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.