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LETTER TO EDITOR
Year : 2016  |  Volume : 17  |  Issue : 2  |  Page : 68-69
 

Incidental laryngeal web: Look before you leap


1 Department of Anaesthesiology and Critical Care, Pt. B.D.S. PGIMS, Rohtak, Haryana, India
2 Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
3 Department of Anaesthesiology and Critical Care, Medanta - The Medicity, Gurgaon, Haryana, India

Date of Web Publication16-Dec-2016

Correspondence Address:
Pooja Bihani Jaju
Department of Anaesthesia and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-0311.193104

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How to cite this article:
Kamal K, Jaju PB, Jaju R, Paliwal B. Incidental laryngeal web: Look before you leap. Indian Anaesth Forum 2016;17:68-9

How to cite this URL:
Kamal K, Jaju PB, Jaju R, Paliwal B. Incidental laryngeal web: Look before you leap. Indian Anaesth Forum [serial online] 2016 [cited 2017 Jul 24];17:68-9. Available from: http://www.theiaforum.org/text.asp?2016/17/2/68/193104


Sir,

Laryngeal web is a thin transparent or thick fibrous membrane with an incidence of 1 in 10,000. About 75% of laryngeal webs occur at the glottis level, and the rest are supraglottic or subglottic.[1] Asymptomatic laryngeal webs diagnosed incidentally on direct laryngoscopy (DL) after anesthetic induction present a challenging situation for anesthesiologist ranging from difficult to failed intubation. We present a rare case of failed intubation in an adult, caused by unanticipated subglottic web.

A 65-year-old male, American Society of Anesthesiology Grade II, weighing 70 kg was posted for DL-guided biopsy for suspected growth on the right vocal cord under general anesthesia. Except hoarseness for the last 2 months, he had no history of breathlessness, difficulty in swallowing, or chronic medical illness. He had undergone DL-guided biopsy under local anesthesia (LA) 1 month back which was reported as nonspecific chronic laryngitis. Airway assessment revealed mallampati grading II and normal neck movements. Indirect laryngoscopic findings revealed thickening of the right vocal cord with adequate chink. In the operation room, standard anesthesia monitors were attached and an intravenous (IV) line was secured. Anesthesia induction was done with fentanyl 100 μg IV and propofol 100 mg IV. Succinylcholine 100 mg IV was given after checking adequacy of mask ventilation. Although resistance was encountered during mask ventilation, it was overlooked. On DL, Cormack-Lehane (CL) grade of vocal cords was IIb. Endotracheal intubation was attempted with 5 mm internal diameter (ID) microlaryngeal tube, but it could not be negotiated beyond the vocal cords. Subsequent intubation attempts with 4.5 mm, 4.0 mm ID uncuffed endotracheal tube (ETT) were unsuccessful. Bronchoscopy was planned to examine the subglottic region; however, considering the short nature of the surgical procedure, it was decided to do bronchoscopy after the biopsy. The airway was successfully secured with 3.5 mm ID ETT with some air leak which was acceptable. Anesthesia was maintained with 1% isoflurane with oxygen-air mixture. After completion of the procedure, ETT was removed and bronchoscopy was performed which revealed a web covering anterior part of subglottis [Figure 1]. Biopsy showed it to be a case of chronic laryngitis only. As the patient was asymptomatic, no further interventions were performed for laryngeal web.
Figure 1: Bronchoscopy revealing the presence of subglottic web

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Laryngeal webs can be congenital and acquired. Acquired laryngeal web is a bridge of scar tissue covered by epithelium located between the vocal cords involving the anterior commissure and can result from iatrogenic injuries such as enthusiastic endoscopic surgery involving both true vocal cords simultaneously, endotracheal intubation, laryngeal surgeries, emergency cricothyroidotomy, bronchoscopy, high tracheostomy, radiotherapy, or laryngeal neoplasm. Clinical symptoms vary with the severity of disease ranging from hoarseness of voice to stridor.[1]

Airway management for unsuspected subglottic web is challenging. Under anesthesia, there is variable presentation ranging from difficult or failed intubation to postoperative obstruction requiring tracheostomy.[2],[3] Different sizes of tracheal tubes must be ready during induction and undue force should not be applied to advance the tube if resistance is encountered. Laryngeal mask airways have been reported to be used in the presence of laryngeal webs, but adequate tidal volume was delivered at the cost of increased airway pressures.[4] Sometimes, emergency tracheostomy may be required in situation of "can't ventilate, can't intubate."

This patient was asymptomatic in the preoperative period. The CL grade was IIb after optimal external laryngeal maneuver and the web being subglottic in location could not be visualized on DL. Trauma during DL-guided biopsy done under LA 1 month back might be the possible etiology of laryngeal web in this case. Asymptomatic laryngeal webs usually do not require any treatment; hence, the patient was discharged with advice to consult doctor in case of increasing hoarseness of voice.

The present case highlights that one should keep a high level of suspicion for web while dealing with patients undergone laryngeal procedures in the past and keep the difficult airway cart ready even if difficult intubation is not suspected on clinical evaluation of such patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Zalzal GH, Cotton RT. Glottic and subglottic stenosis. Cummings Otolaryngology: Head and Neck Surgery. 5th ed. Philadelphia: Mosby, Elsevier; 2010. p. 2312-24.  Back to cited text no. 1
    
2.
Chong ZK, Jawan B, Poon YY, Lee JH. Unsuspected difficult intubation caused by a laryngeal web. Br J Anaesth 1997;79:396-7.  Back to cited text no. 2
    
3.
Capistrano-Baruh E, Wenig B, Steinberg L, Stegnjajic A, Baruh S. Laryngeal web: A cause of difficult endotracheal intubation. Anesthesiology 1982;57:123-5.  Back to cited text no. 3
    
4.
Singh PM, Khanna P. Incidental laryngeal web simulating intra-operative refractory bronchospasm. Indian J Anaesth 2013;57:82-3.  Back to cited text no. 4
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