Discussion
Infants with dysphonia and weak crying after birth should be highly
suspected of the congenital laryngeal web. Also, infants who are
presented with persistent hoarseness, recurrent laryngeal wheezing, or
acute laryngitis after birth should be admitted to the
Otorhinolaryngologic Department. In case of the exclusion of the
laryngeal web, laryngoscopy may be adopted to confirm the diagnosis in
newborns who exhibit weak crying and/or breathlessness after birth. The
development of fiberoptic laryngoscopy and bronchoscopy has provided a
great improvement in the diagnosis of congenital laryngeal web and other
laryngeal malformations. These techniques may help to clarify the
presence and extent of the laryngeal web obstructing the glottis. Thus,
the local scarring and adhesion brought out by the blind operation under
an ambiguous diagnosis can be avoided.
As reported, the laryngeal web was often found with complications
involving other laryngeal malformations. Also, in our clinical practice,
some children with laryngeal web exhibited a combination of
laryngomalacia and vocal cord paralysis. The laryngeal web was first
proposed by Cohen, whose clinical typology offered some guidance for its
clinical treatment. A claimed that type I and II laryngeal web were
often found without any comorbidities while type III and IV laryngeal
web were frequently combined with other structural malformations of the
larynx or were presented as a manifestation of the clinical syndrome.
The most common syndrome associated with the laryngeal web was the
22q11.2 deletion syndrome【3】. The type I and II laryngeal web often
involved relatively thin tissues, where the performance of microscopic
endoscopic surgery could produce a great outcome. This treatment
improved the hoarseness and allowed the patient to speak in an almost
normal voice. However, type III and IV laryngeal web were generally
combined with subglottic stenosis, requiring open surgery to achieve a
better outcome. This could firstly resolve the child’s breathing
difficulties, and it also allowed them to speak in a normal voice. Open
surgery can be performed in a variety of ways. In our hospital, the open
laryngoplasty was combined with T-tube and hyoid reconstruction of the
cricoid cartilage, which was performed to treat the laryngeal web of
type III and IV. This procedure showed excellent results. The T-tube was
placed for 6 months, slightly above the glottis, to prevent the
adhesions of the vocal cords. To support and enlarge the tracheal lumen
and better address the subglottic stenosis, the cricoid cartilage was
reconstructed using the hyoid bone. All children were successfully
extubated, but some of them exhibited slight hoarseness even after
surgery. Such patients could be followed up with further rehabilitation
to restore a normal speaking voice with high-quality daily life.
The successful treatment of the laryngeal web relies on the resolution
of dyspnea and the acquisition of a normal voice. Patients with type III
and IV laryngeal web generally showed more difficulty in obtaining a
normal speaking voice. The clinical reports available on voice quality
in children with laryngeal web are relatively scarce. Moreover, the few
clinical reports that are available on the evaluation of voice quality
have been mainly presented from the physician’s own competent judgment.
Also, it is difficult to obtain objective data of voice quality from
pediatric patients. In a clinical case report covering 22 children with
laryngeal web, Tery used his subjective judgment to describe the
postoperative outcome of the children’s voice quality【4】. Here, they
treated the laryngeal web with a T-tube and found that 90% of the
children had fair voice quality after surgery, with their daily lives
not being affected. In the subsequent study, we need to follow up on the
children presented with the laryngeal web even in their adolescence and
adulthood. Thus, we can obtain objective data to evaluate the quality of
such patients’ voices.
In 2010, Goudy reported 18 cases of the congenital laryngeal web over a
period of 25 years in their hospital【5】. This study covered the
largest number of clinical cases to date. However, most of them were the
laryngeal web of type I and II, with only one case being laryngeal web
type IV. In the past 22 years, Lawlor reported a total of 16 cases of
the congenital laryngeal web, which included two cases of type IV
laryngeal web【6】. In the last 10 years, a total of seven children with
type III and IV laryngeal web was admitted to our hospital. Satisfactory
results were achieved through open laryngoplasty, which was combined
with intraoperative T-tube and hyoid reconstruction of the cricoid
cartilage. In conclusion, performing laryngoplasty combined with the
implanting of a T-tube and reconstruction of the cricoid cartilage by
hyoid bone may play a crucial role in the treatment of congenital
laryngeal web with subglottic stenosis, providing good clinical
outcomes.