How To: Novel Technique for Endoscopic Placement of Stent in Management of Anterior Glottic Webs

Introduction

Anterior glottic webs are abnormal fusions of the anterior vocal folds that may be congenital or acquired. Congenital anterior glottic webs are rare and result from failure of recanalization of the larynx during development. Acquired anterior glottic webs are more common and typically occur due to trauma or inflammation of the larynx (Ann Otol Rhinol Laryngol. 2013;122:672-678).

The treatment of anterior glottic webs is primarily surgical and can be performed by endoscopic or open approaches. Endolaryngeal procedures are preferred because they are less invasive and have lower morbidity. Endoscopic techniques involve either mucosal flap elevation with suture stabilization or incision of the web with stent placement (ibid).

Standard endoscopic stent placement techniques involve sutures placed with either a specialized needle carrier or microlaryngoscopic instruments. In practice, this placement can be difficult because most operating rooms are not equipped with a specialized needle carrier created for this purpose. In addition, it is difficult to pass sutures endoscopically from the laryngeal lumen out of the anterior neck when working in the tight surgical field of a laryngoscope. Finally, regardless of the technique used, there are issues of skin breakdown and scar formation at the site of the stabilizing suture on the anterior neck skin and the need for a second general anesthesia to remove the stent. 

Method

The procedure is performed under general anesthesia using a Dedo-Pilling Micro-Laryngoscope with the patient in suspension. The web is incised using a CO₂ laser. A modified ruler is used to measure the vertical length of the web and serve as a template for the stent. Reinforced silicone sheet with 0.007-inch thickness is used to prepare the keel stent. A 3–0 polypropylene suture is then passed along what will become the anterior edge of the keel as it sits in the airway.

Next, a horizontal 1-cm skin incision is made at the level of cricothyroid membrane. This incision allows all the stabilizing sutures to be placed subcutaneously, thus obviating issues of skin breakdown secondary to the traditional technique of tying the suture on the anterior neck over a bolster or button. An 18- or 20-gauge intravenous catheter is passed through the midline of the cricothyroid membrane into the subglottis under endoscopic vision. The needle is withdrawn, leaving the polymer sheath in place (Fig. 1). During the venous catheter placement, the endotracheal tube balloon is deflated or moved distally; extra care should be taken not to perforate it. A renal stone extractor is then introduced into the endolarynx through the catheter sheath and pulled superiorly through the laryngoscope using alligator forceps. The end of the suture attached to the inferior aspect of the keel is passed into the stone extractor basket, which is then closed, securing the suture. The stone extractor is pulled out from the cricothyroid incision site, pulling the suture along.