Laryngeal Keel and Its Implications during Airway Management

A 15-YR-OLD boy with dysphonia and difficulty clearing secretions due to a glottic web underwent an endoscopic excision and Gore-Tex (W. L. Gore & Associates, Inc., USA) laryngeal keel placement (fig. 1). Laryngeal keels are used to achieve and maintain separation at the anterior commissure and prevent glottic scarring and stenosis after surgery involving the glottis.  Patients usually return in 3 to 5 weeks for removal. Anesthesiologists may encounter laryngeal keels during airway management when patients present for their placement, removal, or emergency intubations.

There are a variety of shapes and materials used for laryngeal keels, including metal, Teflon, cartilage, silicon, silastic, and Gore-Tex, as was used in our patient. Gore-Tex is a strong, but soft, chemically inert, and biocompatible material widely used for laryngeal keels and was shown in one study to result in near-perfect healing and had a positive impact on voice outcome.  When a keel is placed endoscopically, direct laryngoscopy is followed by transoral scar lysis and sutures are passed from within the larynx through the keel and the anterior neck to secure it percutaneously. Open approaches involve creating a transcervical laryngofissure with direct web lysis, followed by placing a stiffer keel that is directly sutured to the thyroid cartilage.

Because glottic repairs may cause laryngeal edema in patients with already compromised airways, a few anesthetic strategies should be considered. When possible, a general anesthetic with a natural airway and spontaneous respiration allows for maximum exposure to the glottis during keel placement and accommodates rigid bronchoscopy and flexible bronchoscopy. If intubation becomes necessary during the procedure, a smaller endotracheal tube than expected should be used and administration of intravenous steroids is recommended. When patients with keels subsequently require intubation, care must be taken not to displace or disrupt the keel. Displacement may lead to improper healing, adhesion formation, and further airway stenosis. It should be noted that when a disrupted keel leads to airway compromise, a supraglottic airway may be insufficient or even contraindicated, and a definitive airway should be established. Complete dislodgement and aspiration of the keel has been reported.  If this were to occur, the keel should be removed with rigid bronchoscopy to prevent distal airway obstruction, mucosal damage, or granulation tissue formation.