Risks and practical challenges in tracheal intubation in children with acquired laryngeal webs: Case report and literature review

Abstract

Background Laryngeal webs represent a rare pathological condition characterized by the narrowing of the vocal folds. Laryngeal webs and their relationship to airway management challenges/complications are well known, however, posterior laryngeal webs, predominantly acquired, represents steeper angle between the oral cavity and the glottic airway compared to congenital laryngeal webs. In addition, there is limited experience with the literature for accurately measuring vocal fold opening to minimize tracheal intubation attempts, and for determining the optimal method of artificial airway and surgical approach. Case presentation A 13-year-old male previously underwent adenoidectomy under general anesthesia six months ago. Subsequent to the procedure, the patient experienced a lower pitch in his voice, accompanied by a rough, hoarse quality. A consecutive fiberoptic bronchoscopy revealed that a glottic web covered the dorsal half of the paired vocal folds, restricting vocal fold abduction. The diagnosis was laryngeal webs and accordingly a trans-supportive laryngoscopic microscopic CO₂ laser excision was scheduled to resect the glottic web. Considering that laser-induced heat in an oxygen-enriched environment can lead to airway fire or burns, endotracheal intubation was preferred. However, due to the absent of glottic airway measure, incorrect size of tracheal tubes were used. In addition, the different risks associated with the angle between the oral cavity and anterior/posterior glottic airway were underestimated, leading to vocal cord edema and emergency airway occurrence. An emergency tracheotomy was performed promptly to ensure the patient's oxygenation. Inspired by this case, we developed a simple image identification program for rapid measurement of the vocal fold and provided recommendations for surgical approach selection based on differences in the degree of difficulty of the artificial airway and surgical intervention. Conclusion The presented case and the literature reviewed suggest that improved preoperative assessment of patent glottic airway opening, appropriate use of airway management techniques, rescue strategies, and selection of an optimal surgical treatment are of utmost importance for preventing life-threatening complications in patients with acquired laryngeal webs.