Laryngeal Trauma

1. Laryngeal Trauma Jean Paul Font, MD Francis B. Quinn, Jr., MD Grand Rounds Presentation Department of Otolaryngology University of Texas Medical Branch at Galveston March 28, 2007

2. Introduction Incidence: 1 in every 30,000 ER visits Laryngeal injuries in 30 to 70 % in penetrating neck trauma (especially zone II) Blunt and penetrating neck injury Airway Major vascular structures Cervical esophagus Cervical spine.

3. Laryngeal Embryology 3rd and 5th branchial arches 3rd week Respiratory primordium is derived from primitive foregut 4th -5th weeks Tracheoesophageal (TE) septum forms by fusion of (TE) folds

4. Anatomy Support: Hyoid, thyroid, cricoid Protection of the larynx Superiorly by the mandible Inferiorly by the sternum Laterally by the sternomastoid muscle Posteriorly by the cervical spine Innervation: RLN, SLN

5. Anatomy Supraglottis External support Soft tissue attachments Glottis Relies on external support Narrowest in the adult Susceptible to obstruction Subglottis Cricoid-narrowest in infants

6. Laryngeal Function Function Breathing passage Airway protection Clearance of secretions Vocalization

7. Mechanism of Injury Blunt trauma MVA Clothesline Crushing Strangulation injuries Penetrating trauma GSW- related to the type of weapon Directly penetration or indirectly by the blast effect Knives Eddie Griffin destroyed a Ferrari Enzo worth $1.5 million Eddie Griffin destroyed a Ferrari Enzo worth $1.5 million

9. Mechanism of Injury Blunt injuries Most commonly from motor vehicle accidents Forward thrust Neck extension impacting steering wheel Removes the mandibular barrier Laryngeal skeleton is compressed between a foreign object (i.e., steering wheel or dashboard) and the anterior aspect of the cervical spine Decrease incidence- seat belt harness and air bags

10. Initial Evaluation ATLS principles Intubation hazardous Schaefer in 1991- worsen preexisting injury Further tears or cricotracheal separation Respiratory distress Tracheotomy under local anesthesia Avoid cricothyroidotomies Worsen injury If no acute breathing difficulties Detailed history and careful physical examination

11. Pediatric patient Blunt pediatric neck injuries Uncommon the larynx lies higher than the adult Protected by the mandible More often life-threatening Significant injury including laryngotracheal disruption Smaller cross-sectional area of the pediatric population Rigid bronchoscopy followed by tracheotomy over the bronchoscope

12. Diagnosis History Change in voice Pain Dyspnea Dysphagia Odynophagia Hemoptysis Inability to tolerate the supine position Physical Exam Respiratory rate (saturations) Stridor Neck skin Contusions, Abrasions or Line pattern Subcutaneous emphysema Tracheal deviation Open wound Air bubbles Exposed tracheal cartilage Don�t probe open wounds May dislodge a hematoma

13. Diagnosis Unstable Tracheotomy and neck exploration Stable patients Flexible fiberoptic laryngoscopy in the ER CT scan, direct laryngoscopy, bronchoscopy and esophagosopy

14. Ct Scan CT allows: Evaluation of the laryngeal skeletal framework Noninvasive avoiding unnecessary operative explorations

15. CT Scan Reserved Suspected laryngeal injury by history and physical examination No obvious surgical indications

16. Laryngotracheal Injury Classification Group I injuries No fracture Minor hematoma, edema or laceration Group II injuries Nondisplaced fractures Edema or hematoma Minor mucosal disruption without exposed cartilage Group III injuries Displaced fractures Massive edema or mucosal disruption Exposed cartilage and/or cord immobility Group IV injury (group III) Addition of two or more fracture lines Skeletal instability or significant anterior commissure trauma Complete laryngotracheal separation

18. Medical Management Group I injuries Minimum of 24 hours of close observation Head of bed elevation Voice rest Humidified air Anti-reflux medication Serial flexible fiberoptic exams Antibiotics for laryngeal mucosa disruption

19. Steroid Controversial Early systemic steroids therapy are often given to reduce laryngeal edema One randomized controlled trial (Ghorayeb 1985) Intravenous dexamethasone for preventing traumatic laryngeal edema in pediatric bronchoscopy This study showed no reduction in postbronchoscopy laryngeal edema with the use of intravenous dexamethasone

20. Surgical Management Hemostasis Evacuation of hematoma Reconstruction of the laryngeal framework Coverage of de-epithelialized surfaces Group II to V required surgical intervention Surgical options Endoscopy alone Endoscopy with exploration Endoscopy with exploration and stenting

21. Surgical Management Any doubt about the extent of injury endoscopy should be performed Indications for surgical exploration include: Large mucosal lacerations Exposed cartilage Multiple or displaced cartilaginous fractures Vocal cord immobility Fractured cricoid Disruption of the cricoarytenoid joint Lacerations involving the free margin of the vocal cord or anterior commisure Explore within 24 hours of the injury Maximize airway and phonation results

22. Surgical Management Laryngeal skeleton is exposed from the hyoid to sternal notch Midline thyrotomy May use a vertical fracture (2 to 3mm of midline) Nondisplaced fractures Suture outer perichondrium Primary closure with nonabsorbable sutures Debridement should be minimized Mucosal lacerations Meticulously repaired using fine absorbable sutures Knots outside the laryngeal lumen (prevent granulation)

23. Surgical Management Displace fractures of the cartilages are reduced Stabilized using stainless steel wires, nonabsorbable suture or miniplates. Small fragments of cartilage with no intact perichondrium are removed to prevent chondritis. Anterior commissure- suspend the anterior true vocal cords to the outer perichondrium of the thyroid cartilage Close the thyrotomy Nonabsorbable suture, wires or miniplates

24. Surgical Management Endolaryngeal stenting Disruption of the anterior commissure Massive mucosal injuries Comminuted fractures of the laryngeal skeleton From the false vocal fold to the first tracheal ring Stability and prevent endolaryngeal adhesions Removed in a period of 10 to 14 days to prevent mucosal damage

25. Stents Types of stents Endotracheal tube (COVER THE TOP END TO PREVENT ASPIRATION) Finger cots filled with gauze or foam Polymeric silicone stents Secure the stent Heavy, nonabsorbable suture Larynx at the ventricle Cricothyroid membrane Tied outside the skin Endoscopically removed

26. Conclusion Laryngeal trauma although uncommon can be life-threatening Recognizing any airway compromise and need for immediate intervention could prevent immediate death as well as acute and long term morbidity Initial management should follow ATLS principles Most authors agree that tracheotomy should be performed on patients exhibiting respiratory distress In patients with no acute breathing difficulties, a detailed history, careful physical examination and appropriate diagnostic tools should be use to differentiate the need for medical from surgical management

28. References Schaefer, S.D. Use of CT Scanning in the management of the acutely injured larynx. Otolaryng Clinics NA. Vol 24(1): 31-36. February 1991. Perdiki, G. Blunt Laryngeal Fracture: Another Airbag Injury The Journal of Trauma: Injury, Infection, and Critical Care. Vol. 48, No. 3. p544-546. 2000 Hwang, S. Y. Management dilemmas in laryngeal trauma The Journal of Laryngology & Otology., Vol. 118, pp. 325�328. May 2004 Verschueren,D. S. Management of Laryngo-Tracheal Injuries Associated With Craniomaxillofacial Trauma. American Association of Oral and Maxillofacial Surgeons. P203-214. 2006 Ford, H. Laryngotracheal Disruption From Blunt Pediatric Neck Injuries: Impact of Early Recognition and Intervention on Outcome. Journal of Pediatric Surgery, Vo130, No 2: pp 331-335. (February), 1995 Goudy, S. L. Neck Crepitance: Evaluation and Management of Suspected Upper Aerodigestive Tract Injury. Laryngoscope 112. p791-795: May 2002 O�Mara, W and Hebert, F. External laryngeal trauma. J La State Med Soc. Vol 152(5): 218-222. May 2000. Schaefer, S.D. The treatment of acute external laryngeal injuries. Arch Otolaryng HNS. Vol 117: 35-39. January 1991 Cummings: laryngeal Injury. Otolaryngology: Head & Neck Surgery, 4th ed. Mosby, Inc, 2005. 4223-4238 Fuhrman, G.M., Stieg, F.H., and Buerk, C.A. Blunt laryngeal trauma: Classification and management protocol. J Trauma. Vol 30(1): 87-92. January 1990 Ghorayeb BY, Shikhani AH. The use of dexamethasone inpediatric bronchoscopy. J Laryngol Otol 1985;99:1127�9