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PubMed This is a summary of 15 peer-reviewed journal articles Updated
Pediatrics · Laryngeal Cleft

Managing the Gap: Treatment Strategies for Laryngeal Cleft

At a Glance

Laryngeal cleft treatment focuses on preventing food and liquid from entering the lungs. Mild cases are often managed with thickened feeds, feeding therapy, and reflux medications. More severe clefts, or those that do not improve with conservative care, require endoscopic or open surgical repair.

The goal of treating a laryngeal cleft is simple but vital: to stop food and liquid from entering the lungs (aspiration) and to ensure the child can breathe and grow safely [1][2]. The treatment path is largely determined by the Benjamin-Inglis type of the cleft and the severity of your child’s symptoms.

Conservative Management (Non-Surgical)

For children with Type I clefts and mild symptoms, doctors often begin with “conservative” management. This is a non-invasive approach that focuses on protecting the airway during growth [1].

  • Thickened Feeds: Using specialized infant thickeners makes liquids move more slowly, giving the throat more time to close correctly and preventing “leaks” through the cleft [3][4]. Never thicken liquids without direct guidance from your pediatrician or Speech-Language Pathologist (SLP), as certain commercial thickeners are unsafe for premature babies [3]. If you are breastfeeding, your SLP may advise you on specific nursing positions. Note that breastmilk is notoriously difficult to thicken because its natural enzymes (amylase) break down many starches, so you may need to pump and use specific thickeners [4].
  • Feeding Therapy: Working with a Speech-Language Pathologist (SLP) to learn specific positions or pacing techniques that reduce the risk of choking [3]. For example, holding your baby completely upright for at least 30 minutes after feeding can help reduce the risk of aspiration [3].
  • Reflux Management: Because stomach acid can irritate the cleft and make swelling worse, anti-reflux medications are often prescribed as part of the treatment plan [5].

Injection Laryngoplasty (The “Trial” Procedure)

If conservative management isn’t enough, or if the team wants to “test” if closing the gap will solve the problem, they may perform injection laryngoplasty (also called injection augmentation) [6].

  • How it works: A surgeon injects a temporary “filler” material into the area of the cleft to bulk up the tissue and narrow the gap [7][8].
  • The benefit: It is a safe, minimally invasive way to see if your child’s swallowing improves immediately. If the injection works but the symptoms return when the filler wears off, it confirms that a permanent surgical repair is likely to be successful [9][10].

Surgical Repair

For children with Type II, III, or IV clefts—or Type I clefts that do not improve with conservative care—surgery is required to physically close the opening [1][11].

Endoscopic Repair

Most Type I and II clefts can be repaired endoscopically. This means the surgeon works entirely through the mouth using a telescope and specialized instruments [12][1].

  • Advantages: No external incisions, shorter hospital stays, and a faster recovery [1].
  • Goal: The surgeon stitches the edges of the cleft together to create a permanent wall between the airway and the esophagus.

Open Surgical Repair

Type III and IV clefts are deeper and more complex, usually requiring an “open” surgery [2][13].

  • The Procedure: The surgeon makes an incision in the neck to reach the airway. A common technique is the anterior laryngofissure, where the front of the voice box is opened to reach the back wall [2].
  • Grafting: To ensure the repair is strong and doesn’t narrow the airway, the surgeon may use a posterior cartilage graft (a small piece of cartilage, often taken from the rib or ear) to reinforce the wall [2][13].

While the path to a permanent fix varies, the multidisciplinary approach ensures that the treatment is tailored to your child’s specific anatomy and needs [14][15].

Common questions in this guide

How do you treat a Type I laryngeal cleft?
Mild Type I clefts are often managed without surgery using thickened feeds, specialized feeding therapy, and anti-reflux medications. If these conservative measures do not relieve symptoms, your child's care team may recommend a temporary trial procedure or an endoscopic surgical repair.
What is an injection laryngoplasty for a laryngeal cleft?
This is a minimally invasive trial procedure where a surgeon injects a temporary filler into the cleft to bulk up the tissue and close the gap. If your child's swallowing improves while the filler is active, it confirms that a permanent surgical repair will likely be successful.
Will my child need open surgery to repair their laryngeal cleft?
It depends on the severity of the cleft. Type I and II clefts are usually repaired endoscopically through the mouth with no external incisions. Deeper Type III and IV clefts typically require an open surgery through the neck, often utilizing a small cartilage graft to reinforce the repair.
Why is breastmilk difficult to use with thickened feeds?
Breastmilk contains a natural enzyme called amylase that breaks down many commercial starches, making it very difficult to keep thick. Because certain thickeners are unsafe for premature babies, always consult your speech-language pathologist before thickening any liquids.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.Based on my child's cleft type and symptoms, are we starting with conservative management or moving toward surgery?
  2. 2.If we try injection laryngoplasty, how long will the filler material last, and what symptoms should we expect to see improve?
  3. 3.Will the surgical repair be performed endoscopically, or is an open approach with a cartilage graft necessary?
  4. 4.How will we monitor my child's swallowing after the procedure to ensure the cleft is fully closed?
  5. 5.What is the risk of the cleft reopening after a repair, and how common is a second procedure?

Questions For You

Tap a prompt to share your answer — we'll use it plus this page's context to start a tailored conversation.

References

References (15)
  1. 1

    Laryngeal cleft: A literature review.

    Martha VV, Vontela S, Calder AN, et al.

    American journal of otolaryngology 2021; (42(6)):103072 doi:10.1016/j.amjoto.2021.103072.

    PMID: 33957543
  2. 2

    Outcomes of surgical repair of Type III and IV laryngotracheoesophageal clefts with posterior cartilage grafting.

    Tan L, Li Q, Chen C

    European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery 2024; (281(9)):4881-4887 doi:10.1007/s00405-024-08701-1.

    PMID: 38761217
  3. 3

    Swallowing dysfunction among patients with laryngeal cleft: More than just aspiration?

    Strychowsky JE, Dodrill P, Moritz E, et al.

    International journal of pediatric otorhinolaryngology 2016; (82()):38-42.

    PMID: 26857313
  4. 4

    Clinical predictors of laryngotracheoesophageal clefts and tracheoesophageal fistulae in children with dysphagia.

    Mattos C, Phinizy P, Duffy KL, et al.

    Pediatric pulmonology 2021; (56(12)):3792-3795 doi:10.1002/ppul.25628.

    PMID: 34387933
  5. 5

    Type 3 Laryngeal Clefts Presenting with Upper Airway Obstruction without Aspiration.

    Weitzman RE, Shah HP, Modi VK, Maurrasse SE

    The Laryngoscope 2024; (134(2)):977-980 doi:10.1002/lary.30849.

    PMID: 37436152
  6. 6

    Management of Type I and Type II laryngeal clefts: controversies and evidence.

    Bowe SN, Hartnick CJ

    Current opinion in otolaryngology & head and neck surgery 2017; (25(6)):506-513 doi:10.1097/MOO.0000000000000414.

    PMID: 28914624
  7. 7

    Injection laryngoplasty in neonates and young children with unilateral vocal fold immobility.

    Shapiro SZ, Brietzke SE, Shah SV, Ostrower ST

    International journal of pediatric otorhinolaryngology 2019; (117()):127-130 doi:10.1016/j.ijporl.2018.11.020.

    PMID: 30579066
  8. 8

    Inpatient injection laryngoplasty for vocal fold immobility: When is it really necessary?

    Zuniga S, Ebersole B, Jamal N

    American journal of otolaryngology 2017; (38(2)):222-225 doi:10.1016/j.amjoto.2017.01.016.

    PMID: 28131551
  9. 9

    Injection laryngoplasty for laryngeal cleft type I in an 8-week-old infant.

    van Stigt MJB, van Oorschot HD, Bittermann AJN

    BMJ case reports 2022; (15(3)) doi:10.1136/bcr-2021-247014.

    PMID: 35236684
  10. 10

    Temporary Vocal Fold Augmentation Outcomes for Refractory Chronic Cough with Concurrent Nonparalytic Glottic Insufficiency due to Vocal Fold Atrophy.

    Dwyer CD, Fein M, Gordon L, et al.

    Journal of voice : official journal of the Voice Foundation 2024; doi:10.1016/j.jvoice.2024.07.020.

    PMID: 39107214
  11. 11

    [Evaluation and treatment of children's laryngeal clefts].

    Chen C, Tan LT, Xu ZM

    Zhonghua er bi yan hou tou jing wai ke za zhi = Chinese journal of otorhinolaryngology head and neck surgery 2018; (53(1)):9-15 doi:10.3760/cma.j.issn.1673-0860.2018.01.003.

    PMID: 29365373
  12. 12

    Postoperative dysphagia immediately following pediatric endoscopic laryngeal cleft repair.

    Kiessling P, Smith A, Puccinelli C, Balakrishnan K

    International journal of pediatric otorhinolaryngology 2021; (142()):110625 doi:10.1016/j.ijporl.2021.110625.

    PMID: 33454453
  13. 13

    Repair of short type IV laryngotracheoesophageal cleft using long, tapered, engaging graft without need for tracheotomy.

    Propst EJ

    The Laryngoscope 2016; (126(4)):1006-8 doi:10.1002/lary.25472.

    PMID: 26153063
  14. 14

    Congenital laryngo-tracheo-esophageal clefts: updates from a quaternary care pediatric airway unit.

    Ishii A, Christophel E, Chollet M, Sandu K

    European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery 2024; (281(1)):283-294 doi:10.1007/s00405-023-08263-8.

    PMID: 37816841
  15. 15

    [Clinical diagnosis and treatments of type Ⅱ-Ⅳ congenital laryngotracheoesophageal cleft in 8 children].

    Zhao J, Wang GX, Wang H, et al.

    Zhonghua er bi yan hou tou jing wai ke za zhi = Chinese journal of otorhinolaryngology head and neck surgery 2021; (56(9)):972-976 doi:10.3760/cma.j.cn115330-20201029-00839.

    PMID: 34666447

This page explains laryngeal cleft treatment options for educational purposes. Always consult your pediatrician or pediatric ENT specialist for medical advice tailored to your child's specific anatomy and needs.

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