Combined laryngeal cleft injection laryngoplasty and salivary botulinum toxin for saliva aspiration

OBJECTIVES: Children with type I laryngeal clefts and sialorrhea can have posterior drooling, aspiration of oral secretions, and respiratory complications. Laryngeal cleft injection laryngoplasty (LCIL) and salivary botulinum injections (Sal‐Bot) have been used separately for short‐term treatment of type I laryngeal clefts and sialorrhea. Our goal was to evaluate combined LCIL and Sal‐Bot and create recommendations for further treatment based on response to initial treatment. METHODS: Retrospective chart review of nine patients who underwent direct laryngoscopy and bronchoscopy with combined LCIL and Sal‐Bot from 2012 to 2019. Charts were reviewed for patient characteristics, response to treatment, and pre and post‐op hospitalizations. Subsequent procedures were performed depending on efficacy of initial treatments. RESULTS: Nine patients were identified. All had pre‐existing neurologic conditions, gastrostomy tubes, and a history of coughing and choking on secretions. Only one patient was able to feed orally (purees). 1 U/kg of botulinum toxin per gland was injected into each parotid and submandibular gland. The average units of botulinum toxin injected was 67 U. The mean laryngeal cleft injection volume was 0.35 cc. Subsequent treatment was based on timing of symptomatic improvement and individual patient factors. Five patients had respiratory‐related hospitalizations in year preceding the procedures (median 1.5, range 1–10). Three (60%) had a reduction in respiratory‐related hospitalization 1 year post procedure (median 1, range 1–3). One patient died during the follow up period due to continued chronic respiratory failure. CONCLUSIONS: This is the first study of combined laryngeal cleft injection laryngoplasty and botulinum toxin injections for patients with posterior laryngeal penetration and aspiration of oropharyngeal secretions. We highlight strategies for choosing subsequent procedures based on response to initial treatment. LEVEL OF EVIDENCE: 4.