laryngeal trauma 20080722

7/23/2019 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),


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.


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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laryngeal trauma 20080722

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