laryngeal trauma 20080722
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Laryngeal TraumaLaryngeal Trauma
R3
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EpidemiologyEpidemiology
Incidence: 1 in every 30,000 ER visits
8/100,000/year
Laryngeal injuries in 30 to 70 % in penetrating
neck trauma (especially zone II)
Overview
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AnatomyAnatomy
Support: hyoid, thyroid, cricoid
the only complete ring around the airway andloss of this ring almost invariably leads tostenosis
Protection of the larynx
Superiorly by the mandible
Inferiorly by the sternumLaterally by the SCM muscle
Posteriorly by the cervical spine
Overview
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Laryngeal fracture is an uncommon injury
presenting acutely to the otolaryngologist. the injury is uncommon due to protection of the larynx
superiorly by the mandible (particularly when the head isflexed),
inferiorly by the sternum and laterally by theSCM muscle
frequently associated with multiple other life-threatening injuries, associated loss of airway and
immediate death at the accident scene may ensuewhen such patients arrive in casualty they are often
acutely managed by a trauma team.
Overview
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Blunt InjuryBlunt Injury
Most Common Cause
Direct blows/rupture/ shear force
MVA
Declining with seat belts, airbagsSteering wheel (Dashboard)
Sports
Cycling, motorcycle racing, ice hockey, martial arts
Assault
Suicide
Classification
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Blunt InjuryBlunt Injury
Clothesline
All-terrainvehicle/Snow Mobile vsTree Branch
Large energy to small
areaMassive trauma,
frequently instantdeath/ asphyxiation
Crushed LarynxTracheal Separation
Bilateral RLN injury
Strangulation
Low velocity Initial hoarseness and
skin abrasion
Hyoid fracture = classic
injury Subsequent edema/loss
of airway
Classification
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Penetrating InjuryPenetrating Injury Gunshot Wound
range and velocity
Knife/slash Wound Cleaner, less peripheral damage
Be vigilant for injuries away fromobvious effected area
Classification
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Inhalation/Inhalation/ IngestionIngestion
Inhalation
Hot air/Smoke/Steam Initial erythema and
carbon sputum
Followed by markededema
Early airway controlprior to fluid
resuscitation
Ingestion
Mucosal Burns Pediatric: household
items
Adult: lye orhydrocarbons
Direct damage whileingesting or
regurgitationAlkali generally worse
than acid
Classification
Glottic reflex limits injury to supraglottis
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IatrogenicIatrogenic Intubation
Larynx/Pharynx laceration or abrasion Arytenoid dislocation
Neuropraxia of lingual, hypoglossal, SLN or RLN
Prolonged Intubation
Generally change to tracheotomy in 7-10 days (earlier withinhalation injury)
Tracheotomy Cricoid/RLN injury
Classification
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Traumatic Emergencies InvolvingTraumatic Emergencies Involving
the Pediatric Airwaythe Pediatric AirwayDavid L. Mandell, MDDavid L. Mandell, MD Classification
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Pediatric PatientPediatric Patient
Pediatric Considerations
Larynx more superior (C4 vs C7) = more mandibleprotectionGenerally more soft tissue and less cartilage damage
Looser soft tissue
Less fibrous supportMore elastic cartilage
Tend to underestimate severity b/c lack of fxs
Circumferential area less = vulnerable to submucosalchanges = More often life-threatening
Rigid bronchoscopy followed by tracheotomyover the bronchoscope
Classification
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Symptom & SignSymptom & Sign Hemoptysis
Voice changes, hoarseness Difficulty in swallowing
Neck pain
Air-bubble from neck wound Deformity of thyroid cartilage
Investigation
HematomaSubcutaneous emphysema
Bruising, Abrasion
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Stable ConditionStable Condition
cervical CT (with a CT angiography protocol)
Laryngoscopy
Flexible bronchoscopy
Esophagoscopy
Investigation
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Investigation
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DilemmasDilemmas Investigation
management dilemmas in laryngeal trauma
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GroupGroup
Massive edema, hematoma, deepmucosal tears, exposed cartilage,
displaced fractures, unilateral TVCimmobility
Severe airwaycompromise, stridor
SevereIII
Same as III with arytenoid dislocation,comminuted fractures, bilateral TVCimmobility
Impending airwayobstructionProfoundIV
Laryngotracheal separation, skeletalcollapse
Complete airwayobstruction
CriticalV
Obstructing hematoma, edema, minormucosal laceration, nondisplaced
fracture
Compromised airway,hemoptysis
ModerateII
Minor hematoma, small laceration, nofracture, minimal to no airway
compromise
Mild Voice change,dyspnea, cough
MildI
SignsSymptomsDegreeGroup
Investigation
well validated prospectively with regard to outcome?
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Airway ControlAirway Control the choice of airway control should be based on the
patients presentation.
nondisplaced laryngeal injury only close monitoring, a destroyed larynx immediate tracheostomy.
Intubation Consider if mucosa intact or minimal displaced fxs O/W risk of more injury, and tube in the way
Cricothyrotomy associated facial injuries, signs of substantial neck trauma, or a
destroyed larynx,
Tracheostomy For children or adults endotracheal intubation is not an option
Awake in OR
Pediatric Consider bronchoscope intubation then tracheotomy
Management
Upper Airway Injury and Its Management
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Airway ControlAirway Control
LMA should not be used
effectiveness is decreased when the anatomy isdistorted, and they may worsen the injury.
neuromuscular blockade should beavoided until the airway is secure.
If the patient is awake and ventilating (even
with a compromised airway),
Upper Airway Injury and Its Management
Management
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Airway ControlAirway Control
The disadvantages of orotracheal intubation
the need for extension of the neck for advanced airway management skills in the use of a
flexible bronchoscope or fiberoptic wand.
If the use of neuromuscular blockers is deemednecessary, a surgical airway may be preferable.
Upper Airway Injury and Its Management
Management
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Management
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Surgical Exploration/RepairSurgical Exploration/Repair Aim
Airway patency
External anatomy restoration Internal functional anatomy
Neck exploration Midline thyrotomy for endolaryngeal injury
Hemostasis, remove clot or debridement Meticulous repair of lacerations
Cover cartilage
Reduce fxs wire or plate Relocate arytenoids Flaps for tissue loss
Management
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Reduction of FracturesReduction of Fractures
Wire/Suture
PlatingMiniplates vs. absorbable
Offers immediate rigid fixation
Well tolerated in situ Better strength in animal studies
Management
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Management
plate
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Soft Tissue RepairSoft Tissue Repair
Repair mucosa/vocal cords with absorbable
5.0/6.0Resuspend vocal cords with 4.0 absorbable to
external perichondrium of thyroid cartilage
Cover cartilage
Grafts if needed (mucosa, STSG)
Disrupt mucosa and expose cartilage lead togranulation tissue
Management
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StentsStentsDenuded ant commissure, poor architecture
Prevents webbing, supports frameworkSoft, shape of larynx
Secured by skin buttons
Removed 10-14 days O/W granulation
Management
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StentsStentsTypes of stents
Endotracheal tube (COVER THE TOP END TO PREVENT ASPIRATION) Finger cots filled with gauze or foam
Polymeric silicone stents
Secure the stentsHeavy, nonabsorbable suture
Larynx at the ventricle
Cricothyroid membraneTied outside the skin
Endoscopically removed
Management
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PediatricPediatric Management
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Post operationPost operation
Antibiotics
Anti-reflux
Elevate Head
Tracheotomy CareStent removal
Decannulate
Management
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Aspiration/Dysphagia/Odynophagia
Dysphonia, Vocal Fold immobilityWait 6-12 months before intervention if RLNFistulaUnable to decannulateGranulation Tissue/ObstructionPre-op delayed diagnosisPost-op
Subglottic stenosisDilation, ExcisionCricoid split, Resection
Complication
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RLN Injury
Attempt primary repair, but only expect tone
Tracheal separation
Reapproximate cartilages
Severe trauma
Consider partial/total laryngectomy
Management
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Mortality 10-30%
Higher Risk inBlunt Trauma (63%)
Need for emergency airway
Higher risk of poor voice/airway fromblunt trauma
Prognosis
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Classification
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Management
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Management
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Pediatric PatientPediatric Patient Classification
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Classification
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ATLS principles
Intubation hazardous Schaefer in 1991- worsen preexisting injury Further tears or cricotracheal separation
Respiratory distress
Tracheotomy under local anesthesiaAvoid cricothyroidotomiesWorsen injury
If no acute breathing difficulties Detailed history and careful physical examination
Classification
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ReferenceReferenceUpper Airway Injury and Its Management,
Thoracic and cardiovascular surgery, 2008,pp.8~12
Management dilemmas in laryngeal trauma, The
Journal of Laryngology & Otology. May 2004,Vol. 118, pp. 325328
Traumatic Emergencies Involving the Pediatric
Airway, David L. Mandell, MD. Clin Ped EmerMedDec 2004, pp. 41-48
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Thank youThank you
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