In response to supraglottoplasty for laryngomalacia with obstructive sleep apnea: A systematic review and meta‐analysis

We would like to thank Dr. Lee and colleagues for their questions, as it is likely that other readers may have the same questions. First, regarding “sleep exclusive laryngomalacia,” the phrase was carefully selected to encompass patients who do not meet criteria for “congenital laryngomalacia.” M.C. and S.A.S both rereviewed each of the manuscripts and verified that the two distinct groups of patients were accurately categorized based on the supraglottoplasty meta-analysis definitions. However, Dr. Lee and colleagues make a good point, that the sleep exclusive laryngomalacia group is not homogenous. Possibly a more accurate term would be “noncongenital laryngomalacia.” As applied to obstructive sleep apnea (OSA), the category of sleep exclusive laryngomalacia is meant to encompass those patients without congenital laryngomalacia, and the phrase was selected because the patients presented with supraglottic collapse during sleep. Second, there are a few meta-analyses evaluating individual patient data alone, such as that for maxillomandibular advancement (MMA) and another one evaluating MMA and tracheostomy as treatment for OSA. Although the supraglottoplasty meta-analysis did provide a cure rate for OSA, definitive generalizations cannot be made, as there were limited numbers of patients. For sleep exclusive laryngomalacia, there were only 19 patients with individual data, and for congenital laryngomalacia there were only 38 patients with individual data. The actual cure rates for supraglottoplasty as treatment for OSA may be higher or lower, and future studies with data would provide more generalizable findings. Third, regarding the effect size using standardized mean differences (SMD), the SMD were provided in the abstract, the Results section, and in Table IV. For the apnea-hypopnea index, in sleep exclusive laryngomalacia, the SMD is 20.99 (21.37, 20.62) and for congenital laryngomalacia the SMD is 21.26 (21.79, 20.73); both correspond to a large effect using Cohen’s guidelines. However, for lowest oxygen saturation, in sleep exclusive laryngomalacia the SMD is 0.40 (0.04, 0.76) (small effect), and in congenital laryngomalacia the SMD is 1.31 (0.32, 2.30) (large effect). Lastly, we agree that it is important to evaluate patients with and without comorbidities as they can confound outcomes. In Table V, the meta-analysis provides the major comorbidities (second column). Unfortunately, the studies themselves do not provide individual patient data for patients with comorbidities. It is common for articles to not provide individual patient data; therefore, we would encourage authors in the future to provide individual patient data in their articles, which would facilitate the performance of meta-analyses.