Laryngeal trauma
Overview
• Rare condition
– 1 in 30,000 ED visits
– Anatomical protection
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Anterior/Superior – Mandible
Posterior – Cervical spine
Lateral – Sternocleidomastoid
Inferior – Sternum
Mechanism of Injury
Blunt trauma
• Anterior blunt trauma
• Clothesline fracture
• Strangulation injury
Anterior blunt trauma
• Motor Vechicle Accident
– Rapid deceleration
– Hyperextended neck
compressed between
steering wheel and spine
– Most common without
shoulder belt
Blunt Trauma
• Clothesline
– Motorcycle/Snow Mobile object
– Large amount energy to small area
– Massive trauma, frequently instant
death/asphyxiation
• Crushed Larynx
• Tracheal Separation
• Bilateral RLN injury
Blunt Trauma
• Strangulation
– Low velocity
– Multiple cartilagenous fracture
– Initial hoarseness and skin abrasion
– Hyoid fracture = classic injury
– Subsequent edema/loss of airway ,observe airway
atleast 12-24 hrs
Blunt Trauma
• Pediatric Considerations
– Larynx more superior (C4 vs C7) = more mandible
protection
– Generally more soft tissue and less cartilage damage
• Looser Soft Tissue
• Less Fibrous Support
• More elastic cartilage
– Tend to underestimate severity because lack of fxs
Process of calcificaion
• Older than 3o yrs elasticity decrease due
to calcification
• More calcifacation  more comminuted
fracture
Penetrating Trauma
• Mostly knife and gunshot wounds
• KE=mv2: Degree of injury directly related to
velocity and mass of source
• Vascular injury most common cause of death
• Stab wounds: difficult to determine depth of
injury
• Important to rule out esophageal injury
Inhalation injuries
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Hot air/Smoke/Steam
Glottic reflex limits injury to supraglotis
Initial erythema and carbon sputum
Followed by marked edema
Consider early airway control prior to fluid
resuscitation
Ingestion Injuries
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Mucosal Burns
Direct damage while ingesting or regurgitation
Alkali generally worse than Acid
Alkali :saponification liquefractive
Acid : coagulation necrosis
Fibrosis ,stricture
Iatrogenic Trauma
• Intubation
– Larynx/Pharynx laceration or abrasion
– Arytenoid dislocation
– Neuropraxia of lingual, hypoglossal, SLN or RLN
• Prolonged Intubation
– SGS (large diameter, high pressure)
– Generally change to tracheostomy in 10 days (earlier
with inhalation injury)
• Tracheotomy
– Cricoid/RLN injury
History
• May be missed initially with multi-trauma
• Symptoms
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Hoarseness
Laryngeal pain
Dysphagia
Dyspnea
Hemoptysis
Aphonia / Apnea
Stridor
Subcutaneous emphysema
Physical Exam
• Airway – secure if unstable
– Intubation
• Can cause more injury (laceration or tracheal separation)
– Emergent trach/cric (through laceration)
• Can be dangerous and injure surrounding structures
• Breathing
• Circulation – signs of major vascular injury
(expanding hematoma, major blood loss)
Physical Exam
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Hoarse/aphonic
Stridor (inspiratory and/or expiratory)
Crepitus
Contusions/abrasions c/w trauma
Wounds (entrance/exit)
Externalized airway or open fxs
Don’t forget c-spine, pulses, neuro exam
Physical Exam
• If airway stable then fiberoptic exam
– Gentle! Minor trauma could collapse airway
– Hematoma (size, location)
– Mucosal Lacs, Exposed cartilage
– Arytenoid immobility (partial or complete)
– Vocal Cords
(same plane? lesions? mobility?)
Imaging
• CT
– Excellent to evaluate laryngeal skeleton
– Rule out fractures
– Some agure not necessary if going to OR
• Angiogram
– Consider for penetrating trauma
– Zones I and III
• Gastrografin Swallow Study
– Suspected esophageal injury
Classification
Management
• Observation Candidates (Groups I & II)
– Stable Airway (may need trach/intubation)
– Minor lacerations not involving ant commissure
– Single, nondisplaced fracture
– No cartilage exposure
– Minor hematoma (non-obstructing, nonexpanding)
Management
• Observation/Medical Management
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Bed rest
Voice rest
Head elevated
Humidified air
Antibiotic for mucosal tear
Antireflux
Steroids
Management
• Surgical Candidates (Groups III-V)
– Ant commissure involved
– Exposed cartilage (risk of granulation/stenosis)
– Multiple/comminuted or displaced fxs
– Cricoid Fxs,cricotracheal separation
– Extensive mucosal disruption
– Early intervention (12hrs) =
best airway/voice results
Surgical Options
• Airway Control
– Intubation
• Consider if mucosa intact or min. displaced fxs
– Tracheotomy
• Awake in OR beware C-spine
• Below normal position ring3-4
– Pediatric
• Consider bronchoscope intubation then tracheostomy
Surgical Options
• Direct
Laryngoscopy/Tracheoscopy/pharyngoscope
– After Airway control
- Evaluated and treatment Ex drain
hematoma,reduction CA joint
• Esophagoscopy
– rigid esophagoscope
Surgical Options
• Surgical Exploration/Repair
– Neck exploration
– Midline thyrotomy
for endolaryngeal injury
– Hemostasis, remove clot
– Debridement
– Meticulous repair of laceration
• Cover cartilage
– Reduce fxs – wire or plate
– Relocate Arytenoids
– Flaps prn for tissue loss
Surgical Options
• Soft Tissue Repair
– Repair Mucosa/VCs with absorbable 5.0/6.0
– Resuspend TVC with 4.0 absorbable to external
perichondrium of thyroid cartilage
– Cover cartilage!
• Grafts if needed (mucosa, stsg)
Laryngeal exploration and repair
• Incision
Horizontal,midline
• Skin flapsubplatysmal
plan sternal notch to
hyoid
• Separated strap muscle
Laryngeal exploration and repair
• Midline thyrotomy
• In case of thyroid
cartilage fx
• Vertical incision
• Evaluated injury
,palpate arytenoid
cartilage
Laryngeal exploration and repair
Laryngeal exploration and repair
Surgical Options
• Reduction of Fractures
– Wire/Suture
– Plating
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Miniplates vs. absorbable
Offers immediate rigid fixation
Well tolerated in situ
Better strength
Surgical Options
• Stents
– Disrupt ant commissure :Prevents webbing,
supports framework
– Stabilized unstable fracture
– Massive mucosal injury
– Soft, shape of larynx
• Soft polymersic silicon
• ETT
• Finger Cots
– Removed 10-14 days
Endolaryngeal stenting
Surgical Options
• Vocal Cord immobile,RLN Injury
– Cricoarytenoid joint dislocated  reduction
– Attempt primary repair nerve  not improve motor
fn but improve vocalization
• Cricotracheal seperation
– Reapproximate cartilages
– Posterior anastomosis anterior anastamos
– All knot extraluminal
• Severe trauma
– Consider partial/total laryngectomy
Post Op Care
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Antibiotics
Anti-reflux
Elevate Head
Trach Care
Stent removal
Decannulate
Early ambulation
Avoid NG tube
Trauma Complications
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Aspiration/Dysphagia/Odynophagia
Dysphonia
Fistula
Unable to decannulate
Granulation Tissue/Obstruction
Vocal Fold immobility
– Wait 6-12 months before intervention if RLN
• Subglottic stenosis
– Dilation, Excision
– Cricoid split, Resection
Prognosis
• Mortality 10-30%
• Higher Risk in
– Blunt Trauma (63%)
– Need for emergency airway
• Higher risk of poor voice/airway from blunt
trauma