laryngeal injury
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8/3/2019 Laryngeal Injury
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LARYNGEAL INJURY …By Methawee 12Dec2011
Laryngeal injury : consequence of neck injury
Definitive treatment must be provided within 24 hours.
Proper Mx is essential to preserve life , airway,voice,deglutition.
Securing airway & protect C-spine : the first priority
Severity of injury & Delayed Rx => poor outcome
Classification
1. External laryngeal injury
2. Internal laryngeal injury < Iatrogenic >=> more frequent
External laryngeal injury
Blunt injury
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1.Crushing injury : Most common from motor vehicle accident
2.Clothesline injury
3.Strangulation injury: significant differences in the pattern of injury between
suicidal and homicidal strangulation, 24 with the latter being more likely to
cause laryngotracheal separation and concomitant neurovascular injuries.
Special consideration
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Elderly person : More calcification of larynx :↑risk of comminuted fx
Childhood
1. ↓laryngeal fracture : Larynx is situated higher in the neck &
protected by mandible
The larynx lies at the level of C3 in the neonate and descends during
the first 3 years of life to its adult position at the level of C6
2. ↑soft tissue injury : loose attachment overlying mucous membrane&
lack of fibrous support
3. ↓ relative cross-sectional area of larynx
2.+3. => ↑ airway obstruction
Female person :Long & thin neck↑supraglottic injury
Penetrating injury
1.Gunshot wounds : more severe tissue damage
Severity related to Velocity& Distance
2.Knife wounds : less tissue damage & cleaner
Associated injury from blast effect: thoracic duct, cervical nerve, great vessels
and viscera
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Internal laryngeal injury< Iatrogenic >
Precipitating factor of Intubation injury
• Duration of intubation, Size of ETT, Type of ETT, Pressure cuff
• Intubation techniques : Nasotracheal VS orotracheal intubation
• Local infection,Recurrent trauma, Immunocompromised host
1.Intubation Injury (acute injury: intubation period)
Most endolaryngeal injuries result as cpx.of intubation from intubation technique
… From forceful manipulation & insertion of ETT or too large ETT
Glottic or subglottic injury is common
• In children : subglottis
• In adults: medial surface of the posterior commissure( on which the
tube rests)
perichondritis, granulation tissue formation จาก nerve injury
interarytenoid scarring and bilateral vocal cord immobility
Possible cpx of intubation
Pharyngeal lacerations, Cricoarytenoid dislocation
Injury to the lingual, hypoglossal, superior laryngeal&recurrent laryngeal nerves
and vocal folds
Best Mx =Prevention ,Education for correct techniques of intubation/ Choosing a
correct size of ETT
Intubation Injury ( Delayed injury: Prolonged intubation )
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10% after short-term translaryngeal intubationand rises to 90% after long-term
intubation
• Supraglottic : Stenosis
• Glottic :Edema, vocal cord paralysis,Granuloma,interarytenoid fibrosis
○ Cricoarytenoid joint dislocation• Subglottic: Edema,granuloma,Stenosis
• Tracheal: Granuloma, Tracheomalacia,Stenosis ,TE fistula
Mx: Conversion to tracheostomy7 -10 days after intubation
Inhalation injury
Causes : superheated air esp. steam
Limited injury to supraglottic area due to ….reflex closure of the glottis
Associated injury: other parts of the body esp. closed areas
Initial presentation : unremarkable except erythema of upper airway & carbon-
stained sputum
Mx: - secured airway & fluid resuscitation
Injury from caustic ingestion
Typically in childhood ( from various household products )
In adults => suicidal attempt(hydrocarbons : more common )
alkali : liquefaction necrosis of muscle, collagen, and lipids
and creates an injury that worsens with time
acids : coagulation necrosis of the superficial tissues
S&S
direct contact larynx during ingestion
Limited injury to supraglottic area due to ….reflex closure of the glottis
Associated with oral, pharyngeal, and esophageal injuries
Mx
• 24 hours for airway observation : GOAL-safe airway & cardiovascular
resuscitation
• Presence of facial or body burns and soot in the oral cavity and
finding at endoscopy of laryngeal edema predict the need for airway
intervention
• Endotracheal intubation plays an even lesser role
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• If patients are to undergo microlaryngoscopy, tracheobronchoscopy, or
esophagoscopy, the procedure should be performed within 24 hours of
injury.
• The upper aerodigestive tract should be irrigated in cases of caustic
injury to remove any residual substances
• Further treatment depends on the nature and extent of injuries found
and the consequences of healing and scarring
• Caustic and thermal injuries can cause laryngeal and tracheal airway
strictures
(severity is greater than that of strictures associated with postintubation
laryngotracheal stenosis)
DIAGNOSIS
Classic symptoms :Hoarseness, laryngeal pain, dyspnea, dysphagia
***Severe compromised laryngeal lumen : aphonia & apnea => Need
tracheotomy
Other symptoms :Aspiration : immobility of one or both vocal folds
Signs
•
Laryngeal tenderness :to differentiate acute from old deformity• Skin changes: contusions or abrasions from blunt injury, line pattern from
strangulation injury,entrance and exit wound from penetrating injury
• Loss of thyroid cartilage prominence
• Stridor : relate to location of the lesion
• Subcutaneous emphysema&massive pneumomediastinum
• Hemoptysis : injury to upper aerodigestive system
( difficult to differentiate from facial trauma )
• Vocal-fold immobility
• Laryngeal hematoma• Laryngeal edema
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• Laryngeal lacerations
*** Laryngeal trauma is often associated with concomitant cervical and
intracranial injuries and
frequently occurs as part of multisystem polytrauma.
Investigation
FOL :
• Evaluate endolaryngeal anatomy for Pts with stable airway
• Size & location of hematoma / lacerations
• Motion of arythenoid & TVC
• Airway patency?
• Exposed cartilage?
IDL : Not proper
Rigid esophagoscopy : The best for examine hypopharynx & esophagus after
R/O C-spine injury
Plain films : Identify fractures but only two dimensions,Visualize the entire C-
spine
to avoid missing C-spine injury
CT scan ในทุก case ยกเว้นกรณีอกรน้อยและตรวจร่งกยปกติ
ไม่มีบวม
• Noninvasive manner for evaluate the laryngeal framework
• most useful method for evaluating laryngeal trauma
• CT scan can be deferred only in those patients with a history of relativelyminor trauma to the neck, no laryngeal tenderness or surgical
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emphysema, stable airway, and the finding of minimal laryngeal injuries
on flexible laryngoscopy***
CT to identify….
• To assess the extent of laryngeal injury
• To confirm indirect or fiberoptic laryngoscopic findings
• To detect cartilage fractures that are not clinically apparent
• To assess poorly visualized areas( subglottic and anterior commissure
regions)
• To identify associated cervical injuries
Management
Goal
• To preserve life by maintaining the airway
• To preserve voice,swalowing quality
Emergency Care
Primary survey : ABCD
• Airway & Breathing
• Cardiac resuscitation & control of hemorrhage
• Stabilization of neural and spinal injuries
Secondary survey :Investigation& Specific Mx for organ injuries
• Tracheotomy is more effective ( To prevent airway damage )
• Intubation in this setting is hazardous
…Attempted ETT on a traumatized larynx : iatrogenic injury
BUT …intubation can be done
1. Under direct visualization by experienced personnel with a small ETT
2. If endolaryngeal mucous membrane is intact& laryngeal skeleton is
minimally displaced
***A child with laryngeal injury
Difficult to perform tracheotomy & O2 sat drop more quickly
After successful bronchoscopy , tracheotomy can be done as needed หลังจาก ใส่bronchoscope
Treatment Decision Making : Medical VS Surgical treatment
Approximately 40% of patients with laryngeal trauma can be managed
conservatively, and in those patients who require surgical treatment, the extent
of the original injury correlates with the long-term outcome.
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Medical treatment…
For…
1. Edema
2. Small hematoma with intact mucosal coverage
3. Small lacerations without exposed cartilage
4. Single nondisplaced thyroid cartilage fractures in stable larynx
• Voice rest• Systemic steroids : if presenting within 24 hours of injury
• Elevate head
• Humidified air
• Antibiotics ในกรณี laryngeal mucosa has been breached
• Antireflux measures
• Avoid NG tube
***Uncertain blunt trauma : observe for signs of progressive airway
compromise at least 24 hrs
Surgical treatment …
FOR…. ใน group 3,4,5
1. Lacerations involving the free margin of the vocal fold
2. Large mucosal lacerations
3. Exposed cartilage
4. Multiple and displaced cartilage fractures
5. Avulsed or dislocated arytenoid cartilages
6. Vocal fold immobility
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Surgical treatment …
• Tracheotomy
•
Endoscopy• Exploration
• Thyrotomy
• Closure of laceration
• Insertion of stents
• Grafting
• Fixation of fractures
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Timing
Early exploration : (Better outcome & more effective)
• Lower post-op infection rate
• Quicker healing
• Less granulation tissue& scarring
We aim to repair all laryngeal injuries within 12 hours of presentation and arereluctant to accept delays beyond 24 hours.
Delayed exploration
• ↓Edema : Easy to repair ?
• In C-spine or traumatic brain injury pts
• Delays in treatment can lead to granulation and scar tissue formation,
which
can progress to laryngeal stenosis, a difficult surgical problem to correct.
Direct laryngoscopy, Bronchoscopy, esophagoscopy should be done beforesurgery ทุกราย เพื อประเมิน injury
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Thyrotomy
Closure of laceration :Meticulous technique by 5-0 or 6-0 absorbable suture
material
Exposed cartilage must be covered to prevent granulation tissue and fibrosis
Failure to do : grafting and healing by secondary intention (chance for scarformation)
Grafting
Loss of tissue is large & exposed cartilage
Donor site1.Mucous membrane => most closely resembles normal
endolaryngeal epithelium
2.Dermis :Split-thickness skin
Insertion of stents
To maintain internal configuration of larynx(normal scaphoid shape of the
anterior commissure)
& prevent stenosis
I/C ของการใส่Stent 3 ขอ้
• Anterior commissure disruption
• Multiple & displaced cartilage fracture
• Multiple & severe endolaryngeal laceration
After placement of a stent , Anterior commissure is reconstituted by suturing
TVC to outer perichondrium
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Remove in 10-14 d. : ↓risk of infection, ↓ Granulation tissue formation
ORIF: suturematerial, stainless steel wire, titanium miniplate and
screw
VOCAL CORD IMMOBILITY
• Cricoarytenoid joint dislocation :endoscopic manipulation and reduction
• Recurrent laryngeal nerves injury
: Only if a complete palsy exploration of the affected nerve
*** Cricoarytenoid joint mobility can be assessed preoperatively, but definitive
assessment of joint mobility requires microlaryngoscopy and instrumentation
(passive mobility test)
Cricotracheal Separation
Precarious airway
Loss of cricoid support
High risk of injury to RCN
Late development of SGS
Mx : -Tracheotomy +/- Bronchoscope
- Avoid ETT
- Cricotracheal anastomosis & mucosal repair (Intact cricoid cartilage)
1. Repair with the posterior anastomosis, using a combination of 3-0
absorbable and nonabsorbable sutures, and works toward the anterior
trachea
2. All knots are extraluminal, and the sutures are run through the
submucosal plane
3. Avascular and damaged tissue is resected
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4. If there is an associated crush injury to the trachea, a temporary soft
polymeric silicone stent may have to be placed in the lumen prior to
anastomosis
- Internal fixation +/- stenting (Fx of cricoid cartilage)
PARTIAL OR TOTAL LARYNGECTOMY
In cases of massive laryngeal injury with significant tissue loss , BUT… rare
S evered Recurrent Laryngeal Nerve
• Immediate nerve reapproximation under an operating microscope
• Nerve regeneration???,Prevent muscle atrophy, Maintain some strength of
voice
Postoperative Care
• Strict voice rest for 48 to 72 hours
• NG tube should be inserted at the time of surgery and should remain
until the safety of swallowing is confirmed
• Post-op antibiotics for 5 -7 days (if mucosal tear)
• Elevate head
• Ambulate as soon as possible
• Remove stent in2 wk after surgery(mucosal tear),3 wk (anterior
commissure disruption )
• Tracheostomy tube care
•
Decannulation as soon as the stent is removed• Antacids & H2-blockers : to prevent reflux
• Regular endoscopic examinations :granulation tissue is removed to
prevent long-term scarring
• In patients with cricotracheal separation, the neck is kept in flexion for
7 days postoperatively to prevent traction on the anastomosis
Follow-up : continue at least 1 year
To assess true vocal fold function return
To assess development of SGS
COMPLICATION
Granulation tissue
Prevent by covering all exposed cartilage
Avoid stents when possible
Careful excision
Laryngeal stenosis
Excision with mucosal coverage
Stenting selected cases
LaryngotracheoplastyTracheal resection with reanastomosis
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Vocal-fold immobility
Observe
Vocal-fold injection
Thyroplasty-type vocal-fold medialization
Arytenoidectomy and vocal-fold lateralization for bilateral paralysis
Outcome depend on …
• Extent of the original injury
• Quality of subsequent repairs
Group 1 -2 : excellent recovery without surgery
Group 3 -5 : good result if early repair
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