Presentation
Transferred from a regional hospital with 24 hours of progressive stridor and dyspnea after recent upper respiratory tract infection. Initially stabilized with intravenous dexamethasone and nebulized epinephrine, a CT neck was performed prior to transfer for ENT assessment.
Patient Data
There is subtle irregularity of the vocal cords and narrowing of the subglottis. The laryngeal cartilages appear unremarkable. There is no edema, mass lesion or displacement of the supra or glottic structures. The scan is otherwise unremarkable for the patient's presentation.
Upon transfer to the emergency department the patient was noted to have soft stridor and a soft voice but oxygen saturation was normal. The patient was able to manage their own saliva and was not in any pain. Further history revealed progressive dysponea over the past twelve months and notably a difficult intubation two years earlier for a surgical procedure.
Nasendoscopy revealed an anterior glottic web. After failure to further improve with steroids, the patient proceeded to microlaryngoscopy the next day.
There is an adhesion (anterior glottic web) between the anterior commissure extending past the mid point of the vocal cords restricting the airway to the posterior third of the glottis. There is also a subglottic stenosis.
The patient proceeded to laser division of the glottic web and subglottic stenosis along with balloon dilatation of the subglottic stenosis. Biopsies of the glottis and subglottis were also taken to further investigate the cause.
Upon extubation, the patient's breathing was much improved. Subsequent investigations for autoimmune laryngeal pathology were unremarkable and the histopathology revealed essentially scar tissue.
Case Discussion
Acquired anterior glottic webs are the most common type of glottic web. They are commonly due to traumatic injury to the larynx from either intubation, laryngeal surgery, external trauma or infection. They can range from small microwebs to those involving the entire length of the membranous vocal fold. Symptoms will depend on the extent of the web 1,2.
A number of conditions are associated with anterior glottic webs namely laryngeal framework stenosis. This may be either supraglottic stenosis, thyroid cartilage constriction resulting in glottic stenosis and/or subglottic stenosis resulting from cricoid cartilage deformity. The differential diagnosis for anterior glottic webs includes; sarcoidosis, granulomatosis with polyangiitis, and amyloidosis 1.
In this case, previous trauma to the larynx during difficult intubation two years prior is the likely cause for the patient's glottic web and subglottic stenosis.
This case highlights that subtle but potentially life-threatening laryngeal pathology may be difficult to identify on radiology. All patients with stridor warrant prompt ENT referral for indirect laryngoscopy to identify pathology and instigate appropriate airway management.
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