|LETTER TO EDITOR
|Year : 2023 | Volume
| Issue : 1 | Page : 36-37
Airway management in an infant with congenital laryngeal web and subglottic stenosis
Deepak Singla, Barkha Bharati, Priya Thayyile Kandy
Department of Anaesthesiology, AIIMS, Rishikesh, Uttarakhand, India
|Date of Submission||09-Feb-2023|
|Date of Acceptance||08-Mar-2023|
|Date of Web Publication||20-Apr-2023|
Dr. Deepak Singla
Department of Anaesthesiology, AIIMS, Rishikesh, Uttarakhand
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Singla D, Bharati B, Kandy PT. Airway management in an infant with congenital laryngeal web and subglottic stenosis. Airway 2023;6:36-7
|How to cite this URL:|
Singla D, Bharati B, Kandy PT. Airway management in an infant with congenital laryngeal web and subglottic stenosis. Airway [serial online] 2023 [cited 2023 Jun 7];6:36-7. Available from: https://www.arwy.org/text.asp?2023/6/1/36/374362
A 1-year-old infant presented to the ear–nose–throat (ENT) surgery outpatients' department with hoarseness of voice, along with recurrent chest infections, and hospitalisations, thrice since birth. During the last hospitalisation, flexible laryngoscopy was done, and the child was diagnosed with a laryngeal web [Figure 1] which involved approximately 40% of the glottic lumen. On examination, stridor was present; however, the chest was clear. X-ray neck (anteroposterior and lateral views) [Figure 2] was normal. Computed tomography scan and magnetic resonance imaging were not done preoperatively as administration of sedation or anaesthesia may have compromised the airway in a non-operating room environment. The patient was planned for Coblation release of the laryngeal web under general anaesthesia.
On the day of surgery, a difficult airway cart including tracheostomy and cricothyroidotomy sets was kept ready, the ENT team was on standby for tracheostomy and the child was shifted inside the operating room. Room air saturation was between 97% and 99%. No premedication was used to avoid compromising the airway. General anaesthesia was induced with inhaled sevoflurane in oxygen. After confirming the adequacy of mask ventilation, injection fentanyl 10 μg and injection succinylcholine 10 mg intravenously (IV) were given. We chose succinylcholine to get good relaxation rapidly, which would be helpful not only for intubation but also for emergency tracheostomy in case intubation failed. We used Miller's straight blade for laryngoscopy, and vocal cords as well as laryngeal web were clearly visualised. Intubation was attempted first with a size 3.0 uncuffed endotracheal tube (ETT). However, it could not be passed beyond the vocal cords.
Positive pressure ventilation with mask was again restarted and another attempt was made with a 2.5 size uncuffed ETT with a stylet. This time intubation was successful [Figure 3]. The child was given injection atracurium 5 mg IV and maintained on sevoflurane and 50% oxygen with air. The lungs were ventilated using pressure-controlled ventilation with peak inspiratory pressure of 18–22 cmH2O, achieving a tidal volume of 90–100 ml. After releasing the laryngeal web, surgeons planned to do an intraoperative tracheostomy as significant subglottic stenosis was still not relieved. Hence, a tracheostomy was done, and a 3.0 size tracheostomy tube was inserted. Posttracheostomy, the required peak pressures came down to 16–18 cmH2O. Surgery was completed and the child was shifted to the intensive care unit for observation on T-piece with 4 l/min oxygen support.
Congenital laryngeal webs, which constitute 5% of all congenital laryngeal lesions, are one of the rare airway anomalies. They occur with incomplete recanalisation of the primitive larynx during embryogenesis. They are classified by Cohen. into 4 types (i.e., Type 1 to Type 4) based on the degree of obliteration of the glottic lumen. Type 1 webs involve <35% of the glottic aperture, and Type 2 webs involve 35%–50% of the glottic aperture. Type 3 and 4 laryngeal webs are usually thick, involve 50%–75% and >75% of the glottic lumen and may have subglottic stenosis.,
For an anaesthesiologist, airway management is a challenge in such patients. Various options for securing the airway include endotracheal intubation using conventional ETT or special laser-resistant ETTs if a laser surgery is planned. While the airway is secured by intubation, access to the surgical field may be hampered. Other options include transoral transtracheal jet ventilation. The advantage of this technique is proper visualisation of surgical field and no risk of fire as with ETTs. However, using jet ventilation may result in barotrauma, problems related to airway puncture and carbon dioxide retention. Finally, tracheotomy can be considered. This is especially true in Type 3 and 4 laryngeal webs as they may be associated with subglottic stenosis. In our case, as jet ventilation was not available in our setup, we decided to go ahead with tracheal intubation based on the fibreoptic laryngoscopy findings. Along with that, the ENT team was on standby for emergency tracheostomy if need be. Thus, in severe cases, especially Type 3 and 4 laryngeal webs, proper preoperative evaluation of airway and appropriate planning is a must, and one must be ready with alternatives if the initial plan fails.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Baburajan R, Balakumar V, Saravanam PK, Lakshmanan S, Ravikumar A. Laryngeal keel in severe congenital glottic web: Case report and review of literature. BMJ Case Rep 2022;15:e244263.
Cohen SR. Congenital glottic webs in children. A retrospective review of 51 patients. Ann Otol Rhinol Laryngol Suppl 1985;121:2-16.
de Trey LA, Lambercy K, Monnier P, Sandu K. Management of severe congenital laryngeal webs – A 12 year review. Int J Pediatr Otorhinolaryngol 2016;86:82-6.
[Figure 1], [Figure 2], [Figure 3]