes.

Adjunctive therapies

Combining laser surgery with other therapeutic modalities, such as pharmacological treatments for GERD, may provide a more comprehensive approach to managing laryngomalacia.

Long-term studies

Continued longitudinal studies are needed to further understand the long-term outcomes of laser surgery, including the impact on vocal function, airway dynamics, and overall quality of life.

CONCLUSION

Laser surgery has revolutionized the management of severe laryngomalacia, offering a minimally invasive yet highly effective treatment option. The precision of CO2 laser technology allows for targeted reduction of supraglottic obstruction, significantly improving respiratory and feeding outcomes in affected infants. While the procedure is associated with certain risks, the overall safety profile is favorable, with low complication rates and excellent long-term outcomes. Continued research and advancements in laser technology hold promise for further enhancing the efficacy and safety of this crucial intervention.

SUPPLEMENTARY MATERIALS

None.

ACKNOWLEDGMENTS

None.

AUTHOR CONTRIBUTIONS

Conceptualization: YSK. Data curation: YSK. Formal analysis: YSK. Investigation: KYJ. Methodology: KYJ. Project administration: SKB. Software: YSK. Validation: YSK. Visualization: YSK. Writing–original draft: SKB. Writing–review & editing: all authors.

CONFLICT OF INTEREST

Seung-Kuk Baek is an editorial board member of the journal, but was not involved in the review process of this manuscript. Otherwise, there is no conflict of interest to declare.

FUNDING

None.

DATA AVAILABILITY

None.

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