Severe Supraglottic Exercise-Induced Laryngeal Obstruction When Non-Invasive Management Has Not Resolved Symptoms

This protocol applies to patients with severe exercise-induced laryngeal obstruction (EILO) in whom supraglottic involvement — specifically the aryepiglottic folds — has been confirmed on continuous laryngoscopy during exercise, and whose clinically significant breathing problems have persisted despite a full course of non-invasive treatment.

Previous treatment — goal not achieved

Non-invasive management of ILO was attempted — encompassing approaches such as speech and language therapy, respiratory physiotherapy and breathing techniques, inspiratory muscle training, and other conservative modalities. The intended goal of relieving respiratory symptoms (dyspnoea, wheeze, and stridor) was not achieved, and escalation is warranted.

Clinical situation

Supraglottic EILO is anatomically distinct from glottic forms of the condition. Establishing the structural cause through continuous laryngoscopy during exercise is essential: the approach at this stage is specific to supraglottic anatomy, particularly the aryepiglottic folds, and does not apply to glottic presentations.

Treatment direction

For refractory supraglottic EILO, a surgical intervention targeting the supraglottic structures is considered — applied selectively to cases that have not responded to non-invasive care, and only under shared decision making. The complete protocol details the specific procedure, patient selection, and clinical targets.

Treatment goal

Reduction of laryngeal obstruction at the supraglottic level, with the aim of widening the laryngeal inlet and improving exercise ventilatory capacity.

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References

DOI: 10.1183/13993003.02221-2016

Based on the finding that supraglottic ILO during exercise shows similarities to laryngomalacia in infants, several ENT surgeons have performed supraglottic surgery in patients with severe EILO and clinically significant breathing problems.

By nature, supraglottoplasty is a treatment for supraglottic EILO (i.e. not for glottic forms of EILO); therefore underpinning the importance of CLE testing to establish the structural anatomical cause underlying each case of EILO.

The aim of the surgery has been to lower the height of the aryepiglottic fold in order to widen the laryngeal inlet and reduce laryngeal obstruction, thereby increasing exercise ventilatory capacity.

Thus, the current standard of care should restrict surgery to refractory cases that have failed non-invasive treatment and the principles outlined under the concept of "shared decision making" should be carefully applied.

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