Challenges in the anesthetic management of a pediatric patient with glottic web – A lesson

Dear Editor,

The laryngeal web is a rare condition with a membrane across the laryngeal lumen in proximity to the vocal cords, which causes airway obstruction in pediatric patients.[1]

A 19-month-old male child weighing 9.5 kg presented with cough and fast, noisy breathing, as informed by his parents for four days. On examination, the child had mild stridor with sub-costal retractions and a heart rate of 120/min, respiratory rate of 50/min with SpO₂ of 92% at room air, and bilateral air entry was equal with added sounds. The child required oxygen support from nasal continuous positive airway pressure therapy (CPAP). Parents gave a history of recurrent respiratory tract infections since five months of age, needing hospital admission and management with intravenous antibiotics and nebulizations. The computed tomography (CT) scan revealed narrowing in the subglottic area with a diameter of 3.5 × 3 mm. A thick laryngeal web (type 3 Cohen’s classification) with a narrow opening in the posterior part of the glottis was noted by a flexible bronchoscope. So, the child was posted for tracheostomy followed by laryngeal web excision and balloon dilatation of subglottic stenosis.

The plan of airway management in this case poses a challenge to the anesthesiologist. The narrowed glottic opening compromises intubation success, and the performance of tracheostomy in children without a definitive airway is fraught with multiple risks. Therefore, we planned to maintain spontaneous breathing at an increased depth of anesthesia with sevoflurane, along with fetamine boluses and propofol infusion. Plan A was to attempt to secure the airway using a small-sized endotracheal tube (ETT), and plan B included a placement of a supraglottic airway device or just a mask with the oral airway. Inj. glycopyrrolate and inj. dexamethasone were administered in the preoperative period. In the operating room, the child was connected to standard monitoring of electrocardiogram (ECG), SpO₂, and non-invasive blood pressure. The difficult airway cart was prepared with airway types of equipment like oral and nasopharyngeal airway, laryngeal mask airway, Frova introducer, pediatric stylet, and ETT of size 2.5,3 (uncuffed). We expected that ETT sizes 2.5,3 internal diameter might be able to negotiate through the opening in the posterior part of the glottic aperture when guided through a bougie or stylet. The ear nose throat (ENT) surgeons were scrubbed and ready. Inhalation induction was done with a Jackson-Rees circuit with 100% oxygen to target an end-tidal sevoflurane of 3%. Injection ketamine boluses of 5 mg + 5 mg were also administered intravenously and a propofol infusion at 200 mcg/kg/min was started to maintain spontaneous breathing along with deepening of anesthesia. After two minutes, gentle laryngoscopy was attempted and the glottic region was tropicalized with lignocaine 1%, and spontaneous breathing was allowed with a 3% end-tidal concentration of sevoflurane. Following this, laryngoscopy was attempted with a 2-size C-MAC blade and a 2.5 mm ID uncuffed ETT along with the stylet was tried but failed. Then, the second attempt was with a pediatric Frova (Cook Medical, Bloomington, USA, 8 Fr 35 cm long) guided size 3 uncuffed ETT and it was able to pass easily with a gentle pop. The images of the tubes are shown in Figure 1. The ventilating circuit was connected and anesthesia was maintained with sevoflurane, O₂, and air. A tracheostomy was performed after the administration of atracurium and a 3.5-size cuffed Portex tracheostomy tube was placed. The rest of the procedure went uneventful and the child was weaned from anesthesia post-procedure.

Figure 1.

ETTs loaded with stylet and pediatric Frova

In our case, we had a type 3 thick laryngeal web defined by Cohen’s classification. For thick laryngeal webs, treatment option includes tracheostomy followed by surgical excision. We kept the smallest diameter ETT with internal diameter sizes of 3 and 2.5 mm to enable passage through the narrow lumen. A similar pediatric case with laryngeal web was managed successfully with Cole’s tube of size 2 mm, which was just kept at the laryngeal orifice after an attempt of failed intubation. In due course of time, emergency tracheostomy was performed.[2] Child with laryngeal web occluding the glottic opening by >75% will require a surgical airway, as intubation will mostly be impossible[3] Tracheostomy in children, especially non-paralyzed without a secured airway is associated with numerous life-threatening complications like pneumothorax, subcutaneous emphysema, and hypoxic arrest. The incidence of pneumothorax is as high as 17% in children[4] and it can occur either by direct injury to the pleura during tracheostomy or from high negative inspiratory pressures in patients who are distressed and not paralyzed on mechanical ventilation. Therefore, expecting this complication, a pediatrician with a suitable-sized chest drain was present in the operating room. Maintaining the proper depth of anesthesia and proper planning helped us manage this case in an uneventful manner. Also, the snug fit of the pediatric Frova with the 3 mm ID tube allowed us to use it as a dilator and enabled easy railroading even when the smaller 2.5 mm ID tube with stylet failed.

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