Michelle Mekky, MA, CCC-SLP, BRS-S
Speech-Language Pathologist
Memorial Hermann Hospital &
Children’s Memorial Hermann Hospital
Purpose
Educate the SLP on the medical
diagnosis, medical treatment, and
ultimate rehabilitation of voice and
swallowing following
airway/laryngeal trauma.
Nelson Review Article
• Why this article
• Lack of clinical research on this patient
population in the SLP literature
Laryngeal Anatomy
Anatomy continued
Mechanism of Injury
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Blunt Trauma-fractures/dislocation
Penetrating Trauma
Intubation Trauma
Thermal and Chemical Trauma
Blunt Trauma
• Larynx is relatively well-protected
• Lateral shielding by sternocleidomastoid
muscle
• Posterior protection from cervical
vertebrae
• Anterior protection by mandible
Examples of Blunt Trauma
Ex. of Blunt Trauma (cont)
Internal Trauma
Fractures and Dislocations
• Midline or paramedian are most
common
• Comminution & complex fractures do
occur
• Surgical Management: ORIF &/or
tracheostomy
• Use of stents
Laryngeotracheal Separation
• Severe airway compromise
• Many die at the scene of the accident, unless
mucosal attachment remains
• Tracheostomy performed ASAP
• Intubation in the field may do more harm
than good
• Bilateral recurrent nerve injury and subglottic
stenosis are common complications
• Ultimate surgical intervention is sometimes a
total laryngectomy
Penetrating Trauma
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Car accidents
Knifes
Bullets (handgun versus shotgun)
Other accidents: falling on sticks or
glass
• Blast injuries
Vascular Injuries
• Occur in 25-56% of penetrating neck
wounds
• Most commonly to the carotid and
subclavian arteries-most common cause
of death
• 20-30% of penetrating neck wounds
result in laryngeal, tracheal, or
esophageal injuries
Intubation Trauma
• Prolonged intubation leads to trauma in
4-13% of cases
• Larger endotracheal tubes cause more
trauma
• History of smoking or ETOH
consumption can be very drying to the
mucosa
• GERD/LPRD
Intubation trauma caused by:
• Abnormal anatomy (~10% of the
population)
• Difficult laryngescopy
• Multiple intubations/extubations
• Skill of person placing (resident vs.
attending)
• Emergent versus Elective
When trachs are placed
• In most hospitals tracheostomies are
performed after 10-14 days of
endotracheal intubation
• If multiple trips to the OR are required
• Policies vary greatly between the
different ICUs
Reaction to Intubation
• Within 48 hours of intubation
granulation tissue begins to form
• Mucosal ulceration is usually present
Immediate Laryngeal
Complications
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Glottic or subglottic edema
Mucosal laceration
Dislocation of the arytenoids
Avulsion of the epiglottis
Vocal cord paralysis
When to refer to ENT post
intubation/extubation
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Hoarse voice greater than 48 hours
Sore throat greater than 48 hours
Dysphagia
Odynophagia
Stridor
Management of Arytenoid
Dislocation
• Needs to occur by ENT with 24-48
hours of identification
• Can sometimes be treated by direct
endoscopy
Treatment of Avulsion of the
Epiglottis
• Open repair
• Laser excision
True VC Paralysis
• May occur as result of intubation &/or extubation
• Brandwein et al. discovered that the anterior branch
of the recurrent laryngeal nerve is vulnerable to
compression between the inflated cuff of the ETT,
the lateral projection of the abducted arytenoids, and
the thyroid cartilage.
• Cord is usually lying in the paramedian position
Late injuries of Intubation
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Intubation granuloma
Cricoarytenoid ankylosis (fibrosis)
Glottic webs
Subglottic stenosis
Avoiding Late Injuries of
Intubation
• Limiting amount of time the pt is intubated
• Using the smallest ETT which will permit
adequate respiratory support
• Using low-pressure cuffs
• Careful fixation of the tube to limit movement
during assisted ventilation
• Use of steroids and antibiotics
• Early recognition/tx of such laryngeal injuries
Intubation Granuloma
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Forms when blood supply is poor
Area is exposed to potential contamination
Steroids is a medical tx
Antibiotics to promote healing of the mucosa
Late presentations: voice changes, globus,
repetitive medical course of tx
• Sometimes permanent
Glottic Web
• Can result from simultaneous
denudation of both VFs near the
anterior commissure
• When they heal together they produce
a web
• Probably occurs more often as a
complication or surgery rather than
from intubation
Picture of Glottic Web
Medical tx of Glottic Webs
• Surgical placement of anterior tantalum
keel
• Endoscopic management with a laser or
mechanical lysis-followed by placement
of an internal Teflon keel
Subglottic Stenosis
• Definition: narrowing of the subglottic
space above the inferior margin of the
cricoid cartilage and below the level of
the glottis
• Can be anterior, posterior, or complete
Subglottic Stenosis (cont)
• Grade I - Obstruction of 0-50% of the
lumen obstruction
• Grade II - Obstruction of 51-70% of the
lumen
• Grade III - Obstruction of 71-99% of
the lumen
• Grade IV - Obstruction of 100% of the
lumen (ie, no detectable lumen)
Picture of Subglottic Stenosis
Tx of Subglottic Stenosis
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Tracheostomy
Open reduction
Cricotracheal resection
Medical management of GERD/LPRD if
in the patient’s known history
• Steroids/Antibiotics
• Grafting
Consequences of SelfExtubation
• Edema
• Possible vocal cord damage
• Cartilage dislocation
Thermal and Chemical Trauma
• Inhalation of hot gases (caustic or not)
cause trauma
• Stabilize the airway
• Sudden edema is of primary concern
Long term Injuries
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Loss of mucosal integrity
Infection
Chondritis (inflammation of cartilage)
Fibrosis
What the MD looks for:
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Cough
Carbon particles
Blood in the sputum
Voice change
Stridor
Dyspnea (shortness of breath)
Course of Treatment
• At least admitted for observation
• Difficult to determine if tracheostomy is
indicated
Medical Management of the
Airway
• Oral intubation after spine is clear
• Rarely a cricothyroidotomy is performed
for an emergent airway when a trach
cannot be completed
• Must be revised to a tracheostomy
ASAP (within a few hours)
Role of the SLP
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Aphonia/Hoarseness
Aspiration/Penetration
Avulsed/Amputated Epiglottis
Edema
Unilateral VC paresis/paralysis
Bilateral VC paralysis
Hearing Loss
Aphonia/Hoarseness
• Get dx from ENT
• Medical management is the best course
of tx for bringing back voicing
• Facilitate communication with a
communication board and/or written
communication systems
Aspiration/Penetration
• Determine if postural changes are helpful
during MBS/FEES
• MUST take into account fatigue on ability to
perform maneuvers (respiration and
structural)
• May try: supraglottic swallow, supersupraglottic swallow, head down, or head
rotation.
• Diet Modification is usually necessary with or
without enteral access
Avulsed/Amputated Epiglottis
• May lead to initial odynophagia with all
oral intake
• Chin down or super-supraglottic
swallow may be a helpful to try during
MBS/FEES
Edema
• Vocal rest
• Medical Management
– Steroids
– Anti-inflammatories
Unilateral VC Paresis/Paralysis
• Many patients with unilateral paresis recover
in the first 7-10 days post trauma
• Those with paralysis usually overcompensate
with the good cord in 1-3 weeks
• Temporary tx’s by ENT: fat injection
• Permanent tx’s by ENT: medialization
laryngoplasty or thyroplasty
Bilateral Vocal Cord Paralysis
• Causes
– Paralysis (neurological)
– Fixation of the cricoarytenoid joints
– Both
Tx of Bilateral VC Paralysis
• Usually trached and NOT a candidate
for a speaking valve
• Written communication/Communication
board/electrolarynx during acute
hospital stay
• If permanent with no recovery to either
cord then: Speech generating device
with or without electrolarynx
Hearing Loss
• Reported cases of acoustic trauma SN HL
following blunt neck trauma
• Segal et. al suggests it could be due to sheer
forces acting on the cervical spine that
transition to the inner cranium
• Other theories suggest a neuromuscular
mechanism, a neuro-vascular mechanism, or
a mechanical vascular obstruction
• Tinnitus/Balance difficulties
Hearing Loss (cont)
• Audiological/ENT referral is appropriate
• Referral to physical therapy may be
indicated
• Speech tx for aural rehabilitation
Thoughts for the Future
• Research in voice recovery s/p airway
trauma
• Research in swallowing function s/p
airway trauma