management of laryngeal trauma

Management of LaryngealTrauma
Nadir Elias, DMDa, James Thomas, MDb, Allen Cheng, MD, DDSc,*
KEYWORDS

� Laryngeal trauma � Laryngotracheal injury � Laryngofissure

KEY POINTS

� The key step in treatment of any laryngeal injury is the establishment of a secure airway.

� Early intervention (within 24–48 hours) is an important factor for improved patient outcomes (func-tional speech, swallowing, and airway patency).

� An awake tracheostomy is the airway of choice with grade II or higher laryngeal injuries.

INTRODUCTION Whereas blunt injuries have been described as be-

The larynx is a complex anatomic structure and aproperly functioning larynx is essential for breath-ing, voice, and swallowing. Injuries to the larynxand trachea can result in significant and potentiallyfatal consequences. Laryngeal trauma is oftenassociated with other injuries, including intracra-nial injuries (17%), penetrating neck injuries(18%), cervical spine fractures (13%), and facialfractures (9%).1 Laryngeal injuries are rare, occur-ring in only 1 of 5000 to 137,000 emergency roomvisits1–3 and among only 1 in 445 patients with se-vere injuries.4 Because of this, even surgeons witha great deal of experience in managing maxillofa-cial trauma have limited exposure to managementof laryngeal and tracheal injury. This article dis-cusses the evaluation, diagnosis, and manage-ment of patients with laryngeal and tracheal injury.

nics.com

CLASSIFICATION OF LARYNGEAL INJURIES

Several classification systems have beendescribed to assist in developing an algorithmicapproach to managing these difficult and rare in-juries. These classification systems have beenbased on mode of injury, types of tissues involvedin the injury, anatomic locations of injury, andseverity of the injury. Modes of injury have beendivided into blunt and penetrating injuries.

a Advanced Craniomaxillofacial and Trauma Surgery, LStreet, Suite 300, Portland, OR 97209, USA; b Private PracOR 97209, USA; c Oral/Head and Neck Oncology, Legacy* Corresponding author. 1849 Northwest Kearney, SuiteE-mail address: [email protected]

Oral Maxillofacial Surg Clin N Am 33 (2021) 417–427https://doi.org/10.1016/j.coms.2021.04.0071042-3699/21/� 2021 Elsevier Inc. All rights reserved.

Descargado para BINASSS Circulaci ([email protected]) en National L2021. Para uso personal exclusivamente. No se permiten otros usos sin au

ing associated with greater length of hospitaliza-tion,5 our experience has been that penetratingairway injuries, often associated with ballisticwounds, are much more likely to be associatedwith greater endolaryngeal disruption. The typesof tissues involved have been divided into hardand soft tissue injuries. Locations of injuries havebeen classified as injuries that affect the supraglot-tic larynx, the glottis, and subglottic larynx.

Lynch5 was the first to classify traumatic injuriesbased on location. In 1969, Nahum6 describedlaryngeal injuries based on injury location and likeli-hood of recovery with and without intervention. In1980, Schaefer and colleagues developed whathas become the most popular classification systemto assess the severity of such injuries.7 This classi-fication describes laryngeal injuries on a scale ofI-IV. Schaefer’s classification was later modifiedby Fuhrman and colleagues8 to include laryngotra-cheal separation (Table 1) and again by Verschue-ren and colleagues4 in 2006 to include the use ofcomputed tomography (CT) imaging in staging (Ta-ble 2). In this article, the discussion of the initialevaluation and management of a patient with laryn-geal trauma is within the framework of the LegacyEmanuel Classification, as outlined by the algorithmin Fig. 1. However, the principles are generalizableand can be applied to whichever system the readerfinds most helpful in their practice.

egacy Emanuel Medical Center, 1849 NW Kearneytice, Voicedoctor.net, 909 NW 18th Avenue, Portland,Good Samaritan Cancer Center, Portland, OR, USA300, Portland, OR 97209.

oralmaxsurgery.thecli

ibrary of Health and Social Security de ClinicalKey.es por Elsevier en julio 15, torización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.

mailto:[email protected]

http://crossmark.crossref.org/dialog/?doi=10.1016/j.coms.2021.04.007&domain=pdf

https://doi.org/10.1016/j.coms.2021.04.007

http://oralmaxsurgery.theclinics.com

Table 1Fuhrman-Schaefer classification of laryngeal injuries

Stage Injury

I Minor laryngeal hematoma, edema, laceration; nodetectable fracture

II Edema, hematoma, mucosal disruption with noexposed cartilage, nondisplaced fractures

III Significant edema, noted mucosal disruption, exposedcartilage with or without cord immobility, displacedfractures

IV Significant edema, noted mucosal disruption, exposedcartilage with or without cord immobility, displacedfractures with 2 or more fracture lines, skeletalinstability/anterior commissure trauma

V Complete laryngotracheal separation

Elias et al418

Descar20

INITIAL EVALUATION AND INITIALMANAGEMENT

The initial evaluation of a patient suspected of hav-ing laryngeal or tracheal injury, as with any trauma,

Table 2Legacy Emanuel Medical Center laryngeal injury clas

Stage Diagnostic Findings

I Minor airway symptoms� Voice changesNo fracturesSmall lacerations

II Airway compromiseNondisplaced fracturesNo cartilage exposureVoice changes� Subcutaneous emphysema

III Airway compromiseEdemaMucosal lacerationsPalpable laryngeal fracturesExposed cartilageSubcutaneous emphysemasVoice changes

IV Airway compromiseMucosal lacerationsExposed cartilagePalpable displaced laryngealfractures with skeletalinstability

Subcutaneous emphysemasVoice changes

Abbreviation: ORIF, open reduction internal fixation.Adapted from Verschueren DS, Bell RB, Bagheri SC, Dierks EJ

ciated with craniomaxillofacial trauma. J Oral Maxillofac Surg

gado para BINASSS Circulaci ([email protected]) en National Library o21. Para uso personal exclusivamente. No se permiten otros usos sin autorizac

begins with the primary survey as outlined inAdvanced Trauma Life Support algorithms.Because the larynx and trachea are critical com-ponents of the airway, prompt identification andmanagement of these injuries are prioritized. This

sification

Management

ObservationHumidified airHead of bed elevation

Immediate awaketracheostomy if airway notalready secured in the field

Humidified airHead of bed elevation� ORIF


Direct laryngoscopyExploration and ORIF


Direct laryngoscopyExploration/ORIFConsider stenting

, Potter BE. Management of laryngo-tracheal injuries asso-. 2006 Feb;64(2):203-14; with permission.

f Health and Social Security de ClinicalKey.es por Elsevier en julio 15, ión. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.

Fig. 1. Protocol for management of laryngotracheal injuries at Legacy Emanuel Hospital and Health Center inPortland, Oregon. ORIF, open reduction internal fixation. (From Verschueren DS, Bell RB, Bagheri SC, Dierks EJ,Potter BE. Management of laryngo-tracheal injuries associated with craniomaxillofacial trauma. J Oral MaxillofacSurg. 2006 Feb;64(2):203-14; with permission.)

Management of Laryngeal Trauma 419

begins with a quick survey of the injuries. Patientswith either blunt or penetrating injury to the neckmust be ruled out as having airway injury. Themechanism of the injury should also raise one’ssuspicion. In a review of laryngeal injuries from1992 to 2004, high speed motor vehicle accidentswere the most common mechanism (49%), fol-lowed by sports-related injuries (29%).4 Certainmechanisms of injury, such as hanging, gunshotwounds, or work-related high-energy injuries tothe neck, should obviously generate an elevatedlevel of suspicion.

Stable Versus Unstable Airway

The first essential question is to establish whetherthe airway is secured and whether the patient isstable. If the patient is stable and protecting theirairway, there is time for a more deliberate exami-nation. This is important because occult trachea-laryngeal disturbance can occur with minimalexternal signs of trauma.

The initial airway physical examination startswith visual inspection for swelling, soft tissue injuryoverlying the airway, loss of anatomic landmarks inthe neck, and signs of troubled breathing. Acursory examination of the patient’s voice is per-formed, noting the presence or absence of stridorand/or dysphonia. Next, use gentle palpation toassess for subcutaneous emphysema andpalpable disruption of the hyoid bone, thyroidcartilage, cricoid, and trachea. The most commonfindings on physical examination include subcu-taneous air, hoarseness, tenderness of the anteriorneck to palpation, and stridor.9

A fiberoptic examinationmay also beperformed iftiming allows and other injuries do not take


precedence. The fiberoptic examination may helpto verify that the patient’s airway is stable enoughfor transfer to the scanner. An awake fiberoptic ex-amination also has the benefit of allowing visualiza-tion of the larynx in function. This examination ismeant to be performed quickly and efficiently soas to not impede overall trauma management. Theevaluating surgeon must keep in mind that trauma-tized airways that appear stable tend to deteriorateover timebecauseof theonset of edema, expansionof hematomas, and other contributory factors.

The next step is a CT scan of the head and neck,which is done in addition to CT scans of chest,abdomen, and pelvis that are routinely performedas part of the trauma survey (Fig. 2). In stable pa-tients with penetrating neck injury, a CT angiogramis also included to evaluate for vascular injury. CTimaging allows for rapid and accurate identifica-tion of hard tissue injuries to larynx and tracheaand identification of soft tissue air emphysema.10

If the airway is not secure and/or is unstable,or the patient is unstable for other reasons, thepatient is taken emergently to the operatingroom where securing the airway followed by sta-bilization of the patient is the immediate priority.Traditionally, this is via an oral endotracheal intu-bation. However, if the patient has a knownlaryngeal or tracheal injury, oral endotrachealintubation can fail, particularly because of falsepassage or further disruption of the injuredairway. Although securing the airway trumpsany other priority, in this situation the most idealairway is a tracheostomy, performed awake witheither mask or laryngeal mask airway support, asthe situation allows. If endotracheal intubation isthe route chosen, a fiberoptic intubation with apediatric bronchoscope is one of several tools


Fig. 2. Axial CT neck images of a 64-year-old male victim of a motorcycleaccident with severe multisystemtrauma. Injuries included (A) hyoidbone fracture, (B) a thyroid cartilagefracture, and (C) and cricoid cartilagefracture. (D) Three-dimensionalreconstruction of the CT demon-strating the previously mentionedfractures.

Elias et al420

Descar20

to be considered by the anesthesiologist. In thepresence of endolaryngeal lacerations, the pri-mary risk is that of intubating a blind submuco-perichondrial pouch that produces immediateand total airway obstruction. The stat surgicalairway that follows not only risks the patient’slife but can also worsen the existing laryngotra-cheal injuries.Once the airway is secured and the patient is

stable, the next step in the evaluation involvesphysical examination, CT imaging (if not alreadyperformed), and panendoscopy. Anatomically,the larynx is subdivided into the supraglottic lar-ynx, glottic larynx, and subglottic larynx, and tra-chea. Injury can occur at any and all of theselevels. Therefore, the examination is performed insuch manner where each of these areas are care-fully inspected. It is important to remember that,particularly with blunt trauma, disruption of thelaryngeal framework can occur without obviousexternal findings. For example, disruption of thecricoarytenoid joint and shortening of the truevocal cord can occur with blunt trauma and man-ifest itself with vocal changes, without externalsigns of injury. If left untreated, the dislocatedarytenoid may scar in that position resulting in per-manent, more difficult to correct vocal distur-bance. It is widely agreed on that earlyidentification and treatment of laryngeal injuriesyields superior results, ideally within the first 24to 48 hours if circumstances allow.


Nondisplaced Versus Displaced CartilageFractures

The CT scan answers an essential branch point inour management algorithm, which is whether ornot there are displaced fractures of the cartilagi-nous larynx. The CT scan is especially valuablebecause it can detect occult fractures missed onexamination.11

Patients without cartilage fractures or with non-displaced cartilage fractures are managed in amore conservative manner. Patients with nondis-placed cartilage fractures are carefully assessedfor vocal disturbances. Signs of voice changesshould prompt a fiberoptic nasopharyngoscopyto assess for endolaryngeal injury. If the patienthas already been intubated or has a tracheostomy,a direct laryngoscopy under anesthesia is per-formed instead. While under anesthesia, a bron-choscopy and esophagoscopy are alsoperformed to assess the full extent of injury.If no signs of endolaryngeal injury are observed,

the patient is observed and receives supportivecare. If the laryngeal examination demonstratesmucosal injury, consideration should be given tosurgical repair versus serial endoscopic examina-tion. Mucosal lacerations are repaired primarilythrough a thyrotomy (laryngofissure) approach, orin some cases, endoscopically. Denuded laryn-geal cartilage that is not amenable to primaryclosure is treated with a thyrotomy approach



coupled with use of a laryngeal stent or laryngealkeel.12

If the CT scan identifies displaced cartilagefractures, these are treated with open reductionand internal fixation. Before this, many such pa-tients benefit from having the airway securedwith an awake tracheostomy. This avoids theneed for endotracheal intubation, which is chal-lenging and further disrupts the displaced carti-lage fractures. Once the airway is secured,direct laryngoscopy is performed to assess forendolaryngeal injury, as discussed previously.Consideration is given to including esophago-scopy and/or bronchoscopy. If there are no signsof endolaryngeal injury, the surgeon may proceedwith open reduction and internal fixation of thedisplaced cartilage segments. If there are signsof significant endolaryngeal injury, repair themvia laryngofissure approach followed by openreduction internal fixation of the cartilagefractures.

ANATOMIC CONSIDERATIONSEpiglottis

The epiglottis, as the superior extent of the supra-glottic larynx, connected by ligaments to the hyoidbone and thyroid cartilage, is significantly affectedby laryngeal trauma. Hyoid fractures can result inan epiglottic hematoma (Fig. 3). An epiglottic

Fig. 3. Illustration of an epiglottic hematoma, whichmay result from hyoid or thyroid fracture. Note thatas the hematoma expands, the airway is at risk for crit-ical obstruction. (From Bell RB, Verschueren DS, DierksEJ. Management of laryngeal trauma. Oral MaxillofacSurg Clin North Am. 2008 Aug;20(3):415-30; withpermission.)


hematoma quickly results in stridor, difficulty withspeech, and eventually dyspnea and potentialairway embarrassment. Partial or complete avul-sion of the epiglottis can also occur with severehyoid and thyroid fractures. This manifests asdysphagia and aspiration.

Hyoid Bone Fractures

Hyoid bone fractures are a result of high-energyimpact and, in our Legacy Emanuel series, wereoften seen in sporting injuries, such as baseball,jet skiing, and martial arts.4 Such injuries arealso seen in suicidal hanging and in attemptedmanual strangulation. Most hyoid fractures donot require surgical intervention. However, theyare usually accompanied by temporary odyno-phagia. Significantly displaced hyoid fracturesare managed by either open reduction and inter-nal fixation of the hyoid bone or partial hyoidresection.

Distortion of the Glottis

Injury to the larynx can result in changes in theanterior-posterior dimension of the vocal cords,the positioning of the vocal cords relative to eachother, the mobility of the cords, and soft tissueinjury of the cords. Any of these distortions canresult in voice changes. Voice changes of volumeloss and pitch lowering indicate shortening of thevocal cords. Voice changes of roughness indicateasymmetry of the vocal cords, such as a unilateralchange in length or asymmetric swelling.

Displaced fractures of the thyroid cartilageinvolving the anterior commissure and/or aryte-noid dislocation can result in foreshortening ofthe vocal cords. This is identified on endoscopicexamination, confirmed on CT scan, and is astrong indication for open reduction internal fixa-tion (Fig. 4).

Mucosal injury involving the vocal cords that re-mains unrepaired will heal by secondary intention,but such healing can result in synechiae betweenopposing vocal cords and at the anterior commis-sure. Careful inspection for such injuries is essen-tial and their presence is an indication for repair.

Cricoid Injury and Cricotracheal/Laryngotracheal Separation

Injury of the subglottic larynx can result in cricoidfractures and/or cricotracheal separation, both ofwhich result in devastating airway obstructionthat is difficult to rescue in the field because thesegenerally require an emergent tracheostomy. Pa-tients who are able to be stabilized are often foundto have recurrent laryngeal nerve injury.


Fig. 4. Fracture of the thyroid cartilage may result inedema, shortening, and possible avulsion of the vocalcords resulting in significant voice changes. (From BellRB, Verschueren DS, Dierks EJ. Management of laryn-geal trauma. Oral Maxillofac Surg Clin North Am.2008 Aug;20(3):415-30; with permission.)

Fig. 5. Complete laryngotracheal separation withtracheal retraction may result in profound airwaycompromise and death if not treated with immediateairway stabilization in the form a tracheostomy. (FromBell RB, Verschueren DS, Dierks EJ. Management oflaryngeal trauma. Oral Maxillofac Surg Clin NorthAm. 2008 Aug;20(3):415-30; with permission.)

Elias et al422

Descar20

If the larynx or cricoid becomes separated fromthe trachea, the trachea tends to retract inferiorlytoward the mediastinum (Fig. 5). Reconstructionrequires limited circumferential dissection of thetrachea to allow placement of bolstering suturesfor tension-free approximation of the dividedairway.

OPERATIVE TECHNIQUEEndoscopy

It is beyond the scope of this article to discuss thenuances of performing endoscopic examination ofthe upper aerodigestive tract. However, we willdiscuss some pearls related to these techniques.Flexible nasopharyngoscopy is an efficient,

widely available (found on most hospital airwaycarts), and effective way to examine the airway inan awake or sedated patient. Performing this onan awake patient affords the benefit of beingable to visualize the larynx in function, specificallythe presence of absence of vocal cord motion. Theeffective performance of this examination in anawake trauma patient is uniquely challenging.Blood and swelling in the airway or difficulty withtopical anesthesia in an agitated patient canmake good visualization impossible.In these cases, performance of an endoscopic

examination in an anesthetized patient after theairway has been secured is the other option.


This is ideally performed directly using a laryngo-scope, because this can address the collapse ofthe potential space that occurs when a patientis in a supine position. However, many trauma pa-tients with airway injury are at risk of cervicalspine injury and remain on cervical spine precau-tions that limit neck extension. This difficulty iscompounded among patients with classic intuba-tion challenges, such as anterior airways andmandibular hypoplasia. In such instances, werevert back to fiberoptic examination assistedby a videolaryngoscope. A videolaryngoscope isintroduced in the traditional fashion, with the tipof the blade placed within the vallecula. This sus-pends the base of tongue and mandible anteri-orly, opening the potential space in theoropharynx, which allows the fiberoptic scopeto be more useful.Examination of the trachea is performed with

either a flexible or rigid bronchoscope. In the traumasetting, the flexible bronchoscope is the simplest touse, does not require neck extension, and allowscreation of video documentation of the injuries.Examination of the cervical and thoracic esoph-

agus is performed either with a rigid or flexibleesophagoscopy. Rigid esophagoscopy is thoughtto be more sensitive than flexible esophagoscopyin identifying injuries.13 It also does not require



insufflation to create a potential space for visuali-zation, which runs the risk of causing soft tissueair emphysema in the mediastinum and neck.However, as with laryngoscopy, it is difficult toperform on patients in a cervical collar and thosewith anatomic limitations. Also, a rigid esophago-scope also runs the risk of further disrupting aninjured larynx.

Fig. 6. Retraction of the strap musculature to allowfor visualization of the cartilaginous injuries. (FromBell RB, Verschueren DS, Dierks EJ. Management oflaryngeal trauma. Oral Maxillofac Surg Clin NorthAm. 2008 Aug;20(3):415-30; with permission.)

Tracheostomy

The tracheostomy is a routine procedure that is avaluable part of the armamentarium of any sur-geon active in trauma. There are also as manyways to perform the procedure as there are sur-geons performing it. As such, we focus this discus-sion not on how to perform a tracheostomy, butmodifications for performing a tracheostomy in apatient likely to have laryngeal injury.

Tracheostomy in this setting is often performedbefore the patient’s cervical spine has beencleared. As such, maintaining neck immobilizationis paramount. The head is typically stabilized withtape to the bed or operating table while the ante-rior portion of the cervical collar is removed for ac-cess. Additional support to the neck is provided bythe anesthesiologist.

As previously mentioned, it is ideal to perform anawake tracheostomy. This requires a concertedeffort between the anesthesiologist and surgeon.Although the procedure is described as “awake,”it is most optimally performed with some degreeof sedation. This is typically a combination of anamnestic with a general anesthetic at a dose thatmaintains spontaneous respiration. In addition tooxygenation, mask ventilatory support, typicallyby face mask, is essential. Good local anesthesiais of critical importance. We typically deliver fieldblocks to the cervical plexus along the anteriorborder of the sternocleidomastoid muscle oneither side and infiltration from the skin down tothe trachea.

In the absence of useful overlying lacerations, ahorizontal incision is used for the tracheostomy ata level that can be incorporated into an apron inci-sion later for neck exploration, if needed.

Once the trachea is visualized, the tracheotomyshould ideally be placed distal to the injury, usuallybetween the third and fourth tracheal rings.Although a cricothyroidotomy is the most expe-dient in an emergency situation, it does interferewith laryngeal reconstruction and risks limiting cri-cothyroid mobility in the future (limiting uppervocal range and maximal volume). If a cricothyroi-dotomy has been previously performed, the airwayshould be converted to a tracheostomy as soon asit is practical.


Surgical Exposure

If existing lacerations do not provide sufficientexposure, a limited neck exploration may benecessary. A horizontal incision is designed thatis made to incorporate the incision of the tracheos-tomy. The incision is wide enough to explore thelateral neck if necessitated by the nature of theinjury. The skin flaps are developed in a suprafas-cial plane over the strapmusculature. The flaps areelevated superiorly to the level of the hyoid boneand inferiorly to the clavicles.

If broader exposure is necessary, the sternoclei-domastoidmuscles are skeletonizedon themedial/deep sides for access to create an outer tunnel.Blunt and sharp dissection are used medial to thecarotid sheath allowing lateral retraction to createthe inner tunnel. This allows wide access to the lar-ynx, pharynx, and esophagus on either side.

The median raphe is identified and dissection iscarried in this plane through the infrahyoid strapmuscles. The strap muscles are bluntly dissectedand retracted laterally until the thyroid cartilage isvisualized (Fig. 6).

Endolaryngeal repair and reconstruction isaccessed by performing a laryngofissure using amidline thyrotomy, if the exposure has not alreadybeen created by the injury. A horizontal incision ismade through the cricothyroid membrane. Using a12 blade, and under the direct visualization, cutfrom an inferior to superior direction directly be-tween the true vocal cords in the midline. This isimportant, because detachment or further disrup-tion of the vocal cord at the anterior commissure isdifficult to correct.Anoscillating saw isused tocom-plete themidline thyrotomy.The twosidesof the thy-roid cartilage can then be retracted laterally (Fig. 7).


Fig. 7. Midline thyrotomy allows for lateral retrac-tion of the thyroid and cricoid cartilages to allowfor visualization of laryngeal and esophageal struc-tures. (From Bell RB, Verschueren DS, Dierks EJ. Man-agement of laryngeal trauma. Oral Maxillofac SurgClin North Am. 2008 Aug;20(3):415-30; withpermission.)

Elias et al424

Descar20

Alternatively, for surgeons with greater experi-ence, a simpler method involves starting with amidline thyroidotomy. The oscillating saw is usedto make a cut in the midline and the two halvesof the thyroid cartilage are gently pulled to 3 to4 mm apart. Generally, if performed with carethis is executed without violating the mucosa andentering the airway. The vocal processes are visu-ally identified as two white spots. They can bedivided in the midline and remain attached to theirrespective thyroid ala. This obviates an incision inthe cricothyroid area and allows improved airtightclosure.If the airway is inadvertently entered during thyroid

cartilage division, it will nearly always be into thespace between the true and false vocal cords, thethinnest areaofmucosa.Usingan11blade, thevocalligamentsaredivided.Up-angledscissors candividethe false cords if needed for visualization. One canthen leave the inferior mucosa intact for an airtightseal after closure.


If an esophageal injury has been identified, thisshould be repaired before the endolaryngealrepair.

Endolaryngeal Repair

After the laryngofissure is performed, the supra-glottic, glottic, and subglottic larynx is directlyvisualized. Mucosal lacerations, particularly ifthere is exposed cartilage, are repaired primarilywith resorbable sutures, such as 4–0 and 5–0 chro-mic gut. Do not debride lacerated mucosa,because this makes primary closure difficult. Thearytenoids are inspected. If dislocated, theyshould be reduced. The vocal cord attachmentsto the thyroid cartilage are also inspected. If thereis detachment, the vocal cords are resuspendedusing fine nonresorbable suture to the thyroidcartilage at Broyles ligament (Fig. 8).Rarely, there may be avulsion injuries of the mu-

cosa that are not amenable to primary closure.Special consideration is given to these, particularlyif there are opposing injuries on the other side. Thismay result in adhesions that inhibit vocal cordmobility. This is managed using a laryngeal stentor a keel. A laryngeal stent is placed with or withouta skin graft (with the underside of the graft facingoutward) (Fig. 9). The stent is then secured withtwo nonresorbable sutures. The first suture ispassed through skin, thyroid lamina, stent, oppo-site thyroid lamina, and back out through theskin. The second suture is passed through skin,subglottic trachea, stent, opposite wall of the tra-chea, and back out through skin. The two suturesare passed through an external silicone button andtied loosely, on either side. The primary advantageof the stent, beyond preventing synechiae and ad-hesions, is that it provides structural stabilizationof the endolarynx circumferentially. By separatingdenuded areas from each other, it allows forepithelial migration and healing by secondaryintention without adhesions. However, it comesat some risk. The stent itself may cause pressureon the endolaryngeal mucosa, creating raw areasthat may heal as adhesions once the stent isremoved. This may result in stenosis later on.An alternative to a laryngeal stent is the use of a

keel. Similar to a stent, it is a barrier that allows forhealing by secondary to intention while preventingadhesions. In contrast to a stent, it does not pro-vide circumferential support of the larynx. Thisavoids the risk of pressure or rubbing injury tothe endolaryngeal mucosa.The laryngofissure must be meticulously

repaired. Fine nonresorbable sutures are used toreconstruct the anterior commissure. Specialattention is given to lining up these two landmarks


Fig. 8. Resuspension of Broyles ligament to theexternal perichondrium. (From Bell RB, VerschuerenDS, Dierks EJ. Management of laryngeal trauma.Oral Maxillofac Surg Clin North Am. 2008Aug;20(3):415-30; with permission.)


in the same horizontal plane, otherwise the vocalcords do not adduct evenly during function. A su-ture is passed through the thyroid cartilage andanterior commissure on one side, then throughthe anterior commissure and thyroid cartilage onthe opposite side to line these points up correctly.

The thyroid (and cricoid, if necessary) is thenrepaired either with suture, wire, or miniplate fixa-tion (Fig. 10). When using miniplates, be sure tochoose screws that do not penetrate the endolar-yngeal mucosa. Resorbable plates and screwshave also been used for this indication.

Reconstruction of Cricotracheal Separation

For reconstruction of a complete separation of thetrachea from the larynx, the trachea must be suffi-ciently mobilized. Blunt dissection is used anterior

Fig. 9. A laryngeal stent can be secured with suturesthat extend through the skin, thyroid lamina bilater-ally before being tied loosely over skin buttons.(From Bell RB, Verschueren DS, Dierks EJ. Manage-ment of laryngeal trauma. Oral Maxillofac Surg ClinNorth Am. 2008 Aug;20(3):415-30; with permission.)


and posterior to the trachea. This can often bedone carefully with a finger. Avoid excessive lateraldissection, because this may compromise thevascular supply to the skeletonized trachea. Thisdissection should be carried inferiorly into the su-perior mediastinum to allow for sufficient superiortraction.

Nonresorbable sutures, such as 2–0 Prolene, areused to reconstruct. These sutures are passedthrough the cartilage of a tracheal ring at leastone or more rings distal the injury. Superiorly, thesuture needle is then passed through the cricoid.Be sure to avoid passing through the tracheal mu-cosa. These sutures are placed 270� around thetrachea. Once all the sutures are passed, they aretied down one by one, working from lateral to ante-rior (Fig. 11). It is important to keep the patient’shead out of extension, to minimize tension acrossthe closure. As a reminder to the patient, a Grillostitch, a heavy nonresorbable suture passed frommenton to sternum, is placed. This discouragesthe patient from extending his or her neck and putt-ing excess tension across the repaired trachea.

After the repair is complete, the patient can usu-ally be extubated, assuming other indications forremaining intubated are not present. However,keeping the patient intubated may be prudent,depending on the surgeon’s judgment and the pa-tient’s clinical status.

Wound Closure

The skin flaps are closed in layers. Special atten-tion must be given to separation of the tracheos-tomy from the rest of the wound. Deep suturesare placed circumferentially around the tracheos-tomy to seal it off. Suction drains are placed underthe skin flaps to prevent saliva or seroma accumu-lation or a subcutaneous aerocele. Although someauthors advocate for passive drains for fear of pro-motion of fistula formation, we have not found thisto be an issue in our experience.

POSTOPERATIVE CAREEnteral Feeds

The patient is initially fed by a nasogastric feedingtube because temporary dysphagia is common.Enteral feeds are continued until the patient isable to protect their airway. If permitted by other in-juries, a swallow evaluation is initiated by a speechlanguage pathologist as early as the third to fourthpostoperative day. If aspiration is present, enteralfeeds are continued until this is resolved.

If there was an esophageal injury, we typicallypostpone initiation of oral feeding for 2 weeks.Before oral feeding, a modified barium swallowandesophogramareperformed toassess for leaks.


Fig. 10. A 64-year-old male victim whose CT images were presented in Fig. 4. Examination of the neck revealedand large submental laceration and edema and ecchymosis extending down to the sternal notch, which raisedthe suspicion for a laryngeal injury. (A) Clinical appearance after initial stabilization with a tracheostomy. (B) In-traoperative exposure for repair of the laryngeal injuries. (C) Open reduction internal fixation of thyroid andcricoid cartilages.

Elias et al426

Descar20

If leaks are present, enteral feeds are continued foran additional 2 weeks and the study is repeated.

COMPLICATIONS

Several perioperative complications canoccurwithlaryngotracheal injuries including voice changes;bleeding; infection; fistula formation; and, mostseriously, loss of airway. However, probably themost substantial and common long-term issue isstenosis of the airway. This can occur in the pres-ence of mucosal injuries that results in adhesions


or wound contracture. Circumferential injuries areat the greatest risk. Despite careful mucosal repairand use of stents, stenosis can still occur. This is achronic and difficult to manage problem. Even witha patent airway, a stenotic airway can result in stri-dor, dyspnea on mild exertion, constant shortnessof breath, and intractable fatigue. Such patientsoften undergo tracheostomy and subsequentlyseek tracheal “sleeve” resection.Initial management of airway stenosis starts with

a careful endoscopic examination to identify the

Fig. 11. Patient suffered a work-related injury where a chain saw re-bounded off a metal pipe resultingin a penetrating anterior neck injurythat led to near complete cricotra-cheal separation. An emergency med-ical technician in the field visualizedbubbles from his neck wound andwas able to intubate his tracheadirectly and secure his airway. Hewas immediately taken to LegacyEmanuel Medical Center, directly tothe operating room. (A) After hemo-stasis was obtained and panendo-scopy performed, the “trach” wasconverted to an oral endotrachealtube. (B) The trachea was mobilizedwith blunt dissection. (C) 2–0 Prolenesutures were used to repair the sepa-ration. Note the sutures are passedthrough a tracheal ring away fromthe site of injury. (D) The patient’sneck was placed in slight flexion andthe sutures tied down in a para-chuting fashion.



location, length, and degree of stenosis. Trachealstenosis isolated to a few rings is often amenableto serial bronchoscopic partial laser ablationscombined with careful dilation. In severe, refrac-tory tracheal stenosis below the second ring,tracheal resection of several rings and primaryanastomosis is performed. Stenosis involving thecricoid is generally managed by cricoid split withinterpositional grafting.

SUMMARY

Injuries to the larynx and trachea are rare. Howev-er, a high degree of suspicion is necessary fortrauma patients with the right mechanism and ex-amination findings, because early identificationand treatment leads to better outcomes. Securingthe airway is the first priority, with an awake tra-cheostomy being the ideal method in patientswith displaced laryngeal fractures with or withoutsubstantial endolaryngeal injury. Early open reduc-tion and internal fixation of displaced laryngealcartilage fractures is recommended. Endolaryng-eal injuries are managed through a laryngofissureor through existing cartilage fractures. The use ofa laryngeal stent or keel can help prevent syne-chiae and laryngeal stenosis. Complete laryngo-tracheal separation is often quickly fatal becauseof loss of the airway in the field.

CLINICS CARE POINTS

� The key step in treatment of any laryngealinjury is the establishment of a secure airway.

� Early intervention (within 24–48 hours) is animportant factor for improved patient out-comes (functional speech, swallowing, andairway patency).

� An awake tracheostomy is the airway ofchoice with grade II or higher laryngeal in-juries.


REFERENCES

1. Jewett BS, Shockley WW, Rutledge R. External

laryngeal trauma analysis of 392 patients. Arch Oto-

laryngol Head Neck Surg 1999;125(8):877–80.

2. Schaefer SD. The acute management of external

laryngeal trauma. A 27-year experience. Arch Oto-

laryngol Head Neck Surg 1992;118(6):598–604.

3. Bent JP, Silver JR, Porubsky ES. Acute laryngeal

trauma: a review of 77 patients. Otolaryngol Head

Neck Surg 1993;109(3 Pt 1):441–9.

4. Verschueren DS, Bell RB, Bagheri SC, et al. Man-

agement of laryngo-tracheal injuries associated

with craniomaxillofacial trauma. J Oral Maxillofac

Surg 2006;64(2):203–14.

5. Lynch M. Repair of the traumatized larynx. Laryngo-

scope 1951;61(1):51–65.

6. Nahum AM. Immediate care of acute blunt laryngeal

trauma. J Trauma 1969;9(2):112–25.

7. Trone TH, Schaefer SD, Carder HM. Blunt and pene-

trating laryngeal trauma: a 13-year review. Otolar-

yngol Head Neck Surg (1979) 1980;88(3):257–61.

8. Fuhrman GM, Stieg FH, Buerk CA. Blunt laryngeal

trauma: classification and management protocol.

J Trauma 1990;30(1):87–92.

9. Stassen NA, Hoth JJ, Scott MJ, et al. Laryngotra-

cheal injuries: does injury mechanism matter? Am

Surg 2004;70(6):522–5.

10. Shi J, Uyeda JW, Duran-Mendicuti A, et al. Multide-

tector CT of laryngeal injuries: principles of injury

recognition. Radiographics 2019;39(3):879–92.

11. Randall DR, Rudmik L, Ball CG, et al. Airway man-

agement changes associated with rising radiologic

incidence of external laryngotracheal injury. Can J

Surg 2018;61(2):121–7.

12. Montgomery WW, Montgomery SK. Manual for use

of Montgomery laryngeal, tracheal, and esophageal

prostheses: update 1990. Ann Otol Rhinol Laryngol

1990;150(9_suppl):2–28.

13. Schaefer SD. Management of acute blunt and pene-

trating external laryngeal trauma. Laryngoscope

2014;124(1):233–44.


http://refhub.elsevier.com/S1042-3699(21)00036-4/sref1




































management of laryngeal trauma

Documents