Education  |   February 2017
Images in Anesthesiology: Laryngeal Cleft
Author Notes
  • From the Division of Otolaryngology, Department of Surgery (R.J.E.), Division of Pediatric Anesthesiology, Department of Anesthesiology (B.M.T., K.M.), and Division of Neonatology, Department of Pediatrics (E.B.), Duke University Medical Center, Durham, North Carolina.
  • Address correspondence to Dr. Eapen:
Article Information
Education / Images in Anesthesiology / Pediatric Anesthesia / Respiratory System
Education   |   February 2017
Images in Anesthesiology: Laryngeal Cleft
Anesthesiology 2 2017, Vol.126, 325. doi:
Anesthesiology 2 2017, Vol.126, 325. doi:
LARYNGEAL cleft is difficult to diagnose in a critically ill neonate. A high index of suspicion is necessary with respiratory distress, feeding intolerance, and frequent accidental extubations.
The figure provides an endoscopic view of type IV laryngeal cleft in a 6-day-old infant who was intubated for the management of respiratory distress. When the endotracheal tube became dislodged, microlaryngoscopy during general anesthesia with spontaneous respiration1  was ultimately employed to diagnose the tracheal cleft. Figure 1A demonstrates the absence of tissue in the postcricoid region (2) and vocal fold splaying (1). Figure 1B is striking for the absence of posterior trachea, creating a large common tracheoesophageal cavity. The lower part of the figure shows less than 1 cm residual trachea at the level of the carina (3). The endotracheal tube had been placed between the vocal folds, into the common tracheoesophageal cavity. Ventilation of the common cavity provided adequate gas exchange. Ultimately, the child aspirated oral or esophageal secretions, resulting in decompensation.
A laryngeal cleft results from the failure of fusion of the laryngotracheal groove during embryogenesis. Severity is graded I to IV; grade IV extends to the thoracic inlet and has significant mortality.2  Suctioning of secretions and gastric contents will assist in preventing aspiration; precise endotracheal tube placement is paramount. If the trachea is an insufficient length to secure the endotracheal tube, as shown in our figure, an orogastric tube may act as a supporting structure to maintain the endotracheal tube in the anterior position.3  Alternatively, mask ventilation, laryngeal mask airway, or extracorporeal membrane oxygenation may be utilized before definitive repair.3 
Competing Interests
The authors declare no competing interests.
Ferrari, LR, Zurakowski, D, Solari, J, Rahbar, R Laryngeal cleft repair: The anesthetic perspective.. Paediatr Anaesth. (2013). 23 334–41 [Article] [PubMed]
Johnston, DR, Watters, K, Ferrari, LR, Rahbar, R Laryngeal cleft: Evaluation and management.. Int J Pediatr Otorhinolaryngol. (2014). 78 905–11 [Article] [PubMed]
Rajmohan, N, Prakasam, H, Francis, JV Anesthetic challenges in managing a case of type III laryngo-tracheo-esophageal cleft.. J Anaesthesiol Clin Pharmacol. (2012). 28 514–6 [Article] [PubMed]