laryngeal fractures

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Overview of laryngeal fractures

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Laryngeal FracturesEpidemiologyRare

M>F

Associated injuries:Intracranial injuries (13%)Open neck injuries (9%)Cervical spine fractures (8%)Esophageal injuries (3%)

EtiologyPenetrating vs. blunt

High vs. low velocity

Most commonly:Road traffic accidentClothesline injury

Also:Direct blows (e.g. assaults, sports injuries, hanging, manual strangulation, iatrogenic causes)Pathophysiology - 1Laryngeal fracture: Skeletal disruption cricothyroid & cricoarytenoid dislocationRTA: extended neck of unrestrained passenger hits steering wheel or dashboardClothesline injury: Moving person hits stationary objectManual strangulation: low-velocity, high-amplitude injury multiple fractures with no cartilage displacement, no hematoma, and no mucosal tears

Direct transfer of severe forces to the larynx devastating injuriesPathophysiology - 2Injuries:Mucosal tearsDislocationsFracturesAlso:EdemaHematomaCartilage necrosisVoice alterationCord paralysisAspirationAirway lossPathophysiology - 3Supraglottis:Horizontal fractures of thyroid alaeDisruption of hyoepiglottic ligament superior & posterior displacement of epiglottis false lumen anterior to epiglottis ? cervical emphysema

Glottis:Cruciate fractures of thyroid cartilage near attachment of true vocal cords

Pathophysiology - 4Subglottis:Crushing force on cricoid cartilage Injury to cricothyroid joint + bilateral recurrent laryngeal nerve injury bilateral vocal cord paralysis

Hyoid bone:Weakest part is center, where most fractures occurPathophysiology - 5Cricoarytenoid joint:Thyroid ala displaced medially or larynx compressed against cervical vertebrae cricoarytenoid dislocation, often unilateral

Cricothyroid joint:Anterior trauma to neck inferior cornu of thyroid cartilage displaced posterior to cricoid cartilage limits cricothyroid muscle function pitch control is lost. Injury to recurrent laryngeal nerve vocal cord paralysis

Clinical Presentation - 1History / Signs of cervical traumaSymptoms of laryngeal trauma:HoarsenessNeck painDyspneaDysphoniaAphoniaDysphasiaOdynophoniaOdynophagia

Clinical Presentation - 2Thorough physical examinationFirst clear cervical spine of injurySigns of laryngeal trauma:StridorSubcutaneous emphysemaHemoptysisHematomaEcchymosisLaryngeal tendernessVocal cord immobilityLoss of anatomical landmarksBony crepitus

Clinical Presentation - 3Tenderness upon palpation of larynx acute fracture (probably)Inspiratory stridor supraglottic airway obstructionExpiratory stridor subglottic airway obstructionInspiratory + expiratory stridor glottic ?

WorkupABCCervical spine x-ray chest x-ray( Barium swallow, cervical arteriography)Endoscopy: transnasal fiberoptic laryngoscopyIDL: avoidCT scan (esp. 3D): extent & location of injuryMRI: not helpfulFiberoptic nasopharyngoscopy, Direct larnygoscopy, Bronchoscopy, EsophagoscopyTreatment Medical - 1Minor injuries:EdemaHematomaSmall, insignificant mucosal tears

Goal is to return to pre-injury laryngeal function:VentilationPhonationProtection of lower airway

Treatment Medical - 2Close clinical observation: in first 24-48 hours after injuryBed rest: with head of bed elevated 30-45Voice rest: to minimize edema, hematoma formation, and subcutaneous emphysemaHumidified air: reduces crust formation and transient ciliary dysfunctionSupplemental oxygen: not neededTreatment Medical - 3NPO: followed by clear, liquid dietTPN: ConsiderNG tube: AvoidSystemic corticosteroids: controversial (they retard inflammation, swelling, and fibrosis, and help prevent granulation tissue formation)Systemic antibiotics: not required if minor trauma; required if mucosal tears or compound fractures (no antibiotics local infection + perichondritis delayed healing + airway stenosis)Antireflux medication: H2-blockers / PPI; help reduce granulation tissue formation and tracheal stenosisTreatment - Surgical