Materials and methods
The retrospective analysis was conducted on a total of 10 children
diagnosed with congenital laryngeal webs. These children were admitted
to our department between 2010 and 2020. Of the 10 children, 3 had type
I and II laryngeal webs (Figure 1-D), while the other 7 children had
type III and VI congenital laryngeal webs (Figure 1-A, B, C). Of the 3
children with type I and II laryngeal webs, all were females, whereas in
seven children with type III and IV laryngeal webs (Table 1), six were
males, and one was female. The oldest child with a type I and II
laryngeal web was five years old at the time of presentation, while the
youngest child was only 1 year and 9 months old. These children
clinically presented with persistent hoarseness and no obvious
respiratory distress. All three children did not undergo a tracheotomy,
and all of them recovered after a single endoscopic procedure. The
oldest children with type III and IV laryngeal webs in our study were
aged 2 years and 2 months old at first presentation to our hospital,
while the youngest child was 1 month old,The average age of children
with type I and II laryngeal webs when they came to our hospital was 43
months, while that of children with type III and IV webs was 13 months.
For all seven children with type III and IV congenital laryngeal webs,
tracheotomy was performed early, at an age ranging between 1 and 11
months. The average age of these patients when they underwent
tracheotomy was 4.86 months. In one of the seven children, we observed a
combined atrial septal defect, while in another case, both atrial septal
defects and laryngomalacia were observed. One child had vocal cord
paralysis, and six children of seven (85.7%) displayed subglottic
stenosis. Among these six children, four had an area of subglottic
stenosis greater than 90% (Cotton Grade III), while the other two had
40% (Cotton Grade I) subglottic stenosis.
All 3 children with type I and II laryngeal webs recovered after a
single endoscopic procedure. The other seven children with type III and
IV laryngeal webs eventually recovered in our hospital through open
laryngoplasty and were successfully extubated. Before surgery at our
hospital, these children had undergone multiple endoscopic or open
surgical procedures, which included a maximum of five and a minimum of
two endoscopic procedures. However, all the previous procedures were
unsuccessful in removing the tracheal tube. The average number of
operations performed on these patients in other hospitals before they
came to our hospital was 2.85. For the one child without subglottic
stenosis, the surgical method was T-tube implantation. For the other six
children with subglottic stenosis, the surgical method was T-tube
implantation combined with reconstruction of the cricoid cartilage. In
five of the patients, cricoid cartilage was reconstructed with free
hyoid bone, while in one patient, cricoid cartilage was reconstructed
with costal cartilage. Preoperative enhanced CT of the neck was
performed in all cases (Figure 2), which suggested varying degrees of
stenosis in the glottic portion and below the glottis. The youngest of
the seven children with type III and IV laryngeal webs when they
underwent open laryngoplasty was 1 year and 1 month old; in contrast,
the oldest was 2 years and 11 months old. The average age at surgery of
the seven children was 24 months. In all seven cases, a T-tube was
implanted intraoperatively, and in the six children with subglottic
stenosis, the cricoid cartilage was incised to remove the scar tissue
under the glottis. The cricoid cartilage was reconstructed using
autologous rib cartilage or hyoid bone (one rib cartilage and five hyoid
bone). In one of the cases who had vocal fold paralysis, the right vocal
fold was removed, and a T-tube was placed through the original tracheal
incision. The T-tube was placed slightly above the glottis and acted as
a support to prevent adhesions. Children who present with choking while
consuming fluids after surgery should be fed a soft or semiliquid diet.
Additionally, this problem could be solved by dietary exercises. The
tube was placed for 3 months in one case, 8 months in another case, and
6 months in five cases. The average time was 5.86 months. After placing
the T-tube for a certain period, the children returned to the hospital
for a follow-up visit and for a change in the regular tracheal tube.
After one month of blockage, all seven children were successfully
extubated.
Open laryngoplasty (T-tube implantation + hyoid bone reconstruction of
the cricoid cartilage)
The surgery was performed under general anesthesia with an anesthetic
cannula inserted in the place of the tracheal tube in the neck of the
child (Fig. 3-A). The cricoid cartilage, thyroid cartilage, and hyoid
bone were exposed. A portion of the hyoid bone was obtained and trimmed
into a pike shape (Fig. 3-B, C). The affected cricoid cartilage was
incised to remove the subglottic stenotic lesion tissues, the anesthetic
cannula was removed, and a T-tube was inserted (Fig. 3-D). The T-tube
was positioned slightly above the glottis using intraoperative
laryngoscopy (Fig. 3-F). Afterward, the cricoid cartilage was repaired
and reconstructed with the hyoid bone (Fig. 3-E), and the incision was
sutured. A schematic diagram of the operation process is shown in Figure
4.
Results
All cases were followed up for over 2 years. We found that three
children with type I and II laryngeal webs had recovered through a
single endoscopic procedure, and their hoarseness was relieved after the
surgery. Seven children with type III and IV laryngeal webs had their
tracheal tubes successfully removed. These children did not resume
dyspnea during the follow-up period, but some children still presented
with hoarseness.