laryngeal injury

8/3/2019 Laryngeal Injury

http://slidepdf.com/reader/full/laryngeal-injury 1/15

LARYNGEAL INJURY …By Methawee 12Dec2011

Laryngeal injury : consequence of neck injury

Definitive treatment must be provided within 24 hours.

Proper Mx is essential to preserve life , airway,voice,deglutition.

Securing airway & protect C-spine : the first priority

Severity of injury & Delayed Rx => poor outcome

Classification

1. External laryngeal injury

2. Internal laryngeal injury < Iatrogenic >=> more frequent

External laryngeal injury

Blunt injury



1.Crushing injury : Most common from motor vehicle accident

2.Clothesline injury

3.Strangulation injury: significant differences in the pattern of injury between

suicidal and homicidal strangulation, 24 with the latter being more likely to

cause laryngotracheal separation and concomitant neurovascular injuries.

Special consideration



Elderly person : More calcification of larynx :↑risk of comminuted fx

Childhood

1. ↓laryngeal fracture : Larynx is situated higher in the neck &

protected by mandible

The larynx lies at the level of C3 in the neonate and descends during

the first 3 years of life to its adult position at the level of C6

2. ↑soft tissue injury : loose attachment overlying mucous membrane&

lack of fibrous support

3. ↓ relative cross-sectional area of larynx

2.+3. => ↑ airway obstruction

Female person :Long & thin neck↑supraglottic injury

Penetrating injury

1.Gunshot wounds : more severe tissue damage

Severity related to Velocity& Distance

2.Knife wounds : less tissue damage & cleaner

Associated injury from blast effect: thoracic duct, cervical nerve, great vessels

and viscera



Internal laryngeal injury< Iatrogenic >

Precipitating factor of Intubation injury

• Duration of intubation, Size of ETT, Type of ETT, Pressure cuff

• Intubation techniques : Nasotracheal VS orotracheal intubation

• Local infection,Recurrent trauma, Immunocompromised host

1.Intubation Injury (acute injury: intubation period)

Most endolaryngeal injuries result as cpx.of intubation from intubation technique

… From forceful manipulation & insertion of ETT or too large ETT

Glottic or subglottic injury is common

• In children : subglottis

• In adults: medial surface of the posterior commissure( on which the

tube rests)

perichondritis, granulation tissue formation จาก nerve injury

interarytenoid scarring and bilateral vocal cord immobility

Possible cpx of intubation

Pharyngeal lacerations, Cricoarytenoid dislocation

Injury to the lingual, hypoglossal, superior laryngeal&recurrent laryngeal nerves

and vocal folds

Best Mx =Prevention ,Education for correct techniques of intubation/ Choosing a

correct size of ETT

Intubation Injury ( Delayed injury: Prolonged intubation )



10% after short-term translaryngeal intubationand rises to 90% after long-term

intubation

• Supraglottic : Stenosis

• Glottic :Edema, vocal cord paralysis,Granuloma,interarytenoid fibrosis

○ Cricoarytenoid joint dislocation• Subglottic: Edema,granuloma,Stenosis

• Tracheal: Granuloma, Tracheomalacia,Stenosis ,TE fistula

Mx: Conversion to tracheostomy7 -10 days after intubation

Inhalation injury

Causes : superheated air esp. steam

Limited injury to supraglottic area due to ….reflex closure of the glottis

Associated injury: other parts of the body esp. closed areas

Initial presentation : unremarkable except erythema of upper airway & carbon-

stained sputum

Mx: - secured airway & fluid resuscitation

Injury from caustic ingestion

Typically in childhood ( from various household products )

In adults => suicidal attempt(hydrocarbons : more common )

alkali : liquefaction necrosis of muscle, collagen, and lipids

and creates an injury that worsens with time

acids : coagulation necrosis of the superficial tissues

S&S

direct contact larynx during ingestion

Limited injury to supraglottic area due to ….reflex closure of the glottis

Associated with oral, pharyngeal, and esophageal injuries

Mx

• 24 hours for airway observation : GOAL-safe airway & cardiovascular

resuscitation

• Presence of facial or body burns and soot in the oral cavity and

finding at endoscopy of laryngeal edema predict the need for airway

intervention

• Endotracheal intubation plays an even lesser role



• If patients are to undergo microlaryngoscopy, tracheobronchoscopy, or

esophagoscopy, the procedure should be performed within 24 hours of

injury.

• The upper aerodigestive tract should be irrigated in cases of caustic

injury to remove any residual substances

• Further treatment depends on the nature and extent of injuries found

and the consequences of healing and scarring

• Caustic and thermal injuries can cause laryngeal and tracheal airway

strictures

(severity is greater than that of strictures associated with postintubation

laryngotracheal stenosis)

DIAGNOSIS

Classic symptoms :Hoarseness, laryngeal pain, dyspnea, dysphagia

***Severe compromised laryngeal lumen : aphonia & apnea => Need

tracheotomy

Other symptoms :Aspiration : immobility of one or both vocal folds

Signs

•

Laryngeal tenderness :to differentiate acute from old deformity• Skin changes: contusions or abrasions from blunt injury, line pattern from

strangulation injury,entrance and exit wound from penetrating injury

• Loss of thyroid cartilage prominence

• Stridor : relate to location of the lesion

• Subcutaneous emphysema&massive pneumomediastinum

• Hemoptysis : injury to upper aerodigestive system

( difficult to differentiate from facial trauma )

• Vocal-fold immobility

• Laryngeal hematoma• Laryngeal edema



• Laryngeal lacerations

*** Laryngeal trauma is often associated with concomitant cervical and

intracranial injuries and

frequently occurs as part of multisystem polytrauma.

Investigation

FOL :

• Evaluate endolaryngeal anatomy for Pts with stable airway

• Size & location of hematoma / lacerations

• Motion of arythenoid & TVC

• Airway patency?

• Exposed cartilage?

IDL : Not proper

Rigid esophagoscopy : The best for examine hypopharynx & esophagus after

R/O C-spine injury

Plain films : Identify fractures but only two dimensions,Visualize the entire C-

spine

to avoid missing C-spine injury

CT scan ในทุก case ยกเว้นกรณีอกรน้อยและตรวจร่งกยปกติ

ไม่มีบวม

• Noninvasive manner for evaluate the laryngeal framework

• most useful method for evaluating laryngeal trauma

• CT scan can be deferred only in those patients with a history of relativelyminor trauma to the neck, no laryngeal tenderness or surgical



emphysema, stable airway, and the finding of minimal laryngeal injuries

on flexible laryngoscopy***

CT to identify….

• To assess the extent of laryngeal injury

• To confirm indirect or fiberoptic laryngoscopic findings

• To detect cartilage fractures that are not clinically apparent

• To assess poorly visualized areas( subglottic and anterior commissure

regions)

• To identify associated cervical injuries

Management

Goal

• To preserve life by maintaining the airway

• To preserve voice,swalowing quality

Emergency Care

Primary survey : ABCD

• Airway & Breathing

• Cardiac resuscitation & control of hemorrhage

• Stabilization of neural and spinal injuries

Secondary survey :Investigation& Specific Mx for organ injuries

• Tracheotomy is more effective ( To prevent airway damage )

• Intubation in this setting is hazardous

…Attempted ETT on a traumatized larynx : iatrogenic injury

BUT …intubation can be done

1. Under direct visualization by experienced personnel with a small ETT

2. If endolaryngeal mucous membrane is intact& laryngeal skeleton is

minimally displaced

***A child with laryngeal injury

Difficult to perform tracheotomy & O2 sat drop more quickly

After successful bronchoscopy , tracheotomy can be done as needed หลังจาก ใส่bronchoscope

Treatment Decision Making : Medical VS Surgical treatment

Approximately 40% of patients with laryngeal trauma can be managed

conservatively, and in those patients who require surgical treatment, the extent

of the original injury correlates with the long-term outcome.



Medical treatment…

For…

1. Edema

2. Small hematoma with intact mucosal coverage

3. Small lacerations without exposed cartilage

4. Single nondisplaced thyroid cartilage fractures in stable larynx

• Voice rest• Systemic steroids : if presenting within 24 hours of injury

• Elevate head

• Humidified air

• Antibiotics ในกรณี laryngeal mucosa has been breached

• Antireflux measures

• Avoid NG tube

***Uncertain blunt trauma : observe for signs of progressive airway

compromise at least 24 hrs

Surgical treatment …

FOR…. ใน group 3,4,5

1. Lacerations involving the free margin of the vocal fold

2. Large mucosal lacerations

3. Exposed cartilage

4. Multiple and displaced cartilage fractures

5. Avulsed or dislocated arytenoid cartilages

6. Vocal fold immobility



Surgical treatment …

• Tracheotomy

•

Endoscopy• Exploration

• Thyrotomy

• Closure of laceration

• Insertion of stents

• Grafting

• Fixation of fractures



Timing

Early exploration : (Better outcome & more effective)

• Lower post-op infection rate

• Quicker healing

• Less granulation tissue& scarring

We aim to repair all laryngeal injuries within 12 hours of presentation and arereluctant to accept delays beyond 24 hours.

Delayed exploration

• ↓Edema : Easy to repair ?

• In C-spine or traumatic brain injury pts

• Delays in treatment can lead to granulation and scar tissue formation,

which

can progress to laryngeal stenosis, a difficult surgical problem to correct.

Direct laryngoscopy, Bronchoscopy, esophagoscopy should be done beforesurgery ทุกราย เพื อประเมิน injury



Thyrotomy

Closure of laceration :Meticulous technique by 5-0 or 6-0 absorbable suture

material

Exposed cartilage must be covered to prevent granulation tissue and fibrosis

Failure to do : grafting and healing by secondary intention (chance for scarformation)

Grafting

Loss of tissue is large & exposed cartilage

Donor site1.Mucous membrane => most closely resembles normal

endolaryngeal epithelium

2.Dermis :Split-thickness skin

Insertion of stents

To maintain internal configuration of larynx(normal scaphoid shape of the

anterior commissure)

& prevent stenosis

I/C ของการใส่Stent 3 ขอ้

• Anterior commissure disruption

• Multiple & displaced cartilage fracture

• Multiple & severe endolaryngeal laceration

After placement of a stent , Anterior commissure is reconstituted by suturing

TVC to outer perichondrium



Remove in 10-14 d. : ↓risk of infection, ↓ Granulation tissue formation

ORIF: suturematerial, stainless steel wire, titanium miniplate and

screw

VOCAL CORD IMMOBILITY

• Cricoarytenoid joint dislocation :endoscopic manipulation and reduction

• Recurrent laryngeal nerves injury

: Only if a complete palsy exploration of the affected nerve

*** Cricoarytenoid joint mobility can be assessed preoperatively, but definitive

assessment of joint mobility requires microlaryngoscopy and instrumentation

(passive mobility test)

Cricotracheal Separation

Precarious airway

Loss of cricoid support

High risk of injury to RCN

Late development of SGS

Mx : -Tracheotomy +/- Bronchoscope

- Avoid ETT

- Cricotracheal anastomosis & mucosal repair (Intact cricoid cartilage)

1. Repair with the posterior anastomosis, using a combination of 3-0

absorbable and nonabsorbable sutures, and works toward the anterior

trachea

2. All knots are extraluminal, and the sutures are run through the

submucosal plane

3. Avascular and damaged tissue is resected



4. If there is an associated crush injury to the trachea, a temporary soft

polymeric silicone stent may have to be placed in the lumen prior to

anastomosis

- Internal fixation +/- stenting (Fx of cricoid cartilage)

PARTIAL OR TOTAL LARYNGECTOMY

In cases of massive laryngeal injury with significant tissue loss , BUT… rare

S evered Recurrent Laryngeal Nerve

• Immediate nerve reapproximation under an operating microscope

• Nerve regeneration???,Prevent muscle atrophy, Maintain some strength of

voice

Postoperative Care

• Strict voice rest for 48 to 72 hours

• NG tube should be inserted at the time of surgery and should remain

until the safety of swallowing is confirmed

• Post-op antibiotics for 5 -7 days (if mucosal tear)

• Elevate head

• Ambulate as soon as possible

• Remove stent in2 wk after surgery(mucosal tear),3 wk (anterior

commissure disruption )

• Tracheostomy tube care

•

Decannulation as soon as the stent is removed• Antacids & H2-blockers : to prevent reflux

• Regular endoscopic examinations :granulation tissue is removed to

prevent long-term scarring

• In patients with cricotracheal separation, the neck is kept in flexion for

7 days postoperatively to prevent traction on the anastomosis

Follow-up : continue at least 1 year

To assess true vocal fold function return

To assess development of SGS

COMPLICATION

Granulation tissue

Prevent by covering all exposed cartilage

Avoid stents when possible

Careful excision

Laryngeal stenosis

Excision with mucosal coverage

Stenting selected cases

LaryngotracheoplastyTracheal resection with reanastomosis



Vocal-fold immobility

Observe

Vocal-fold injection

Thyroplasty-type vocal-fold medialization

Arytenoidectomy and vocal-fold lateralization for bilateral paralysis

Outcome depend on …

• Extent of the original injury

• Quality of subsequent repairs

Group 1 -2 : excellent recovery without surgery

Group 3 -5 : good result if early repair

laryngeal injury

Documents