Discussion
Infants with dysphonia and weak crying after birth should be highly suspected of having congenital laryngeal webs. Additionally, infants who present with persistent hoarseness, recurrent laryngeal wheezing, or acute laryngitis after birth should be admitted to the Otorhinolaryngologic Department. In cases where the laryngeal web is excluded, laryngoscopy may be performed to confirm the diagnosis. The development of fiberoptic laryngoscopy and bronchoscopy has provided great improvement in the diagnosis of congenital laryngeal webs 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 caused by blind operation under an ambiguous diagnosis can be avoided.
The laryngeal web was first proposed by Cohen, whose clinical typology offered some guidance for its clinical treatment. Cohen claimed that type I and II laryngeal webs were often found without any comorbidities, while type III and IV laryngeal webs were frequently combined with other structural malformations of the larynx or presented as a manifestation of the clinical syndrome. In our clinical practice, the most common throat complication was subglottic stenosis. Other complications included vocal cord paralysis, laryngomalacia and atrial septal defects. The most common syndrome associated with laryngeal webs was 22q11.2 deletion syndrome [3]. The type I and II laryngeal webs often involved relatively thin tissues, where the performance of microscopic endoscopic surgery produced an excellent outcome. This treatment improved the hoarseness and allowed the patient to speak in an almost normal voice. However, type III and IV laryngeal webs were generally combined with subglottic stenosis, requiring open surgery to achieve a better outcome. This resolved 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, open laryngoplasty combined with a T-tube and reconstruction of the cricoid cartilage was performed to treat type III and IV laryngeal webs. This procedure showed excellent results. The T-tube was placed for 6 months, slightly above the glottis, to prevent adhesions of the vocal cords and to support and enlarge the tracheal lumen and better address subglottic stenosis. However, the T-tube may cause discomfort, such as choking and coughing early after surgery. Thus, such patients need to be given a soft or semiliquid diet. In children with subglottic stenosis, the lingual bone or autologous rib cartilage can be used to reconstruct the cricoid cartilage. This surgery method can resolve the child’s breathing difficulties and help in the successful removal of the tracheal tube. All children were successfully extubated. We recommend using the hyoid bone to reconstruct the cricoid cartilage, as it can be obtained in the same surgical area, reducing unnecessary trauma. We have advanced the age of surgery to approximately 2 years old, shortening the time for tracheostomy to open the tube, greatly improving the quality of life of the children, and reducing the nursing burden and living burden of the children’s families. However, the child may still have postoperative hoarseness, which may require further rehabilitation. 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 webs generally showed more difficulty in obtaining a normal speaking voice. The clinical reports available on voice quality in children with laryngeal webs 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. Additionally, it is difficult to obtain objective data on voice quality from pediatric patients. In a clinical case report covering 22 children with laryngeal webs, 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 subsequent studies, we need to follow up on the children who presented with laryngeal webs into adolescence and adulthood. Thus, we can obtain objective data to evaluate the quality of such patients’ voices.
In 2010, Goudy reported 18 cases of 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 type I and II laryngeal webs, with only one case being a type IV laryngeal web. In the past 22 years, Lawlor reported a total of 16 cases of congenital laryngeal webs, 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 webs were admitted to our hospital. Satisfactory results were achieved through open laryngoplasty, which was combined with T-tube implantation and reconstruction of the cricoid cartilage.