Laryngeal Trauma

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Laryngeal Trauma

• Jean Paul Font, MD
• Francis B. Quinn, Jr., MD
• Grand Rounds Presentation
• Department of Otolaryngology
• University of Texas Medical Branch at Galveston
• March 28, 2007

2
Introduction

• Incidence 1 in every 30,000 ER visits
• Laryngeal injuries in 30 to 70 in penetrating
  neck trauma (especially zone II)
• Blunt and penetrating neck injury
• Airway
• Major vascular structures
• Cervical esophagus
• Cervical spine.

3
Laryngeal Embryology

• 3rd and 5th branchial arches
• 3rd week
• Respiratory primordium is derived from primitive
  foregut
• 4th -5th weeks
• Tracheoesophageal (TE) septum forms by fusion of
  (TE) folds

4
Anatomy

• Support Hyoid, thyroid, cricoid
• Protection of the larynx
• Superiorly by the mandible
• Inferiorly by the sternum
• Laterally by the sternomastoid muscle
• Posteriorly by the cervical spine
• Innervation RLN, SLN

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Anatomy

• Supraglottis
• External support
• Soft tissue attachments
• Glottis
• Relies on external support
• Narrowest in the adult
• Susceptible to obstruction
• Subglottis
• Cricoid-narrowest in infants

6
Laryngeal Function

• Function
• Breathing passage
• Airway protection
• Clearance of secretions
• Vocalization

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Mechanism of Injury

• Blunt trauma
• MVA
• Clothesline
• Crushing
• Strangulation injuries
• Penetrating trauma
• GSW- related to the type of weapon
• Directly penetration or indirectly by the blast
  effect
• Knives

Cummings laryngeal Injury. Otolaryngology Head
Neck Surgery, 4th ed. Mosby, Inc, 2005
8
Verschueren et al. Management of
Laryngo-Tracheal Injuries. J Oral Maxillofac Surg
2006.
9
Mechanism of Injury

• Blunt injuries
• Most commonly from motor vehicle accidents
• Forward thrust
• Neck extension impacting steering wheel
• Removes the mandibular barrier
• Laryngeal skeleton is compressed between a
  foreign object (i.e., steering wheel or
  dashboard) and the anterior aspect of the
  cervical spine
• Decrease incidence- seat belt harness and air
  bags

He is not cover!
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Initial Evaluation

• ATLS principles
• Intubation hazardous
• Schaefer in 1991- worsen preexisting injury
• Further tears or cricotracheal separation
• Respiratory distress
• Tracheotomy under local anesthesia
• Avoid cricothyroidotomies
• Worsen injury
• If no acute breathing difficulties
• Detailed history and careful physical examination

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Pediatric patient

• Blunt pediatric neck injuries
• Uncommon the larynx lies higher than the adult
• Protected by the mandible
• More often life-threatening
• Significant injury including laryngotracheal
  disruption
• Smaller cross-sectional area of the pediatric
  population
• Rigid bronchoscopy followed by tracheotomy over
  the bronchoscope

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Diagnosis

• History
• Change in voice
• Pain
• Dyspnea
• Dysphagia
• Odynophagia
• Hemoptysis
• Inability to tolerate the supine position

• Physical Exam
• Respiratory rate (saturations)
• Stridor
• Neck skin
• Contusions, Abrasions or Line pattern
• Subcutaneous emphysema
• Tracheal deviation
• Open wound
• Air bubbles
• Exposed tracheal cartilage
• Dont probe open wounds
• May dislodge a hematoma

13
Diagnosis

• Unstable
• Tracheotomy and neck exploration
• Stable patients
• Flexible fiberoptic laryngoscopy in the ER
• CT scan, direct laryngoscopy, bronchoscopy and
  esophagosopy

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Ct Scan

• CT allows
• Evaluation of the laryngeal skeletal framework
• Noninvasive avoiding unnecessary operative
  explorations

Hematoma Fracture Anterior Lamina
SQ emphysema
Cummings laryngeal Injury. Otolaryngology Head
Neck Surgery, 4th ed. Mosby, Inc, 2005
Verschueren et al. Management of Laryngo-Tracheal
Injuries. J Oral Maxillofac Surg 2006.
15
CT Scan

• Reserved
• Suspected laryngeal injury by history and
  physical examination
• No obvious surgical indications

Verschueren et al. Management of Laryngo-Tracheal
Injuries. J Oral Maxillofac Surg 2006.
16
Laryngotracheal Injury Classification

• Group I injuries
• No fracture
• Minor hematoma, edema or laceration
• Group II injuries
• Nondisplaced fractures
• Edema or hematoma
• Minor mucosal disruption without exposed
  cartilage
• Group III injuries
• Displaced fractures
• Massive edema or mucosal disruption
• Exposed cartilage and/or cord immobility
• Group IV injury (group III)
• Addition of two or more fracture lines
• Skeletal instability or significant anterior
  commissure trauma
• Complete laryngotracheal separation

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Medical Management

• Group I injuries
• Minimum of 24 hours of close observation
• Head of bed elevation
• Voice rest
• Humidified air
• Anti-reflux medication
• Serial flexible fiberoptic exams

• Antibiotics for laryngeal mucosa disruption

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Steroid

• Controversial
• Early systemic steroids therapy are often given
  to reduce laryngeal edema
• One randomized controlled trial (Ghorayeb 1985)
• Intravenous dexamethasone for preventing
  traumatic laryngeal edema in pediatric
  bronchoscopy
• This study showed no reduction in
  postbronchoscopy laryngeal edema with the use of
  intravenous dexamethasone

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Surgical Management

• Hemostasis
• Evacuation of hematoma
• Reconstruction of the laryngeal framework
• Coverage of de-epithelialized surfaces
• Group II to V required surgical intervention
• Surgical options
• Endoscopy alone
• Endoscopy with exploration
• Endoscopy with exploration and stenting

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Surgical Management

• Any doubt about the extent of injury endoscopy
  should be performed
• Indications for surgical exploration include
• Large mucosal lacerations
• Exposed cartilage
• Multiple or displaced cartilaginous fractures
• Vocal cord immobility
• Fractured cricoid
• Disruption of the cricoarytenoid joint
• Lacerations involving the free margin of the
  vocal cord or anterior commisure
• Explore within 24 hours of the injury
• Maximize airway and phonation results

Verschueren et al. Management of Laryngo-Tracheal
Injuries. J Oral Maxillofac Surg 2006.
22
Surgical Management

• Laryngeal skeleton is exposed from the hyoid to
  sternal notch
• Midline thyrotomy
• May use a vertical fracture (2 to 3mm of midline)
• Nondisplaced fractures
• Suture outer perichondrium
• Primary closure with nonabsorbable sutures
• Debridement should be minimized
• Mucosal lacerations
• Meticulously repaired using fine absorbable
  sutures
• Knots outside the laryngeal lumen (prevent
  granulation)

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Surgical Management

• Displace fractures of the cartilages are reduced
• Stabilized using stainless steel wires,
  nonabsorbable suture or miniplates.
• Small fragments of cartilage with no intact
  perichondrium are removed to prevent chondritis.
• Anterior commissure- suspend the anterior true
  vocal cords to the outer perichondrium of the
  thyroid cartilage
• Close the thyrotomy
• Nonabsorbable suture, wires or miniplates

Verschueren et al. Management of Laryngo-Tracheal
Injuries. J Oral Maxillofac Surg 2006.
24
Surgical Management

• Endolaryngeal stenting
• Disruption of the anterior commissure
• Massive mucosal injuries
• Comminuted fractures of the laryngeal skeleton
• From the false vocal fold to the first tracheal
  ring
• Stability and prevent endolaryngeal adhesions
• Removed in a period of 10 to 14 days to prevent
  mucosal damage

Verschueren et al. Management of Laryngo-Tracheal
Injuries. J Oral Maxillofac Surg 2006.
25
Stents

• Types of stents
• Endotracheal tube (COVER THE TOP END TO PREVENT
  ASPIRATION)
• Finger cots filled with gauze or foam
• Polymeric silicone stents
• Secure the stent
• Heavy, nonabsorbable suture
• Larynx at the ventricle
• Cricothyroid membrane
• Tied outside the skin
• Endoscopically removed

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Conclusion

• Laryngeal trauma although uncommon can be
  life-threatening
• Recognizing any airway compromise and need for
  immediate intervention could prevent immediate
  death as well as acute and long term morbidity
• Initial management should follow ATLS principles
• Most authors agree that tracheotomy should be
  performed on patients exhibiting respiratory
  distress
• In patients with no acute breathing difficulties,
  a detailed history, careful physical examination
  and appropriate diagnostic tools should be use to
  differentiate the need for medical from surgical
  management

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Any questions ?
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References

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