Management of Anterior Glottic Web with Keel Placement
The procedure treats an anterior glottic web through an open approach. A midline thyrotomy is performed to access the larynx, and after web lysis is performed, a temporary keel is placed. Anterior vocal fold webs usually recur following simple incision due to proximal contact of raw apposing surfaces. Web lysis followed by placement of a keel that separates anterior de-epithelialized glottic tissues is particularly useful when treating large symptomatic anterior webs that involve full thickness of the vocal folds and adjacent tissues. Simple lysis with cold knife or focused laser incision is often adequate for such lesions. There remains a population of patients with substantial webs for whom keel placement is the most predictably effective approach.
Indications/Contraindications
Dysphonia and dyspnea should be present to justify undergoing this multi-stage procedure.
Indicated where transoral techniques have been tried and failed to prevent web recurrence.
In the Clinical Setting
Key Points
Options for keel placement include:
direct laryngoscopy with transoral scar lysis and keel placement secured externally
transcervical laryngofissure with direct web lysis, secure placement and direct suture securing the keel to thyroid cartilage (as seen in this chapter)
It is important to assess the extent of the web with intraoperative inspection (microscope and 70° angled telescope) and instrumental palpation.
Transoral resection of scar needs to be complete, eliminating bulky scar while ensuring secure, snug placement of the keel anteriorly.
Laryngofissure should be performed with careful attention to intraluminal midline mucosal incision.
Pitfalls
The alternative use of transoral keel placement by direct laryngoscopy often fails due to lack of secure anterior fixation. Even when using the laryngofissure approach, the keel must be secured snugly to prevent motion, migration of granulation tissue, and subsequent restenosis.
Failure to remove endolaryngeal hypertrophic scar tissue and/or excessive removal of mucosa predispose to recurrent web formation.
The endolaryngeal portion of keel should be very thin to promote establishment of a well-defined anterior commissure. When necessary to use a saw or drill to penetrate calcified cartilage, avoid penetration of lumen until it can be done precisely with a knife under direct visualization.
Stepwise Procedure
Mount a larynx for open dissection.
Study the external anatomy of the larynx, clearing soft tissues to identify and expose the thyroid notch, inferior margin of thyroid cartilage, cricothyroid membrane, and the bellies of the cricothyroid muscle.
Estimate the plane of the vocal folds by measuring one-half the midline vertical height of the thyroid cartilage anteriorly. This will help in localizing the position of the web relative to the anterior commissure of the vocal folds.
A subtle depression in the thyroid cartilage on the anterior surface often marks the site of insertion of Broyle′s ligament at the anterior commissure.
OR Pearl: Separate soft tissues, including sternohyoid and thyrohyoid muscles, reflecting them laterally to 2 cm away from midline.
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