What is the best method for diagnosing a laryngeal (voice box) cleft?

From the Guidelines

The best way to diagnose a laryngeal cleft is through direct laryngoscopy under general anesthesia with palpation of the posterior larynx, as recommended by the most recent study 1. This approach allows for direct visualization and assessment of the interarytenoid area, which is essential for accurate diagnosis. Before proceeding to this definitive diagnostic method, clinicians should consider a patient's clinical presentation, which often includes symptoms such as chronic aspiration, recurrent pneumonia, choking during feeding, or a "wet" sounding voice. Initial evaluation may include:

• Modified barium swallow studies
• Fiberoptic endoscopic evaluation of swallowing (FEES), which can suggest the presence of a cleft by demonstrating aspiration, but these are not definitive. Microlaryngoscopy with bronchoscopy provides the most accurate assessment, allowing the surgeon to determine the type and extent of the cleft (Type I through IV based on Benjamin-Inglis classification). During the procedure, the interarytenoid area should be carefully palpated with a blunt probe to identify any separation between the cricoid and arytenoid cartilages. This comprehensive approach ensures proper diagnosis and classification, which is crucial for determining appropriate management strategies, as supported by 1. Flexible laryngoscopy, as discussed in 1, may be useful in some cases, but it is not the most accurate method for diagnosing laryngeal clefts. In contrast, direct laryngoscopy under general anesthesia with palpation of the posterior larynx, as recommended by 1, is the most reliable method for diagnosing laryngeal clefts. Therefore, direct laryngoscopy under general anesthesia with palpation of the posterior larynx is the best way to diagnose a laryngeal cleft, as it provides the most accurate assessment of the interarytenoid area and allows for proper diagnosis and classification of the cleft.

From the Research

Diagnosis of Laryngeal Cleft

• Diagnosis of laryngeal cleft can be challenging and requires a high index of suspicion based on clinical presentation, interpretation of preoperative studies, and a thorough endoscopic evaluation under general anesthesia 2.
• The severity of a laryngeal cleft is measured using the Benjamin-Inglis system, which helps guide management decisions 3.
• Diagnostic procedures for laryngeal cleft include:
  • Modified barium swallow (MBS) 4, 5
  • Functional endoscopic evaluation of swallow (FEES) 4, 5
  • Suspension laryngoscopy with bimanual interarytenoid palpation 4
  • Endoscopic evaluation under general anesthesia 2

Diagnostic Algorithm

• A functional diagnostic and management algorithm for type 1 laryngeal cleft has been proposed, which includes MBS, FEES, suspension laryngoscopy with bimanual interarytenoid palpation, and a trial of conservative therapy 4.
• The algorithm helps diagnose and manage type 1 laryngeal cleft prior to consideration of surgical repair.
• Factors supporting surgical repair include clinically apparent aspiration with feeding, severity of pulmonary status, and poor response to medical management and feeding therapy 5.

Role of Endoscopy

• Endoscopic evaluation is a crucial step in the diagnosis of laryngeal cleft, allowing for visualization of the posterior glottis and palpation for any evidence of a cleft 2.
• Endoscopic repair is a viable option for type 1,2, and selective type 3 laryngeal clefts, with a high success rate reported in several studies 2, 5, 6.