Treating paediatric anterior glottic web: single-centre experience of 20 patients with comparison among techniques

Laryngeal keel in severe congenital glottic web: case report and review of literature

Glottic web is an abnormal soft tissue adhesion between the vocal cords which occurs due to failure of recanalisation. Congenital glottic webs comprises 5% of laryngeal anomalies. Cohen classified glottic webs into four types based on percentage of airway obliteration. Patients with severe glottic web-grade III and grade IV present with respiratory distress, stridor, phonatory difficulties or recurrent respiratory infections warranting urgent intervention. We are presenting our experience in managing two such patients with severe congenital glottic web. Diagnosis was confirmed by fibreoptic laryngoscopy under monitored anaesthetic care. Combined endoscopic excision of web with laryngofissure approach for keel stenting. In both our patients, we have used a silicone based keel for laryngeal stenting to provide strength and prevent re-webbing. During follow-up, both patients were found to have adequate phonation and normal airway thus demonstrating this method as safe option for adequate phonatory and airway outcomes.

Case Report: A Rare Cause of Stridor and Hoarseness in Infants-Congenital Laryngeal Web

BACKGROUND

Congenital laryngeal web is a rare disease that can cause stridor, dyspnea, hoarseness, and other symptoms. Children with this disease generally have stridor, weak crying, and hoarseness at birth, but these symptoms can also occur during the days, weeks, months, and even years after birth. Respiratory tract infection will obviously aggravate these manifestations, and recovery is slow after symptomatic treatment. Neck CT and laryngoscopy can detect and diagnose this disease. It is important that the disease can be considered and examined in infants with recurrent stridor and persistent hoarseness after birth.

CASE SUMMARY

We report a 23-month-old boy who was admitted to hospital due to stridor and hoarseness after birth. Combined with the results of laryngoscopy, he was diagnosed with congenital laryngeal web, and was treated with carbon dioxide (CO₂) laser and cryotherapy by bronchoscope. The prognosis was good.

CONCLUSION

Congenital laryngeal web is a rare but challenging laryngeal lesion. It is very important that the disease can be considered and examined for infants with recurrent stridor and persistent hoarseness after birth. The treatment strategy after diagnosis should be determined according to the classification of laryngeal web and the severity of children's symptoms.

Surgical Management of Anterior Glottic Webs

Congenital webs are rare and represent <5% of all congenital laryngeal anomalies. They are usually a partial laryngeal atresia rather than a true web, and present as a thick and fibrotic web with subglottic extension and associated subglottic stenosis. All patients with a congenital anterior glottic web should be evaluated for chromosome 22q11.2 deletion syndrome. Management strategies are mainly based on the severity of airway obstruction and the anatomical extension of the webs. Simple division of the web endoscopically may be adequate for rare thin webs, however, an open approach is usually warranted for thick glottic webs regardless of Cohen grades. Open repair can be either with keel placement or reconstruction of the anterior commissure.

Laryngeal Web in the Pediatric Population: Evaluation and Management

OBJECTIVE

To discuss the presentation, evaluation, and management of pediatric laryngeal web.

STUDY DESIGN

Retrospective case series.

SETTING

Single tertiary care center.

SUBJECTS

All patients with laryngeal web at Boston Children's Hospital in the past 22 years.

METHODS

No exclusion criteria. Charts mined for age at presentation, presenting symptoms, degree/location of web, associated syndromes, number/type of surgical procedures, and postoperative outcomes.

RESULTS

Thirty-seven patients were included (13 male, 24 female). Average age at diagnosis was 3.7 years (0-19.5 years). Mean follow-up was 4.4 years (range, 0-16.4 years). There were 26 congenital webs (70.2%) and 11 acquired webs (29.8%). Presenting symptoms were vocal (29 patients, 78.4%) and respiratory (22 patients, 60%). Underlying syndromes or synchronous airway lesions included the following: premature (n = 5), congenital heart disease (n = 18), subglottic stenosis (n = 5), 22q11.2 deletion syndrome (n = 10), and recurrent respiratory papillomatosis (n = 4). There were 20 type 1 webs, 6 type 2 webs, 8 type 3 webs, and 3 type 4 webs; 10 had subglottic extension of the laryngeal web. Twelve patients were managed conservatively with observation. Eighty-four interventions were performed: 18 open and 66 endoscopic (sharp division, 32; dilation, 33; mitomycin C, 14; laser, 5; keel, 6; triamcinolone injection, 8; stent, 15; removal of granulation tissue, 5). Tracheotomy was required in 11 patients, and 5 patients were decannulated. Voice improved in 12 patients, with respiratory symptoms in 12 patients. Web recurred in 17 patients. One patient died due to airway complications.

CONCLUSIONS

Pediatric laryngeal web is an uncommon but challenging lesion. Patients need to be evaluated for comorbid syndromes and synchronous airway lesions. Management includes open and endoscopic procedures. Procedures should be tailored to the child's presentation.

Web thickness determines the therapeutic effect of endoscopic keel placement on anterior glottic web

This work is a retrospective analysis to investigate the critical risk factor for the therapeutic effect of endoscopic keel placement on anterior glottic web. Altogether, 36 patients with anterior glottic web undergoing endoscopic lysis and silicone keel placement were enrolled. Their voice qualities were evaluated using the voice handicap index-10 (VHI-10) questionnaire, and improved significantly 3 months after surgery (21.53 ± 3.89 vs 9.81 ± 6.68, P < 0.0001). However, 10 (27.8%) cases had web recurrence during the at least 1-year follow-up. Therefore, patients were classified according to the Cohen classification or web thickness, and the recurrence rates were compared. The distribution of recurrence rates for Cohen type 1 ~ 4 were 28.6, 16.7, 33.3, and 40%, respectively. The difference was not statistically significant (P = 0.461). When classified by web thickness, only 2 of 27 (7.41%) thin type cases relapsed whereas 8 of 9 (88.9%) cases in the thick group reformed webs (P < 0.001). These results suggest that the therapeutic outcome of endoscopic keel placement mostly depends on the web thickness rather than the Cohen grades. Endoscopic lysis and keel placement is only effective for cases with thin glottic webs. Patients with thick webs should be treated by other means.