How do you manage an anterior glottic web in an infant?

Management of Anterior Glottic Web in an Infant

Surgical treatment of laryngeal or glottic webs in infants is often curative and should be the primary approach to management, with the specific technique determined by the thickness and extent of the web. 1

Initial Assessment

• Evaluate the severity and extent of the anterior glottic web:
  • Grade according to Cohen's classification (grades 1-4)
  • Assess for subglottic extension
  • Determine thickness of the web
  • Evaluate for associated airway symptoms (stridor, respiratory distress)

Management Algorithm

Step 1: Airway Stabilization

• Ensure adequate oxygenation
• If severe respiratory distress is present, secure the airway:
  • Consider supraglottic airway device for oxygenation in emergency situations 1
  • Tracheostomy may be necessary for severe obstruction until definitive treatment 1

Step 2: Surgical Approach Based on Web Characteristics

For Thin Glottic Webs (without significant subglottic extension):

• Endoscopic approach with CO2 laser:
  • Laser lysis of the web
  • Topical application of mitomycin C to prevent recurrence 2, 3
  • Benefits: Less invasive, shorter recovery time, avoids external incision

For Thick Webs or Those with Significant Subglottic Extension:

• Laryngotracheal reconstruction (LTR):
  • Open surgical approach
  • Indicated when the web has thick subglottic extension 2
  • More definitive for high-grade webs (grade 3-4) with substantial subglottic involvement

Step 3: Prevention of Web Recurrence

Several techniques can be employed to prevent recurrence:

• Topical application of mitomycin C to inhibit fibroblast proliferation 3
• Creation of a raw vertical "alley" between anterior vocal folds during laser surgery 4
• In selected cases, keel placement may be necessary to maintain separation during healing 5

Step 4: Post-operative Care and Follow-up

• Close monitoring for signs of airway compromise
• Regular follow-up with flexible laryngoscopy to assess healing and detect early recurrence
• Voice assessment as the child develops
• If tracheostomy was performed, plan for decannulation when appropriate

Important Considerations

• The thickness of the web and presence of subglottic extension are critical factors in determining the appropriate surgical approach 2
• Not all high-grade webs have thick subglottic extension, so direct visualization during microlaryngeal surgery is essential 2
• Recurrence is a common complication, occurring in approximately 30% of cases 2
• Multiple procedures may be required to achieve optimal results

Pitfalls to Avoid

• Failure to adequately assess the full extent of the web before selecting a surgical approach
• Underestimating subglottic involvement
• Not applying mitomycin C or other anti-fibrotic measures, increasing recurrence risk
• Delaying intervention in symptomatic infants, which may lead to airway compromise
• Inadequate follow-up, missing early recurrence that could be more easily treated

The management of anterior glottic webs in infants requires specialized expertise and should be performed by a multidisciplinary aerodigestive team with experience in pediatric airway management 1.