An abnormal, continuous sheet of mucosa that joins the vocal cords together. This glottic web is analogous to the web one sees between adjacent fingers. Normally, in the absence of a glottic web, the mucosa covers each vocal cord individually to form a crisp “V”.
A glottic web may be congenital, or it may result from injury. Classic teaching is that surgeons ought not to operate on the anterior portion of both vocal cords simultaneously, because the raw, de-epithelialized surfaces may grow together and create an anterior glottic web. Some webs do not need to be addressed because the effect on voice is minimal; in other cases, surgical approaches are indicated because of the poor voice often associated with this abnormality.
Glottic web (2 of 12)
Lab procedure: 11-blade attached to biopsy forceps, wrapped with tape to “guard” all but the tip.
Glottic web (9 of 12)
A depot form of steroid injection in the videoendoscopy laboratory (patient in chair). The intent is to abolish or diminish the inexorable re-adhesion of the vocal cords, sometimes many months after apparent complete healing and re-mucosalization. Note white submucosal material.
Glottic web (10 of 12)
Injection at apex of the web. Note condensed white submucosal steroid, from prior injection.
Glottic web (11 of 12)
16 months after last of a series of web divisions as depicted above. The web does not show any sign of re-forming. Compare with photos 1 and 2.
Glottic web (12 of 12)
Closer view, again showing maintenance of the deep V shape of the glottic aperture, rather than the short, fat U seen before web division. The patient has no shortness of breath.
Inflammatory web (1 of 4)
Chronic hoarseness and peculiar inflammatory web in a woman who has never smoked. Acid reflux has been put aside as a cause, too. Biopsies show severe inflammation and dysplasia. HPV subtyping was negative.
Closer view (2 of 4)
Closer view under narrow band illumination shows the combination of inflammation, granulation, and leukoplakia.
After treatment (3 of 4)
Soon after superficial peeling of the abnormal tissue, kenalog injection, and mitomycin C application. The web is less; voice is much better, but inflammation remains significant.
Closer view (4 of 4)
A closer view of the chronically inflamed cords. In cases of idiopathic (unknown cause) inflammatory webs of this sort, the rule is gradual recurrence of the web not in the early postoperative period as is seen with conventional webs, but instead across many months. Occasionally, transformation to CIS or early cancer then opens the door to radiation therapy.
Post radiation (1 of 2)
More than a year after radiation and chemotherapy for HPV-induced larynx cancer, voice is serviceable but still hoarse. The vocal cord mucosa would have been raw from the radiation, and fused together anteriorly.
Anterior band (2 of 2)
At closer range, the band between the anterior vocal cords is clearly seen. The vocal cords should be unattached to approximately the tip of the arrow.
Glottic web (1 of 4)
This younger woman has been hoarse from birth and has had four prior procedures elsewhere for her congenital glottic web. Here, note that the web attaches most of both vocal cords together. She is very hoarse. The large and small dots are for orienting purposes with following photos. The recommendation: start with simple outpatient web division.
Surgical division of web (2 of 4)
A few weeks after surgical division of the web, topical mitomycin C, early postop voice use to prevent reattachment. Voice is already noticeably improved. As expected, there is a small web re-forming, but well below the margins of the cords (at 'X').
Polyp-like mounds (3 of 4)
Under strobe light, the stretched web tissue has retracted after division into polyp-like mounds, especially on the right side (left of photo).
Complete healing (4 of 4)
Four months later, with complete healing and a residual subglottic web that does not interfere with vibration. The patient says voice improvement is “moderate” for both quality and effort required. She also noted that “people no longer ask me if I’m sick.” She does not feel the need to attempt any further improvement via trimming for better match.
Cyst and web (1 of 4)
After surgery elsewhere, a glottic web and mucus cyst. The original laryngeal condition that led to surgery is not known.
Web (2 of 4)
At much closer range, both abnormalities are seen more clearly. The dotted line indicates the extent of the web.
Coagulating cyst (3 of 4)
Given her prior bad experience with surgery, the patient was unwilling to go to the operating room to address the web, but was willing to address the cyst in the voice lab, using the Thulium laser. The cyst originates from well below the vocal cord, and can therefore be coagulated without risk to voice.
Weeks later (4 of 4)
A few weeks later. Cyst is no longer seen, and voice, while still abnormal given the persistent web, is dramatically improved.
Glottic web (1 of 4)
Chronic hoarseness and glottic web after surgery elsewhere for recurring papillomas.
Proposed incision (2 of 4)
Closer view under narrow band light. The dashed line shows proposed incision during upcoming vocal cord microsurgery.
Less effortful voice (3 of 4)
Several weeks after the web was divided, and topical Mitomycin C applied. Voice is still hoarse, but definitely less effortful, and with a (desirable) lower pitch. The patient is pleased.
Re-mucosalization (4 of 4)
Narrow band light shows that, as indicated by fine capillary pattern, re-mucosalization is nearly complete, other than within dotted line.
Vocal "overdoer" (1 of 4)
A vocal “overdoer” with hoarseness. Note broad-based swelling of both vocal cord margins. A micro-web, thought to be congenital, is also seen at the arrow. Tiny dots indicate a subtle wrinkle or shallow sulcus.
Inspiratory phonation (2 of 4)
The patient has been asked to produce inspiratory phonation to reveal the translucent polyp and “sulcus,” again at tiny dots.
Translucent polyp (3 of 4)
Under strobe light, the translucence of the polypoid elevation is seen more clearly.
Open phase (4 of 4)
At open phase of vibration again under strobe light, the broad based left vocal cord elevation is also seen.