Discussion
Infants with dysphonia and weak crying after birth should be highly suspected of the congenital laryngeal web. Also, infants who are presented with persistent hoarseness, recurrent laryngeal wheezing, or acute laryngitis after birth should be admitted to the Otorhinolaryngologic Department. In case of the exclusion of the laryngeal web, laryngoscopy may be adopted to confirm the diagnosis in newborns who exhibit weak crying and/or breathlessness after birth. The development of fiberoptic laryngoscopy and bronchoscopy has provided a great improvement in the diagnosis of congenital laryngeal web 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 brought out by the blind operation under an ambiguous diagnosis can be avoided.
As reported, the laryngeal web was often found with complications involving other laryngeal malformations. Also, in our clinical practice, some children with laryngeal web exhibited a combination of laryngomalacia and vocal cord paralysis. The laryngeal web was first proposed by Cohen, whose clinical typology offered some guidance for its clinical treatment. A claimed that type I and II laryngeal web were often found without any comorbidities while type III and IV laryngeal web were frequently combined with other structural malformations of the larynx or were presented as a manifestation of the clinical syndrome. The most common syndrome associated with the laryngeal web was the 22q11.2 deletion syndrome【3】. The type I and II laryngeal web often involved relatively thin tissues, where the performance of microscopic endoscopic surgery could produce a great outcome. This treatment improved the hoarseness and allowed the patient to speak in an almost normal voice. However, type III and IV laryngeal web were generally combined with subglottic stenosis, requiring open surgery to achieve a better outcome. This could firstly resolve 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, the open laryngoplasty was combined with T-tube and hyoid reconstruction of the cricoid cartilage, which was performed to treat the laryngeal web of type III and IV. This procedure showed excellent results. The T-tube was placed for 6 months, slightly above the glottis, to prevent the adhesions of the vocal cords. To support and enlarge the tracheal lumen and better address the subglottic stenosis, the cricoid cartilage was reconstructed using the hyoid bone. All children were successfully extubated, but some of them exhibited slight hoarseness even after surgery. 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 web generally showed more difficulty in obtaining a normal speaking voice. The clinical reports available on voice quality in children with laryngeal web 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. Also, it is difficult to obtain objective data of voice quality from pediatric patients. In a clinical case report covering 22 children with laryngeal web, 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 the subsequent study, we need to follow up on the children presented with the laryngeal web even in their adolescence and adulthood. Thus, we can obtain objective data to evaluate the quality of such patients’ voices.
In 2010, Goudy reported 18 cases of the 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 the laryngeal web of type I and II, with only one case being laryngeal web type IV. In the past 22 years, Lawlor reported a total of 16 cases of the congenital laryngeal web, 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 web was admitted to our hospital. Satisfactory results were achieved through open laryngoplasty, which was combined with intraoperative T-tube and hyoid reconstruction of the cricoid cartilage. In conclusion, performing laryngoplasty combined with the implanting of a T-tube and reconstruction of the cricoid cartilage by hyoid bone may play a crucial role in the treatment of congenital laryngeal web with subglottic stenosis, providing good clinical outcomes.