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.

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