What is a laryngeal web?A laryngeal web is defined as the medical condition which causes a web-like tissue in the larynx of a child. This disorder obstructs windpipe partially thus making it difficult to breathe. Congenital laryngeal web can range from mild to severe depending on the thickness of the web tissue layer as it signifies the amount of air hindered. It results in chronic breathing problems in children.
Cohen’s classification of the laryngeal webCohen’s classification of the laryngeal web is used for staging infected lesions. It is characterized on the basis of glottic narrowing from type 1 to type 4. Type 1 defines the least obstructed windpipe and the degree of obstruction is 35% or fewer glottises which are free from subglottic extension having uniform thickness throughout. Type 2 signifies glottis from 35% to 50% which can be slightly thick. Type 3 is normally thick and involves glottis from 50% to 75% whereas type 4 comprises 75% to 90% of the glottis and involves uniform thickness. In type 4 stage, identification of vocal cord is difficult and subglottis lumen is extremely narrowed.
Benjamin’s classification of the laryngeal webBenjamin also categorizes the laryngeal web in four stages. These classifications involve subglottic webs, supraglottic webs, glottic webs and congenital inter arytenoid.
What causes the laryngeal web in adults?Though it is common among children, it can occur in adults as well. The major causes of the laryngeal web in adults include gastroesophageal reflux, previous surgery side effects, previous problems of infection and intubation and smoking. These mostly affect people more than 50 years of age.
Subglottic laryngeal web treatmentCertain types of tests are conducted to diagnose the symptoms of the laryngeal web. The purpose of diagnosis, even when some symptoms are visible, is to identify whether the web is acquired or congenital, to decide the best treatment option and to diagnose other anomalies. According to Cohen, almost 51% of patients are diagnosed with anomalies associated with a laryngeal web. Some anomalies involve vascular rings, valvular atresia, ventricle septal defects and certain malformations like tetralogy of Fallot hypoplastic commonly called left heart syndrome. Sometimes a laryngeal cleft requires an expansion for evaluation of swallowing. Diagnoses involve x-ray, MRI and CT scan. However, xeroradiography has initially constituted this list, now it is no longer in use. Even CT scan acts as an alternative for evaluation and in this process, fine images are obtained to scrutinize subglottic lumen. Microlaryngoscopy is employed which detects the obstruction in the windpipe with the help of a flexible tube. For type 1 or type 2, medicines can be effective. A commonly used tool for treating various stages is the carbon dioxide laser. It was designed by Jako in 1972 for surgery. Other laser surgeries involve thulium laser and potassium titanyl phosphate laser. Other than surgery, mitomycin-c is an alternative option. An antibiotic that inhibits protein synthesis and RNA as it acts as an antineoplastic. Its first use can be traced back to 1963. It was introduced by Mori and Kunimoto for reducing the chances of scars during surgery but now it is widely used for sinus or laryngotracheal surgery or for restoring choanal atresia. Endoscopic surgery is very useful in treating the laryngeal web and its development has led to improved understanding of care after the operation, improvement in techniques of anaesthesia and for managing reflux of acid.
Laryngeal web surgeryThe keel placement technique is the latest surgery for the treatment of the laryngeal web. It includes endoscopic observation in which two flexible needles are used. These needles are normally employed for blood transfusion through the thyroid membrane and cricothyroid membrane. Needles are placed below and above the vocal cord level. Then a prolene suture is guided through the passage and retreated from the oral cavity. After this, the keel is coiled over prolene to fix it properly. The particular end of the suture is guided on the top of the needle placed above the vocal cord. Eventually, both needles retreat while the keel is fixed by several knots on the neck. Endoscopic surgery is also effective in treating laryngeal web with less chance of complications. Procedure- an endoscopy is performed under anaesthesia or general anaesthesia. The position of a patient is in such a way that the affected area is easily accessible to a doctor. The position is settled using a laryngoscope. With the help of a carbon dioxide laser at 2 watts power, an incision is made near the vocal cord. By not damaging the vocal ligament, the mucosal epithelium is cut gently. With lateral convexity, the shape of the cut begins with the anterior commissar and ends with layers of the web. This cut leads to an apron flap depending on the web. Thus, the flap is held by forceps and elevated in the direction of the midline using a carbon dioxide laser. This is continued until the full division of thickness is achieved. This results in the release of a vocal cord while the other has the web. The mucosal flap of the vocal cord is still in touch with the web. This apron flap has two surfaces- a smooth one and a rough one. This smooth surface, epithelialized is upward-facing while the raw surface is downward-facing. Then it is rotated down under the vocal cord which proves to restore the flow of air through the windpipe. After treatment, it is advised to avoid eating for a few hours. Consumption of alcohol and smoking is strictly prohibited until recovery. Intake of juices, soup, energy drinks and pudding is recommended to avoid internal injury. Advantages of endoscopic surgery- it is generally successful in patients of all age and with some other disorders, it is not painful as it is done under anaesthesia, there are reduced chances of reactions and failure of surgery, fast procedure and faster recovery. The application of carbon dioxide laser enables minor tissue injury and it requires a small cut as compared to the open surgery approach. Perforation of the larynx is not required, no restriction on voice after surgery, an effective procedure that does not require frequent calls for a visit and in case of return of the web, it can be done again without complications.
Most common among all symptoms is the stridor and shortness of breath. Stridor is a noise of vibration which signifies blockage in the windpipe. Other symptoms include swallowing problems, improper feeding, dysphonia and weak voice or hoarse cry. Frequent infections of chest, coughing and wheezing also occur frequently. Sometimes children complain about discomfort while raising or bending their head.
• Abnormal cry (weak, soft or absent)
• Abnormal voice (high pitched or weak)
• Chest infections.
• Croup (barking cough)
• Shortness of breath.
• Respiratory distress.
It can occur from intubation for a long time. Sometimes causes are unknown as it is present since birth. A laryngeal cleft can occur due to pregnancy. Unhealthy and improper eating or major breathing problems can lead to a laryngeal web.
• Laryngeal web is often a congenital defect, which means it is present from birth
• In some cases, laryngeal webs are acquired, often resulting from long-term intubation
What is the cost of the treatment of laryngeal web?
The cost can range from $5,000 to $7,000. It is an expensive treatment which can cost more by adding all the hospital formalities such as medicines and injections. Though it can cost less if the patient has an insurance cover.
What is the time duration for the treatment of laryngeal web?
It takes almost 1 hour to be completed. But to recover fully few hours are required to overcome the after-effects of anaesthesia. Complete recovery takes at least 2 weeks before returning to work and daily routine. Until this, heavy activity and chewy foods are avoided to enable faster recovery.
What type of condition does a laryngeal web cause?
The types of conditions caused by the laryngeal web are hoarseness, weak voice, breathing shortness, swallowing issues, a trauma in children, stridor, loss of voice and pain and discomfort.
What are the side effects of laryngeal web treatment?
Pain is frequent for some time, swelling can be noticed around the area, it may be difficult to breathe and eat hard food and may require another surgery. Infection may occur if a reaction occurs due to anaesthesia.
How to prepare for the treatment of laryngeal web?
Avoid all previous medications at least one week before surgery, take medicines as prescribed by a doctor, do not eat anything for at least 10-12 hours before surgery and bring all the necessities beforehand.