Anterior glottic web.

A 15-year-old girl was referred to our institution for evaluation of longstanding hoarseness. When she was 5 years old, she had been diagnosed with a granular cell tumor of the larynx; the tumor was excised, but she developed postoperative glottic scar tissue, which required multiple surgical treatments. At 9 years of age, she had undergone excision of a glottic web.

[FIGURE A OMITTED]

At our evaluation, the patient reported a 6-month history of hoarseness without any respiratory compromise. Flexible nasopharyngoscopy detected a thin anterior glottic web (figure, A). Treatment options were explained to the family; they included either a thyrotomy with placement of a keel stent or endoscopic lysis of the web. After discussion, the family chose the latter.

The patient underwent suspension microlaryngoscopy with lysis of the web uneventfully and with good results (figure, B). Postoperatively, she noted a significant improvement in both her voice and her exercise tolerance. A very small recurrence of the web occurred subsequently, but the patient remained essentially asymptomatic and the family deferred further surgical treatment.

Glottic webs can be either acquired or congenital:

* Acquired laryngeal webs are more common. They can occur secondary to endotracheal intubation, laryngeal trauma, laryngeal surgery near the anterior commissure, radiotherapy and, infrequently, during inflammatory processes such as tuberculosis or diphtheria. (1) More specifically, anterior glottic webs are a well-known complication of C[O.sub.2] laser excisions of laryngeal papillomas near the anterior commissure.

* Congenital anterior glottic webs represent a subset of congenital laryngeal webs. They are rare lesions that have a widely variable presentation. They arise as a result of a dysfunction of embryologic development during the 10th week of gestation when epithelial tissue over the laryngotracheal groove fails to resorb. (2,3)

Patients with either an acquired or congenital web may present with dysphonia, hoarseness, stertor, stridot, and/or airway obstruction. (2,3) The effects of extraneous airway tissue may be initially mild, but they can be exacerbated by comorbid medical conditions, including (but not limited to) upper respiratory infections and synchronous airway lesions. (3) Clinical symptoms are typically evident at a very young age. Altman et al, in a study of congenital airway abnormalities requiring hospitalization, reported a mean age of 7.6 months and a median age of 3.2 months at the time of diagnosis. (3) They also reported a 2:1 male predominance.

Webs are often located in the anterior aspect of the glottis with inferior extension. (2,3) Multiple studies have noted an association between anterior glottic webs and chromosomal abnormalities, such as velocardiofacial syndrome, DiGeorge syndrome, and conotruncal anomaly (chromosome 22ql1.2 deletion). (3,4) In a series of 17 patients with anterior glottic webs, Miyamoto et al found that 11 patients (65%) had a chromosome 22ql1.2 deletion and velocardiofacial syndrome. (4)

Diagnosis and management of glottic webs is critically important to maintain patency of the airway, especially in view of the possibility of synchronous lesions. Patients who present with evidence of airway obstruction require examination by rigid or flexible laryngobronchoscopy. (2,3) Diagnostic imaging--including lateral neck plain films, airway fluoroscopy, computed tomography, magnetic resonance imaging, and barium esophagography--is helpful, but direct visualization is vital. (3) The choice of treatment depends on the extent of obstruction. Lesions that occupy more than 50% of the glottis almost always require intervention. (3) Treatment options include endoscopic and open approaches. Endoscopic lysis of lesions, including the less invasive approaches of dilation and laser ablation, may be successful. (1-3) The mainstay of definitive treatment is via an external approach. The choice of specific approach--which may include either thyrotomy with a keel stent, a laryngotracheal reconstruction with a stent, or a single-stage laryngotracheoplasty--depends on the type of lesion. Open management options, except for laryngotracheoplasty, may necessitate a tracheotomy. (1-3) Some clinicians suggest that open reconstruction provides the greatest success in achieving an adequate airway while preserving adequate vocal production)

References

(1.) Edwards J, Tanna N, Bielamowicz SA. Endoscopic lysis of anterior glottic webs and silicone keel placement. Ann Otol Rhinol Laryngol 2007;116(3):211-16.

(2.) Milczuk HA, Smith JD, Everts EC. Congenital laryngeal webs: Surgical management and clinical embryology. Int J Pediatr Otorhinolaryngol 2000;52(1):1-9.

(3.) Altman KW, Wetmore RF, Marsh RR. Congenital airway abnormalities in patients requiring hospitalization. Arch Otolaryngol Head Neck Surg 1999;125(5):525-8.

(4.) Miyamoto RC, Cotton RT, Rope AF, et al. Association of anterior glotticwebs with velocardiofacial syndrome (chromosome 22ql1.2 deletion). Otolaryngol Head Neck Surg 2004;130(4):415-17.

Richard J. Vivero, MD; Soham Roy, MD

From the Department of Otolaryngology, Miller School of Medicine, University of Miami.