Laryngeal Trauma

Jean Paul Font, MD

Faculty Advisor: Francis B. Quinn, Jr., MD

Grand Rounds Presentation

Department of Otolaryngology

The University of Texas Medical Branch at Galveston

March 28, 2007

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.

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

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

Anatomy

Supraglottis

– External support

– Soft tissue attachments

Glottis

– Relies on external support

– Narrowest in the adult

– Susceptible to obstruction

Subglottis – Cricoid-narrowest in infants

Laryngeal Function

Function

– Breathing passage

– Airway protection

– Clearance of

secretions

– Vocalization

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

Verschueren et al. Management of Laryngo-Tracheal Injuries.

J Oral Maxillofac Surg 2006.

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!

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

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

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

– Don’t probe open wounds

May dislodge a hematoma

Diagnosis

Unstable – Tracheotomy and neck

exploration

Stable patients – Flexible fiberoptic

laryngoscopy in the ER

CT scan, direct laryngoscopy, bronchoscopy and esophagosopy

Ct Scan

CT allows:

– Evaluation of the

laryngeal skeletal

framework

– Noninvasive

avoiding

unnecessary

operative

explorations

SQ emphysema

Hematoma

Fracture

Anterior Lamina

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.

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.

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

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

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

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

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.

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)

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.

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.

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

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

Any questions ?

References

Schaefer, S.D. Use of CT Scanning in the management of the acutely injured larynx. Otolaryng Clinics NA. Vol 24(1): 31-36. February 1991.

Perdiki, G. Blunt Laryngeal Fracture: Another Airbag Injury The Journal of Trauma: Injury, Infection, and Critical Care. Vol. 48, No. 3. p544-546. 2000

Hwang, S. Y. Management dilemmas in laryngeal trauma

The Journal of Laryngology & Otology., Vol. 118, pp. 325–328. May 2004

Verschueren,D. S. Management of Laryngo-Tracheal Injuries Associated With

Craniomaxillofacial Trauma. American Association of Oral and Maxillofacial Surgeons. P203-214. 2006

Ford, H. Laryngotracheal Disruption From Blunt Pediatric Neck Injuries: Impact of Early Recognition and Intervention on Outcome. Journal of Pediatric Surgery, Vo130, No 2: pp 331-335. (February), 1995

Goudy, S. L. Neck Crepitance: Evaluation and Management of Suspected Upper

Aerodigestive Tract Injury. Laryngoscope 112. p791-795: May 2002

O’Mara, W and Hebert, F. External laryngeal trauma. J La State Med Soc. Vol 152(5): 218-222. May 2000.

Schaefer, S.D. The treatment of acute external laryngeal injuries. Arch Otolaryng HNS. Vol 117: 35-39. January 1991

Cummings: laryngeal Injury. Otolaryngology: Head & Neck Surgery, 4th ed. Mosby, Inc, 2005. 4223-4238

Fuhrman, G.M., Stieg, F.H., and Buerk, C.A. Blunt laryngeal trauma: Classification and management protocol. J Trauma. Vol 30(1): 87-92. January 1990

Ghorayeb BY, Shikhani AH. The use of dexamethasone inpediatric bronchoscopy. J Laryngol Otol 1985;99:1127–9