Case Report Robotic epiglottopexy for severe epiglottic prolapse limiting decannulation C. Alessandra Colaianni, Sarah N. Bowe, Heather A. Osborn, Derrick T. Lin, Jeremy D. Richmon, Christopher J. Hartnick * Department of Otology and Laryngology, Massachusetts Eye and Ear Infirmary, Boston, MA, USA article info Article history: Received 20 July 2017 Received in revised form 16 September 2017 Accepted 18 September 2017 Available online 21 September 2017 Keywords: Robot-assisted surgery Laryngomalacia Suprastomal collapse Petiole prolapse abstract Surgical management of supraglottic collapse at the level of the epiglottis limiting decannulation has historically consisted of placement of epiglottopexy sutures which are technically challenging and often unsuccessful. Herein we describe the use of robotic technology to assist with epiglottopexy for a case of a 9 year old child with severe epiglottic petiole prolapse limiting capping and decannulation. Post- operatively the patient is tolerating capping during waking hours. © 2017 Elsevier B.V. All rights reserved. 1. Introduction Supraglottic collapse, consisting of arytenoid or epiglottic pro- lapse, is a special challenge to decannulation in the pediatric complex airway population [1]. Surgical management for obstruc- tive epiglottic prolapse has historically consisted of demucosalizing a portion of the vallecula and adjoining tongue base using either electrocautery or CO2 laser, then placing pexy sutures attaching the epiglottis to the tongue under endoscopic guidance [2,3]. However, placing such sutures is technically challenging, and often results in only superficial passage into the tongue base. This can lead to subsequent breakdown and recurrence of symptoms [1,4]. Addi- tional problems with suture placement include granulation tissue formation at the suture sites, and the possibility of neck infection given direct communication between the neck and the pharynx. Sandu et al. have recently reported a method to circumvent several of these issues, by placing transfixiant sutures through the base of tongue using the Lichtenberger needle carrier [1]. This avoids placing the sutures too superficially. However, even with this technique, operative exposure is difficult due to the necessary angle of entry of the transfixiant sutures and the general limitations of endoscopic surgery. Endoscopic surgery has several associated challenges which make this approach even more difficult, including the limited degree of motion of instrumentation, amplification of physiologic tremors, and compromised dexterity [5]. Robot-assisted surgery carries several advantages over endo- scopic methods, including enhanced visualization, multiarticulated instruments, and elimination of physiologic tremor. Application of robotic technology to otolaryngology has shown promise in over- coming the aforementioned specific challenges of endoscopic sur- gery [5]. Robot-assisted surgery has been described in pediatric otolaryngology, particularly for base of tongue access, laryngeal cleft repair, and in pediatric head and neck [6e8]. Robot-assisted surgery may have a larger role to play in management of the pe- diatric airway. Herein, we describe the use of robotic technology to perform epiglottopexy for a case of severe epiglottic prolapse limiting decannulation. 2. Method of surgery Our patient is a 9-year-old female who had a history of extreme prematurity, with prolonged intubation and subsequent subglottic stenosis and tracheostomy dependence. She had previously un- dergone successful laryngotracheal reconstruction with anterior and posterior rib cartilage grafting to correct her subglottic steno- sis. However, subsequent bronchoscopy revealed persistent * Corresponding author. Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114, USA. E-mail address: christopher_hartnick@meei.harvard.edu (C.J. Hartnick). Contents lists available at ScienceDirect International Journal of Pediatric Otorhinolaryngology journal homepage: http://www.ijporlonline.com/ https://doi.org/10.1016/j.ijporl.2017.09.020 0165-5876/© 2017 Elsevier B.V. All rights reserved. International Journal of Pediatric Otorhinolaryngology 102 (2017) 157e159