LARYNGEAL TRAUMA

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LARYNGEAL TRAUMA

• Richard J. Barnett, MD
• June 2, 2005
• Grand Rounds

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Vertebral Trauma in the Elderly
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Ocular Trauma
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Pediatric Syndromes - RevisitedRevisitedRevisite
d

• (Just in case you missed it the last 6 times)

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Introduction

• Timely, proper management essential
• No cookbook solution
• Adhering to an approach ensures best outcome
  even w/ unexpected findings during exploration

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Useful Facts

• Busy trauma ER will treat 1 laryngeal trauma for
  every 5,000 to 30,000 patients
• Cartilaginous framework of larynx depends on
  perichondrium for blood supply
• Respiratory epithelium lines larynx
• Supraglottic sensation supplied by superior
  laryngeal nerves

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Site of Injury

• Supraglottis -
• less dependent on support if sensation intact
  most can be lost w/o deficits
• disruption of hyoepiglottic ligament
  (posterior/superior displacement) causes false
  lumen anterior to epiglottis
• Glottis -
• narrowest portion of adult larynx so any decrease
  in area may compromise the airway

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• Subglottis -
• cricoid is narrowest portion of neonatal/infant
  airway and circular structure creates unique
  challenge
• cricothyroid joint dislocation w/ weak muscle
  RLN injury
• Hyoid bone - usually central
• Cricoarytenoid joint -
• occurs with displacement of thyroid cartilage
  medially usually unilateral

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Pathophysiology of Laryngeal Injuries - Blunt
Trauma

• Caused by MVAs, personal assaults, or sports
  injuries (65 nonsurvivors in one study)
• Mandible / sternum usually protect larynx
• Shearing force causes vocalis muscle to remove
  internal perichondrium - hematoma

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• Fixed vocal cord from subluxation of arytenoid
  cartilage or damage to recurrent laryngeal nerve
  (near cricoid cartilage)
• Cricoid cartilage - essential in airway
  maintenance (only complete ring)

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• Clothesline injury - can cause cricotracheal
  separation (mucous membrane holds it together)
  assoc. w/ bilateral RLN injury
• Women - supraglottic injuries
• Elderly - comminuted fractures of laryngeal
  cartilage
• Children - less likely to sustain laryngeal
  fractures but more likely to have soft tissue
  injury narrow cricothyroid membrane

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Strangulation

• Includes hanging, garroting, throttling,
  choke-holds
• Static and low velocity force
• Multiple cartilaginous fractures w/o soft tissue
  injury or hematoma (deceptive)
• 10 of violent deaths in US
• Superior thyroid cornu fracture
• accompanied by cordal hematoma, arytenoid
  dislocation, petechiae of endolaryngeal mucosa

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Pathophysiology of Laryngeal Injuries -
Penetrating Trauma

• Knife / gunshot wounds - variety of injuries
  related to velocity and mass of missile
• 60 will have associated injuries
• Associated injuries included skull base or
  intracranial injury (13), open neck injury (9),
  cervical spine injury (8), and esophageal or
  pharyngeal injury (3).

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• Gunshot/military wounds more likely to be severe
• know angle of penetration, type of bullet/weapon,
  distance of attack
• Civilian injuries limited to bullet/knife path
• Knife wounds - difficult to assess depth

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Diagnosis and Evaluation

• History - Anterior neck trauma with dysphonia and
  hoarseness is a severe upper airway injury until
  proven otherwise
• Ask about hoarseness, pain, dyspnea, dysphagia
  (no single symptom correlates w/ severity)

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• Physical - assess neurovascular injuries
  (C-spine, bleeding) look for stridor,
  hemoptysis, subcutaneous emphysema, tenderness to
  laryngeal skeleton (differentiates new fxr from
  old deformity)
• loss of prominent contours of thyroid/cricoid may
  be significant observations

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• presentation of a mass often indicates vascular
  injury
• Location of stridor may give clue to injury
• Carotid bruit sign of occlusal disease
• Shortening of AP diameter of the glottis is one
  indication of thyroid cartilage fracture and
  subluxation

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• Cervical subcutaneous emphysema -
• loss of integrity of upper aerodigestive tract
• ball-valve effect of soft tissue
• tracheal displacement / tension pneumo
• Direct fiberoptic laryngoscopy -
• assess mobility of cords, hematoma, lacerations
  (exposed cartilage), airway patency
• rigid esophagoscopy best for hypopharynx /
  esophageal integrity

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Radiologic Evaluation

• CT has replaced all others (high resolution w/
  contrast) - only necessary if changes management
• 2 groups of patients DO NOT need CTs a) obvious
  fractures, large endolaryngeal lacerations,
  severe penetrating trauma (trach, direct
  laryngoscopy, open exploration) b)
  minimal anterior neck trauma and normal
  physical findings

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• Cervical arteriography, swallow study, C-spine
  films (AP, odontoid, cross-table) may be
  warranted (low c-spine)

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Management

• 2 goals a) preserving life b) restoring
  function by not being trach dependent and
  adequate voice
• Goals are universal but methods to achieve are
  controversial

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Emergency Care

• Controversy in airway establishment
• Intubation only if expertise staff under direct
  visualization using a small endotracheal tube
  (difficult requirements)
• Risks - iatrogenic injury or the loss of an
  already precarious airway
• Most authors advocate tracheotomy under local
• If minimal injury, can undergo intubation (highly
  skilled) for mgmt of other injuries

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• Traumatized larynx in child -
• inhaled anesthesia followed by rigid
  bronchoscopic intubation (prevents additional
  injury and allows visualization)
• If C-spine is suspect or uncertain, under extreme
  circumstances may need large-bore needle into
  cricothyroid membrane w/ O2

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• Remember Inspiratory obstruction due to
  collapsed tissue w/ inspiration via trach and
  expiration via larynx
• Heliox - 7030 mix of heliumoxygen via Venturi
  system useful until surgical airway

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Treatment Decision Making

• Treat conservatively if
• edema, small hematoma w/ intact mucosal coverage,
  small glottic or supraglottic lacerations w/o
  exposed cartilage, single nondisplaced thyroid
  cartilage fractures in a stable larynx
• NOTE some evidence that repair of single
  nondisplaced angulated fractures can prevent
  subtle vocal changes (seen on acoustic impedance)

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• Open laryngeal exploration and repair
• lacerations involving the free margin of the
  vocal fold, large mucosal lacerations, exposed
  cartilage, multiple and displaced cartilage
  fractures, avulsed or dislocated arytenoid
  cartilages, and vocal fold immobility

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• Open larygeal exploration, repair and stenting
• disruption of anterior commissure, displaced
  cartilage fragments, severe and multiple
  endolaryngeal lacerations

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Medical Treatment

• Blunt trauma - atleast 24 hours of observation w/
  trach kit at bedside
• Bed rest w/ HOB elevation, voice rest,
  cool/humidified room air (no additional oxygen
  unless dictated by ABG)
• Steroids - first few hours after injury (no good
  clinical evidence) antibiotics - w/ mucosal
  tears or lacerations

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• Clear liquid diet w/ IV supplementation
• NO nasogastric tube! (trauma and reflux) can use
  antacids and H2 blockers

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Surgical Treatment

• Timing is controversial -
• wait several days for better visualization of
  injuries versus early exploration for complete
  assessment, quicker healing, less granulation
  tissue, and less scarring
• Several large series suggest early intervention
  (24-48 hours)
• more effective in visualizing injuries and allows
  primary repair

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• Trach (if necessary) via 2nd or 3rd ring
• Endoscopy (direct laryngoscopy, bronch,
  esophagoscopy)
• If dislocated arytenoid, endoscopic attempts at
  relocation are attempted
• Open exploration immediately if mandated

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• ORIF of cartilage fxrs preferable to closed
  reduction over bronchoscope w/ stent
• Stent / keel as indicated through laryngofissure
  or thyrotomy
• Exploration -
• superiorly based apron incision at cricothyroid
  membrane
• subplatysmal flaps to hyoid bone / cricoid
• separate or divide straps and expose laryngeal
  framework

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• Enter endolarynx via cricothyroid membrane
• Extend superiorly to divide thyroid cartilage IN
  MIDLINE - examine endolarynx and palpate
  arytenoids
• Cover all exposed cartilage (primarily if
  possible)

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• Repair lacerations (5-0 / 6-0 absorbable suture)
• Mucosal advancement flaps as needed

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• Fix cartilage fractures w/ wire, nonabsorbable
  suture, or miniplates (use only if can secure in
  cartilage and not enter mucosa)
• use drill 1 size smaller than usual for screw
  size (eg .76mm drill for 1.5mm screw)

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• May need to overcorrect thyroid cartilage due to
  natural ala spread
• Remove small fragments-prevent chondritis
• Suture anterior margin of anterior commissure to
  thyroid cartilage
• If part of anterior cricoid ring is lost, suture
  infrahyoid straps into defect

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• Keel if denuded anterior commissure
• Close thyrotomy (wire, nonabsorbable suture,
  miniplates)
• Penrose drain (no suction drains)
• Seal trach wound from rest of wound if incision
  incorporates trach
• No compression dressing
• 24hrs of perioperative antibiotics against oral
  flora

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Postoperative Care

• ICU, NPO, continuous pulse oximetry
• Can usually be fed by POD 3/4
• Routine trach care w/ humidified air via mask
  (avoid a T tube connector)
• Can assess competency of glottis by deflating
  cuff and monitor for aspiration
• Assess airway -
• 4 uncuffed trach and plugging for 24 hours (may
  need to send home and decannulate later as an
  outpatient)

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Grafting

• If adhere to immediate surgical management need
  for a graft is rare
• If cover exposed cartilage w/ graft will create
  scar formation
• Mucous membrane (must enter oral cavity), dermis,
  and split-thickness are suitable if have to use
• Grafting is never a substitute for careful
  closure of laryngeal lacerations

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Stenting

• To prevent loss of scaphoid shape of anterior
  commissure, stabilize severely comminuted
  fractures / lacerations, prevent endolaryngeal
  stenosis
• Increase risk of infection/granulation tissue
• Placement
• should move w/ larynx and be recovered by
  endoscopy alone heavy nonabsorbable suture
  through ventricle and cricothyroid membrane
• Controversy over length of time to leave stent in
  place (14 days)

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• May be hard or soft and are sewn in over button
  external to the skin
• Stent vs Keel
• a) stent - designed to give 360 degree support
  to larynx and contracture/adhesion can be
  prevented (controversial - is injury worse or
  does stent cause problems?)
• b) keel - used to keep opposing surfaces of 2
  vocal cords from contacting - less controversial
  lengthens AP dimension of the larynx

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Keels and Stents (Montgomery, Aboulker)
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Cricotracheal Separation

• Unique injury
• precarious airway, loss of cricoid support, high
  risk of bilateral RLN injury, late development of
  subglottic stenosis
• Assoc w/ asphyxiation of time of injury
• Trach under local if possible (bronch if not)
• Repair w/ absorbable suture through superior
  cricoid cartilage / inferior 2nd ring
• Dont resect cricoid cartilage

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Severed RLN

• Surgical dilemma - if repaired microscopically
  can only prevent atrophy and some strength of
  voice
• Attempts at phrenic nerve / ansa anastomoses not
  proven more effective than primary anastomosis

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Complications

• Accidental decannulation - traction sutures
• Fistula - leave drain 7-10 days w/ antibiotics
• Success measured in terms of restoration of voice
  and airway
• UT Southwestern study 139 pts txd w/ early
  primary mgmt - 2 not decannulated, 13 w/ fair
  voice

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• Most common problem is granulation tissue over
  exposed cartilage
• Best method is to cover cartilage meticulously w/
  primary repair

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Laryngeal Stenosis

• Supraglottic -
• simple excision and local advancement flaps for
  wound coverage
• supraglottic laryngectomy in rare cases

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• Glottic -
• a) anterior glottic webs can be lysed and keel
  placed
• b) posterior glottic webs excised w/
  arytenoidectomy and local flap for coverage
  extensive stenosis may require laryngofissure w/
  direct excision of stenotic area, tissue graft
  placement w/ stent

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• Subglottic stenosis -
  a) repeated dilations or laser
  excisions (conservative) for less extensive
  lesions b) extensive stenosis may
  require anterior or posterior cricoid split w/
  cartilage grafts and stenting c)
  lesions up to 4 cm can be resected w/ laryngeal
  release techniques

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Persistent immobility of vocal cord

• Either RLN injury or cricoarytenoid joint
  fixation
• differentiate by palpation / light anesthesia
• if arytenoid is mobile observe for 1 year
• if fixed arytenoid and adequate voice and airway
  no treatment necessary
• bilateral arytenoid fixation or RLN injury w/
  airway compromise may need arytenoidectomy w/
  vocal cord lateralization - weak voice results

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Future

• Rarity limits clinical studies
• Probable reduction in stenting
• Absorbable plates and mesh
• Tracheal homografts from cadavers
• Laryngeal Transplants

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Take Home Points

• Using basic primary treatment principles greatly
  simplifies management plan
• CT can (sometimes) obviate need for direct
  laryngoscopy and open exploration
• Trach is best alternative airway - clear C-spine
  prior to or do not extend neck!
• Immediate (24hrs) open exploration allows primary
  closure of lacerations and prevents long term
  complications

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• Stenting/keel not needed if skeleton is stable
  after fixation and when mucosal coverage of
  anterior commissure is adequate
• Management determined by CT and flex scope
• Hematoma, small lacerations, and edema will
  usually resolve conservatively
• Cartilage fxrs, large lacs, exposed cartilage,
  ant comm disruption requires repair
• Only use grafts if primary coverage not possible

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