(A731) Recurrent Type IIIb Laryngotracheal Cleft in an Adult Repaired with Fascia Lata Graft

Introduction: Laryngotracheal clefts (LTC) are rare congenital anomalies that occur when the tracheoesophageal septum fails to fuse completely during fetal development. Small clefts are generally repaired endoscopically during infancy, with larger clefts requiring open surgery. Recurrence more than 12 months after repair is rarely reported.

Methods: Review of a case of a Type III LTC recurring in an adult repaired with a fascia lata (FL) graft.

Results: A 22-year-old male with a past medical history of endoscopic LTC repair in infancy was referred for progressive dysphagia. Prior work up was notable for aspiration and gastroesophageal reflux on esophagram, gastroparesis and an EGD concerning for a proximal tracheoesophageal (TE) fistula. Modified barium swallow (MBSS) revealed moderate to severe dysphagia with global impairments in coordination, aspiration of liquids and significant esophageal stasis. On diagnostic endoscopy, a midline cleft was identified between the arytenoids extending through the cricoid and 8 mm into the proximal esophagus.

Given the history of failed endoscopic surgery, the decision was made to proceed to open repair via an anterior translaryngotracheal approach to facilitate a layered closure with a graft to reduce the risk of recurrence. We elected to use a fascia lata (FL) graft due to its favorable biomechanical properties for repair in this location. The graft was interposed between the esophageal and tracheal mucosal flaps, creating a multi-layered closure of the defect. On POD 41, the repair was well-healed with a small type 1 residual cleft. The patient began swallow therapy and resumed a total oral diet by 5 months post-op and continues to do well.

Conclusions: While there are a handful of reports of recurring congenital tracheoesophageal fistulas in adulthood, this is the first report of symptomatic type III LTC recurrence, to our knowledge. Esophageal and gastric motility issues in this patient may have contributed to the delayed failure of his initial repair. In this unusual case, a FL graft was well-suited for interposition between the mucosal layers of the trachea and esophagus.