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.