Laryngeal Trauma
Paul W. Flint, MD
Otolaryngology – Head & Neck SurgeryOregon Health & Science University
5th Edition 2010
Guri Sandhu, MBBS, FRCSConsultant OtolaryngologistImperial College Healthcare NHS Trust, Charing Cross Hospital
Key Points
u Laryngeal trauma is rare although life threateningu Multiple etiologies: blunt, penetrating, intubation
caustic, thermal, radiation u Evaluation and Airway managementu Timing of interventionu Sequelae
Bhojani, RA - J Trauma 2005
Overall incidence is stable
Blunt trauma withincreased mortality
Blunt trauma more likely to require tracheotomy
Mechanics of injury impacted by age and degree of calcification
Blunt trauma:
Signs & Sx’s of external laryngeal trauma
u Hoarseness 28 (85%)u Dysphagia 17 (52%)u Pain 14 (42%)u Dyspnea 7 (21%)u Hemoptysis 6 (18%)
Luutilainen MActa Oto-Laryngologica 2007
n=33
Evaluation
u Airwayu Endoscopyu Imagingu Classification
Sandhu in Cummings OHNS 2010
Developing the Airway Response TeamOperational, Safety, and Educational Initiative.
Lauren Berkow, ACCMNasir Bhatti, OHNSRenee Cover, ORMJeffery Dodd-O, ACCMDavid Effron, Gen SurgElliot Haut, Gen SurgCarol Heiser, ACCMEugenia Heitmiller, ACCMPeter Hill, EDThomas Kirsch, EDChristina Lundquist, ACCMLynette Mark, ACCMDavid Tunkel, Peds OHNS
Imaging
Secure airway
Assess C-spine
Schaefer-Fuhrman classification of laryngeal traumau Group 1 Minor endolaryngeal hematomas or lacerations
No detectable fractureu Group 2 Edema, hematoma, minor mucosal disruption without exposed cartilage
Non-displaced fractureVarying degrees of airway compromise
u Group 3 Massive edema, large mucosal lacerations, exposed cartilageDisplaced fracture(s)Vocal cord immobility
u Group 4 Same as group 3 but more severe with:Severe mucosal disruptionDisruption of the anterior commissureUnstable fracture, 2 or more fracture lines
u Group 5 Complete laryngotracheal separation
Ann ORL 1982; J Trauma 1990
Approach to assess need for surgical intervention
u Laryngeal Framework
u Laryngeal Mucosa
u Vibratory Apparatus
u Laryngotracheal junction
Sandhu in Cummings OHNS 2010
Approach to assess need for surgical intervention
u Laryngeal Framework– Stable
No fracturesA single non-displaced fracture
– UnstableA single displaced fracture>1 fracture lineCricoid fracture
– Potentially non-viableFramework comminution with devitalized cartilage fragments
Sandhu in Cummings OHNS 2010
Approach to assess need for surgical intervention
u Laryngeal Framework– Stable
No fracturesA single non-displaced fracture
– UnstableA single displaced fracture>1 fracture lineCricoid fracture
– Potentially non-viableFramework comminution with devitalized cartilage fragments
Sandhu in Cummings OHNS 2010
Approach to assess need for surgical intervention
u Laryngeal Mucosa– Intact / Minimally injured
No mucosal injuries; Small submucosal hematomaLinear laceration with no exposed cartilage
– InjuredJagged / multiple linear lacerations Exposed cartilageLarge hematoma(s)
– Massively injured
Devitalized and/or significant loss of mucosa
Sandhu in Cummings OHNS 2010
16 yo female with history of fall
Neck tenderness and subcutaneous emphysema
Sandhu in Cummings OHNS 2010
Concomitant injuries with laryngeal trauma
Injury (%)u Open Neck Injury 18u Maxillofacial Fractures 18u Intracranial Injuries 17u Cervical Spine Fracture 13u Chest Injury 13u Other Facial Injury 10u Skull Fracture 7u Open Pharyngeal Injury 4
Jewett, Arch Otol-HNS 1999
Management
u Acute trauma
Approach to assess need for surgical intervention
u Vibratory Apparatus– Intact– Injured
Anterior commissureVibrating edge of the vocal cord(s)Arytenoid dislocation
Sandhu in Cummings OHNS 2010
47 yo female
Touring racing stalls in Dubai
Horse bite to the neck
Tracheotomy performed urgentlyNo definitive repair
Approach to assess need for surgical intervention
u Laryngotracheal junction– Intact– Any degree of laryngotracheal separation
Sandhu in Cummings OHNS 2010
Management – penetrating trauma
u External– Penetrating
» Stab wound
» Emergent cricothyrotomy» Projectile
u Bullet– Low velocity– High velocity
Tracheotomy/cricothyrotomy - acute
u Hemorrhageu Decannulation or tube obstructionu False passageu Laceration of laryngeal framework
Cricothyroidotomy
laryngeal trauma
“Slash”Cricothyroidotomy
necessitates earlyearly endoscopic evaluation and repair
Voice outcome following laryngeal trauma
u Results from SchaeferGroup Voice outcome Airway outcome
Good Fair Poor Good Fair Poor1 20 0 0 20 0 02 38 3 0 40 1 03 18 3 0 21 0 04 22 10 0 31 0 2
u Results from Luutilainen et al2 12 4 0 16 0 03 7 6 0 13 0 04 1 3 0 4 0 0
Cummings OHNS 2010
Mechanisms of trauma
u Internal– Foreign body– Iatrogenic
» Endoscopic» Intubation» Radiation therapy
– Thermal» Ingestion, inhalation
– Caustic» Acid vs. Alkali
Intubation Injuries - delayed
u Granulomau Chondritisu Laryngeal stenosis
– glottic, subglotticu Tracheal stenosis
Mechanisms of Trauma
u Internal– Foreign body– Iatrogenic
» Endoscopic» Intubation» Radiation therapy
– Thermal» Ingestion, inhalation
– Caustic» Acid vs. Alkali
Prolonged intubationdefined by hours
-Weymuller
Mechanisms of Trauma
u Internal– Foreign body– Iatrogenic
» Endoscopic» Intubation» Radiation therapy
– Thermal» Ingestion, inhalation
– Caustic» Acid vs. Alkali
Electro-cautery inducedfire during tracheotomy
Acute
1 week
Management
u Sequelae
Long term sequelae
u Vocal fold motion impairment– Paralysis– Dislocation– Joint fixation
u Stenosis
Post op examPre op exam
Posterior cricoid split & rib graft
23 yo female with poly traumasecondary to MVA
Tracheotomy in the field
Unable to decannulate
Multiple endoscopic procedures
Intubation Injuries - Contributing factors
u Technique– visualization vs. blind, laryngeal blade
u ETT– size, duration, material
u Vent pressure, ETT fixation
Intubation Injuries - Contributing factors
u Patient activity - motionu Unconscious patientu NG tube, GERu Obesity, DM, nutritional status...
Intubation Injuries - Prevention
u Preop laryngoscopy?u Smallest tube, shortest durationu Anti-reflux regimenu Avoid rigid NGT
Intubation Injuries - Prevention
u Monitor vent/cuff pressuresu Early trach in high risk patientsu Endoscopic assessment
– steroid injection may be beneficial
Key Points
u Laryngeal trauma is rare although life threateningu Multiple etiologies: blunt, penetrating, intubation
caustic, thermal, radiation u Evaluation and Airway managementu Timing/sequence of interventionu Sequelae
Trach stenosis due to chronic intubation
Intubation Injuries - delayed
u Tracheomalaciau TE fistulau Intranasal synechiau Sinusitis
Intubation Injuries - acute
u Dental injuryu Soft tissue trauma
– nasal, oral, pharyngeal, hypopharyngealu Vocal fold contusion, lacerationu Vocal fold motion impairment
70 yo maleintubated 7 days S/P CABGwith NGT
Mechanisms of Trauma
u ExternalBlunt
» Hanging» Clothesline injury» Sports Injury» Motor Vehicle Accident
u Internal
Penetrating» Stab wound» Emergent cricothyrotomy» Projectile
BulletLow velocityHigh velocity
Management
u ExternalBluntPenetrating