LARYNGEAL TRAUMA
DODDY SUMARDHIKA
Dept. of Otorhinolaryngology Head & Neck Surgery
Faculty of Medicine Universitas Padjadjaran
Hasan Sadikin Hospital Bandung
2010
INTRODUCTION
• Rare
• External laryngeal trauma 1 in 30.000
emergency room visits
• Multidisciplinary approach
• Timely, proper management of injury to the
larynx is essential to preserve the patient's life,
airway, and voice.
• Severity and delay treatment poor outcome
2
Laryngeal Protection
Mandible
C-spine
Sternum
3
Mechanism of Injury
Penetrating Inhalation/
trauma Ingestion
Blunt
Iatrogenic
trauma
Laryngeal
Injuries
4
Byron J. Bailey, Head & Neck Surgery-Otilaryngology, 4th editon, Lippincot Williams & Wilkins, Philadephia,
2006.
CLASSIFICATION
By Trone et al. (1980) ; Schaefer ; Fuhrman et al.
TABLE 1. LARYNGEAL TRAUMA CLASSIFICATION SYSTEM
Group 1 Minor endolaryngeal hematomas or lacerations without
detectable fracture
Group 2 Edema, hematoma, minor mucosal disruption without exposed
cartilage, varying degrees of airway compromise.
Nondisplaced fracture
Group 3 Massive edema, large mucosal lacerations, exposed cartilage,
displaced fracture, vocal cord immobility
Group 4 Same as group 3 but more severe, with disruption of anterior
larynx, unstable fractures, two or more fracture lines, severe
mucosal injuries
Group 5 Complete laryngotracheal separation.
5
Robert H. Ossof et.al. The Larynx, Lippincot Williams & Wilkins, Philadephia, 2003
Verschueren et al. Management of Laryngo-Tracheal Injuries.
J Oral Maxillofac Surg 2006. 6
ETIOLOGY AND MECHANISM
1. MOTOR VEHICLE ACCIDENTS most common
2. KNIFE & GUNSHOT WOUNDS
3. BLUNT ASSAULT INJURIES
4. SPORTS INJURIES
BLUNT TRAUMA : GUNSHOT : KNIFE :
Disruption of tissue Variable degree of Less tissue
but no tissue loss cartilage loss & destruction
soft tissue injuries
Associated Injuries:
7
Great vessel, RLN, spinal cord,
PATHOPHYSIOLOGY LARYNGEAL
INJURIES
Blunt Trauma
Motor vehicle accidents, personal assaults, or
sports injuries.
Mandible and sternum protect the larynx
Subluxation or dislocation arytenoid fixed
vocal fold
Cricoarytenoid joint injuries recurrent
laryngeal nerve
Byron J. Bailey, Head & Neck Surgery-Otilaryngology, 4th editon, Lippincot Williams & Wilkins, Philadephia, 2006.
8
BLUNT TRAUMA
Fractures hyoid bone and epiglottic injuries
airway obstruction.
Women supraglottic > men
Elderly comminuted laryngeal fractures
calcification
Child less common and less severe
Byron J. Bailey, Head & Neck Surgery-Otilaryngology, 4th editon, Lippincot Williams & Wilkins,
Philadephia, 2006.
9
• Motor vehicle accidents
Rapid deceleration with neck hyperextended
10
Blunt Trauma
• Clothesline Injury
Riding Motor Cycle
Stationary Object
11
Blunt Trauma
• Manual Strangulation
• Hanging Static Force
Low Velocity
• Multiple cartilaginous fractures w/o immediate
mucosal laceration
• Submucosal hematoma
• Significant displacement of the fractures
• Edema
Airway Compromised 12
Penetrating Trauma
• Knife and gunshot wounds
• Gunshot wounds directly
related to the velocity and
mass of the wounding
missile
– Low velocity
moderate blast
effect on surrounding
tissue
– High velocity
impart a significant
amount of kinetic
energy to the tissues High velocity gunshot wound
13
14
15
•Rigid bronchoscopic intubation followed by
tracheotomy
16
DIAGNOSIS and CLINICAL EVALUATION
• Hoarseness
• Aphonia
• Neck/throat Pain
Symptoms: • Dyspnea
• Dysphagia
• Odynophagia
• Hemoptysis
17
DIAGNOSIS and CLINICAL EVALUATION
Sign :
• Stridor • Loss of thyroid cartilage
• Hemoptysis prominence
• Vocal fold immobility
• Subcutaneous
emphysema • Laryngeal hematoma
• Laryngeal edema
• Laryngeal/neck
tenderness • Laryngeal lacerations
• Deviation of
larynx/trachea
18
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
19
Emergency Care
Multisystem trauma Pediatric airway
• Establish airway • Rigid bronchoscopic
• Cardiac resusitation intubation followed
• Control of hemorrhage by tracheotomy
• Stabilization of spinal injuries
Adult airway
• Tracheotomy under local anesthesia,
or rigid bronchoscopic intubation
20
DIAGNOSIS
1. Physical examination
2. Radiology
– Plain film : Chest x-ray, Facial films,
Neck soft tissue
– Computed tomography
– Arteriography
– Cervical spine radiographs
– Contrast esophagogram
3. Fiberoptic laryngoscopy
21
Diagnosis
• Unstable
– Tracheotomy and neck
exploration
• Stable patients
– Flexible fiberoptic
laryngoscopy in the
ER
• CT scan, direct
laryngoscopy,
bronchoscopy and
esophagosopy
22
Ct Scan
• CT allows: Hematoma
– Evaluation of the
laryngeal skeletal Fracture
framework Anterior Lamina
– Noninvasive
avoiding
unnecessary SQ emphysema
operative
explorations
23
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
24
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 25
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
26
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
Verschueren et al. Management of Laryngo-Tracheal Injuries.
J Oral Maxillofac Surg 2006.
27
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 Verschueren et al. Management of Laryngo-Tracheal Injuries.
J Oral Maxillofac Surg 2006.
28
• Thyroid cartilage fracture
• Reduced and segments fixed with
sutures, wires and miniplates 29
Robert H. Ossof et.al. The Larynx, Lippincot Williams & Wilkins, Philadephia, 2003
A. Midline fracture with flattened lamina
B. Translaryngeal wire passed through the tube and the
thyroid lamina in vertical mattress fashion
C. Wire secured with approximation and fixation of fracture,
achieving optimal alignment of laminae
30
Robert H. Ossof et.al. The Larynx, Lippincot Williams & Wilkins, Philadephia,
2003
A. Displaced fracture of lateral lamina
B. Wire-tube technique of reduction and fixation of fracture.
Endolaryngeal aspect of wire is passed submucosally.
C. Reduction completed. For lateral fracture, two wire tubes are
placed, one aboves and one below the level of the true vocal
cord
31
Robert H. Ossof et.al. The Larynx, Lippincot Williams & Wilkins, Philadephia, 2003
Minor cricioid injured may be repaired with wire or sutures. More
severe injuries will require stenting in addition
32
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
Verschueren et al. Management of Laryngo-Tracheal Injuries.
J Oral Maxillofac Surg 2006. 33
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
34
Laryngotracheal separation
Precarious airway
High risk injury recurrent
laryngeal nerve
Subglottic stenosis
Nonabsorbable sutures
35
36
37
38
COMPLICATION
Subglottic stenosis Granuloma
Basic Otorhinolaryngology© 2006 Thieme
39
40
41
SEVERITY OF THERMAL INJURY
Temperature
Material inhaled
Degradation natural protective
mechanism
42
AIRWAY
Upper airway : common
Middle airway
Lower airway
43
TRACHEOSTOMY A MULTIPROFESSIONAL HANDBOOK 2004
EVALUATION
Facial burn 66% thermal inhalation
injuries
Early diagnosis
Fiberoptic and direct laryngoscopy
44
ENDOSCOPIC CRITERIA FOR DIAGNOSIS
INHALATION LARYNGEAL INJURY
Mucosal edema
Necrosis
Ulceration
Carbonized material or debris
45
MANAGEMENT
1. Intubation :
Preferable inhalation injury
Cuff and uncuff tube controversy
2. Tracheostomy :
Controversy
Moylan : avoidance
Jone : laryngeal burn andTRACHEOSTOMY
prolonged A MULTIPROFESSIONAL HANDBOOK 2004
intubation 46
RECONSTRUCTION OF THE AIRWAY
Laryngeal, subglotic, tracheal stenosis
Prolong intubation and chemical inflammation
Contractile nature myofibroblas
Prolonged stenting subglotis stenosis
(Gaiser et al)
Endoscopic dilation and laser therapy
Open neck techniques (laryngotracheoplasty)
47
HOT LIQUID AND SOLID
LIQUIDS
Epiglotis common
Fatalities 6 hours post trauma
Death : asphyxia and massive
sloughing tongue and supraglottic
mucosa.
48
HOT LIQUID AND SOLID
Solid food
Differ from liquid
Oral cavity
Hypopharynx can severe
Epiglotis and hypopharingeal edema.
49
EVALUATION
Hystory
Diagnosis thermal injury confirm endoscopy
Lateral neck film
Management :
Intra venous fluid
Steroid
NGT
Nebulized epinephrin
50
CHEMICAL INJURIES
ALKALIS :
Bleach
Stridor edema epiglottis
Severe injury : edema larynx, hematemesis,
DIC, shock, esophageal perforation.
www.alkali.com
51
CHEMICAL INJURIES
Acid :
Oropharyngeal burn
No acut airway problem
Tracheal bronchial necrosis
aspiration
www.Acid liquid.com
Robert H. Ossof et.al. The Larynx, Lippincot Williams & Wilkins, Philadephia, 2003
52
EVALUATION
Esophageal and laryngeal endoscopy
Clinical finding thermal = chemical
Continue progress
53
MANAGEMENT
Keep airway open
Intravenous fluid
Antibiotic
Steroid
54
UNIQUE CHEMICAL INHALATION
INJURY
Crack cocain Hot gases fumed :
Cocain alkaloid systemic toxic
Hydrochloric acid & alkaline-neutralizing
substance
Cardiac and Neurologic
Burn upper airway : thermal and chemical
55
CRACK COCAIN
commons.wikimedia.org
56
EFFECTS CRACK COCAIN
commons.wikimedia.org 57
EVALUATION AND MANAGEMENT
Fiberoptic laryngeal endoscopy
Supportive
Intubation
Antibiotic
Intravenous hydration
58
INTERNAL INJURIES
Mechanical injuries :
• Intubation
• Endoscopy
• Foreign body extaction
• Suctioning
58
CAUSED INTUBATION INJURIES
59
Basic Otorhinolaryngology© 2006 Thieme
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 61
