Laryngeal TraumaLaryngeal Trauma

IntroductionIntroduction

Incidence: 1:30,000 emergency patientsIncidence: 1:30,000 emergency patients AirwayAirway VoiceVoice Outcome determined by initial Outcome determined by initial

managementmanagement

Anatomy and Physiology Anatomy and Physiology of Larynxof Larynx

Well protected (mandible, sternum, neck flex)Well protected (mandible, sternum, neck flex) Functions: Airway, tracheobronchial protection, Functions: Airway, tracheobronchial protection,

voicevoice Support: Hyoid, thyroid, cricoidSupport: Hyoid, thyroid, cricoid Innervation: RLN, SLNInnervation: RLN, SLN Supraglottis: soft tissueSupraglottis: soft tissue Glottis: relies on external support, crico-arytenoid Glottis: relies on external support, crico-arytenoid

mobility and neuromuscular inputmobility and neuromuscular input Subglottis: cricoid, narrowest in infantsSubglottis: cricoid, narrowest in infants

Anatomy and Physiology Anatomy and Physiology of Larynxof Larynx

Mechanism of InjuryMechanism of Injury

Blunt –Blunt – motor vehicle accident , strangulation, motor vehicle accident , strangulation,

clothesline, sports relatedclothesline, sports related Significant internal damage, minimal Significant internal damage, minimal

external signsexternal signs

Penetrating Penetrating Gun shot wound: damage related to velocityGun shot wound: damage related to velocity Knife: easy to underestimate damageKnife: easy to underestimate damage

Blunt Trauma: Mechanisms Blunt Trauma: Mechanisms of Injuryof Injury

Compression Compression over spineover spine

Static lateral Static lateral forceforce

Laryngo-Laryngo-Tracheal Tracheal separationseparation

Compression Over SpineCompression Over Spine

Static Lateral ForceStatic Lateral Force

Initial EvaluationInitial Evaluation

Secure airway – local tracheotomySecure airway – local tracheotomy Intubation can worsen airwayIntubation can worsen airway Avoid cricothyroidotomyAvoid cricothyroidotomy Pediatric: tracheotomy over Pediatric: tracheotomy over

bronchoscopebronchoscope

HistoryHistory

Change in voice – most reliableChange in voice – most reliable DysphagiaDysphagia OdynophagiaOdynophagia Difficulty breathing - more severe injuryDifficulty breathing - more severe injury Anterior neck painAnterior neck pain Inability to tolerate supine position – Inability to tolerate supine position –

probable airway compromise imminentprobable airway compromise imminent

Physical examPhysical exam Stridor Stridor HoarsenessHoarseness Subcutaneous emphysemaSubcutaneous emphysema HemoptysisHemoptysis Laryngeal tenderness, ecchymosis, edemaLaryngeal tenderness, ecchymosis, edema Loss of thyroid cartilage prominenceLoss of thyroid cartilage prominence Associated injuries - vascular, cervical spine, Associated injuries - vascular, cervical spine,

esophagealesophageal

Physical ExamPhysical Exam

Flexible Fiberoptic Flexible Fiberoptic LaryngoscopyLaryngoscopy

Perform in emergency roomPerform in emergency room Findings dictate next stepFindings dictate next step

CT scanCT scan TracheotomyTracheotomy EndoscopicEndoscopic Surgical ExplorationSurgical Exploration Other studiesOther studies

Laryngoscopic ExamLaryngoscopic Exam

Radiographic ImagingRadiographic Imaging

C-spineC-spine CT if airway stable and mild abnormality CT if airway stable and mild abnormality

on flexible exam.on flexible exam. Good for intermediate cases with scope Good for intermediate cases with scope

limited by edema limited by edema

Angiography and contrast esophagrams Angiography and contrast esophagrams consideredconsidered

CT ScanCT ScanIndications:Indications: Significant Significant

mechanism of injurymechanism of injury Rule out occult Rule out occult

fracture/dislocationfracture/dislocation Confirmation of Confirmation of

suspectedsuspected fracturefracture Determine extent of Determine extent of

fracture(s)fracture(s)

CT ScanCT Scan

Laryngotracheal Injury Laryngotracheal Injury ClassificationClassification Group I: Minor hematoma, no fractureGroup I: Minor hematoma, no fracture Group II: Edema/hematoma, minor Group II: Edema/hematoma, minor

mucosal injury, no exposed cartilage, non mucosal injury, no exposed cartilage, non displaced fracturedisplaced fracture

Group III: Massive edema, mucosal Group III: Massive edema, mucosal tears, exposed cartilage, cord immobilitytears, exposed cartilage, cord immobility

Group IV: See group III, more than 2 Group IV: See group III, more than 2 fracture lines, massive trauma laryngeal fracture lines, massive trauma laryngeal mucosamucosa

Group V: Complete laryngotracheal Group V: Complete laryngotracheal separation separation ((Schaefer, 1982Schaefer, 1982))

Laryngeal TraumaLaryngeal TraumaAsymptomatic or minimal symptoms

F/L

CT scan

Mild EdemaSmall hematoma

Non-displaced linear fractureIntact mucosa

Small lacerations

Displaced fracture (by CT or exam)

Loss of mucosa or extensive lacerationBleeding

Exposed cartilage

Bed restCool mistAntibioticsSteroids

Anti-reflux

Tracheotomy

Panendoscopy

Explore

Laryngeal TraumaLaryngeal Trauma

Respiratory distress, open wounds, bleeding

Tracheotomy

Panendoscopy

Explore

Acute Management of Acute Management of Laryngeal TraumaLaryngeal Trauma

Indications for RepairIndications for Repair

Comminuted Comminuted fracturesfractures

Displaced fracturesDisplaced fractures All fractures All fractures

involving the involving the median and median and paramedian thyroid paramedian thyroid alaala

Cricoid fractureCricoid fracture LT separationLT separation

Large mucosal Large mucosal lacerationslacerations

Laceration of AC Laceration of AC and free edge VCand free edge VC

Disruption CA jointDisruption CA joint VC immobility VC immobility Exposed cartilageExposed cartilage

Laryngeal exploration Laryngeal exploration and repairand repair

Goals of Laryngeal Goals of Laryngeal explorationexploration Cover all cartilage to prevent granulation Cover all cartilage to prevent granulation

tissue and fibrosistissue and fibrosis Primary closure ideal,can undermine Primary closure ideal,can undermine

mucosa or use advancement flaps from mucosa or use advancement flaps from epiglottis or pyriformsepiglottis or pyriforms

Palpate arytenoids and reposition if Palpate arytenoids and reposition if necessarynecessary

Resuspend anterior commisure, ORIF of Resuspend anterior commisure, ORIF of fracturesfractures

Laryngeal Framework Laryngeal Framework RepairRepair

Laryngeal Framework Laryngeal Framework RepairRepair

Treatment GoalsTreatment Goals

Preservation of airwayPreservation of airway Prevention of aspirationPrevention of aspiration Restoration of normal voiceRestoration of normal voice

OutcomesOutcomes

AirwayAirway Poor – trach dependentPoor – trach dependent Fair – mild aspiration or exercise intoleranceFair – mild aspiration or exercise intolerance Good – preinjury statusGood – preinjury status

OutcomesOutcomes

VoiceVoice Poor: aphonia or whisperPoor: aphonia or whisper Fair: changed or hoarseFair: changed or hoarse Good – normal voiceGood – normal voice

OutcomesOutcomes

SwallowingSwallowing NormalNormal AbnormalAbnormal Subjective patient reportSubjective patient report

OutcomesOutcomes

Medical better than surgicalMedical better than surgical Voice results worse with use of stents Voice results worse with use of stents

(airway the same), less time in better(airway the same), less time in better Vocal cord paralysis – poorer outcomeVocal cord paralysis – poorer outcome Improved results with repair <48 hoursImproved results with repair <48 hours

ConclusionsConclusions

Rare injuryRare injury Assess airway first and follow systematic Assess airway first and follow systematic

managementmanagement Timely evaluation with high index of Timely evaluation with high index of

suspicion for classic signs and symptomssuspicion for classic signs and symptoms Don’t forget about associated vascular or Don’t forget about associated vascular or

esophageal injuriesesophageal injuries Treatment based on site/extent of injuryTreatment based on site/extent of injury