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Posterior glottic web in a 6-year-old boy.

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A 6-year-old boy with a history of velocardiofacial syndrome and previous surgical repair of congenital cardiac defects presented to our institution for cardiac catheterization under general anesthesia. The largest endotracheal tube that the anesthesia team was able to place was 3.5 mm in its inner diameter. The tube was placed against moderate resistance, which prompted concern for subglottic stenosis. Previous intubations for cardiac intervention had been performed on this patient without difficulty, but a cardiac procedure 9 months earlier had been complicated by self-extubation on postoperative day 2; thereafter, the patient required 3 additional days of intubation.

To determine the cause of the resistance, the patient was taken to the operating room for direct laryngoscopy with laryngeal telescopes. Laryngoscopy detected a membranous posterior glottic web (figure, A). The cricoarytenoid joints were mobile, but abduction was limited by the tissue band. Microlaryngeal scissors were used to incise the left and right attachments of the band. Postoperatively, airway patency was increased (figure, B), and the patient experienced an immediate improvement in voice quality.

Laryngeal webs are abnormal bands of fibrous tissue and epithelium that extend between two laryngeal surfaces. Congenital webs represent a failure of laryngeal recanalization during development, and they occur on a continuum with laryngeal stenosis and atresia. (1) Congenital webs limit airway patency and vocal fold abduction. They present as stridor, recurrent croup, or a weak cry in infants. Posterior congenital glottic webs are rare; when they do occur, they may mimic vocal fold paresis and necessitate visualization of the posterior airway without an endotracheal tube. Anterior congenital laryngeal webs are associated with several genetic disorders, including velocardiofacial syndrome. (2)

In our patient, the interarytenoid pattern of web formation and the history of cardiac surgery with traumatic extubation suggested an acquired etiology. Acquired laryngeal webs are more common than congenital webs. Acquired webs often occur secondary to prolonged intubation, which can also cause ischemic necrosis of the posterior laryngeal mucosa. Inflammation or infection of the exposed cartilage can lead to cartilage resorption and healing by secondary intention with subsequent fibrosis and granulation tissue formation? Acquired webs usually present in older children and adults as airway compromise or vocal complaints such as hoarseness and dysphonia.

The diagnosis of laryngeal webs requires a thorough endoscopic assessment of the airway. The choice of management is dependent on the location and severity of the lesion. Congenital laryngeal atresia requires emergent tracheostomy. Rupture and dilation of webs may occur inadvertently during intubation of an infant with respiratory distress. Small asymptomatic anterior or posterior webs may be closely observed in children. Endoscopic lysis with cold steel or C[O.sub.2] laser energy with or without dilation is used for thin symptomatic glottic webs. Laryngofissure with keel or stent placement may be performed for more severe obstructions; it allows for simultaneous treatment of subglottic stenosis and cartilage grafting.

Airway injury and web formation may be prevented by the use of smaller endotracheal tubes and lowpressure cuffs. Therapy for laryngopharyngeal reflux may also reduce airway inflammation and decrease the risk of web formation, particularly in patients who undergo repeated debridement of recurrent respiratory papillomas. (4)

References

(1.) Wyatt ME, Hartley BE. Laryngotracheal reconstruction in congenital laryngeal webs and atresias. Otolaryngol Head Neck Surg 2005;132(2):232-8.

(2.) Miyamoto RC, Cotton RT, Rope AF, et al. Association of anterior glottic webs with velocardiofacial syndrome (chromosome 22q11.2 deletion). Otolaryngol Head Neck Surg 2004;130(4): 415-17.

(3.) Weymuller EA Jr. Laryngeal injury from prolonged endotracheal intubation. Laryngoscope 1988;98(8 Pt 2 Supp145):1-15.

(4.) Holland BW, Koufman JA, Postma GN, McGuirt WF Jr. Laryngopharyngeal reflux and laryngeal web formation in patients with pediatric recurrent respiratory papillomas. Laryngoscope 2002; 112(11):1926-9.

Dary J. Costa, MD; John A. Stith, MD

From the Department of Otolaryngology--Head and Neck Surgery, Saint Louis University School of Medicine, St. Louis, Mo.
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Title Annotation:PEDIATRIC OTOLARYNGOLOGY CLINIC
Author:Costa, Dary J.; Stith, John A.
Publication:Ear, Nose and Throat Journal
Article Type:Clinical report
Geographic Code:1USA
Date:Oct 1, 2009
Words:644
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