LARYNGEAL INJURY By Methawee 12Dec2011

Laryngeal injury : consequence of neck injury Definitive treatment must be provided within 24 hours. Proper Mx is essential to preserve life , airway,voice,deglutition. Securing airway & protect C-spine : the first priority Severity of injury & Delayed Rx => poor outcome Classification 1. External laryngeal injury 2. Internal laryngeal injury < Iatrogenic >=> more frequent

External laryngeal injury Blunt injury

1.Crushing injury : Most common from motor vehicle accident

2.Clothesline injury

3.Strangulation injury: significant differences in the pattern of injury between suicidal and homicidal strangulation, 24 with the latter being more likely to cause laryngotracheal separation and concomitant neurovascular injuries.

Special consideration

Elderly person : More calcification of larynx :risk of comminuted fx

Childhood 1. laryngeal fracture : Larynx is situated higher in the protected by mandible neck &

The larynx lies at the level of C3 in the neonate and descends during the first 3 years of life to its adult position at the level of C6 2. soft tissue injury : loose attachment overlying mucous membrane& lack of fibrous support 3. relative cross-sectional area of larynx 2.+3. => airway obstruction Female person :Long & thin necksupraglottic injury Penetrating injury 1.Gunshot wounds : more severe tissue damage Severity related to Velocity& Distance 2.Knife wounds : less tissue damage & cleaner Associated injury from blast effect: thoracic duct, cervical nerve, great vessels and viscera

Internal laryngeal injury < Iatrogenic > Precipitating factor of Intubation injury Duration of intubation, Size of ETT, Type of ETT, Pressure cuff Intubation techniques : Nasotracheal VS orotracheal intubation Local infection,Recurrent trauma, Immunocompromised host

1.Intubation Injury (acute injury: intubation period) Most endolaryngeal injuries result as cpx.of intubation from intubation technique From forceful manipulation & insertion of ETT or too large ETT Glottic or subglottic injury is common In children : subglottis In adults: medial surface of the posterior commissure( on which the tube rests) perichondritis, granulation tissue formation

nerve injury

interarytenoid scarring and bilateral vocal cord immobility Possible cpx of intubation Pharyngeal lacerations, Cricoarytenoid dislocation Injury to the lingual, hypoglossal, superior laryngeal&recurrent laryngeal nerves and vocal folds Best Mx =Prevention ,Education for correct techniques of intubation/ Choosing a correct size of ETT Intubation Injury ( Delayed injury: Prolonged intubation )

10% after short-term translaryngeal intubationand rises to 90% after long-term intubation Supraglottic : Stenosis Glottic :Edema, vocal cord paralysis,Granuloma,interarytenoid fibrosis Cricoarytenoid joint dislocation Subglottic: Edema,granuloma,Stenosis Tracheal: Granuloma, Tracheomalacia,Stenosis ,TE fistula

Mx: Conversion to tracheostomy7 -10 days after intubation Inhalation injury Causes : superheated air esp. steam Limited injury to supraglottic area due to .reflex closure of the glottis Associated injury: other parts of the body esp. closed areas Initial presentation : unremarkable except erythema of upper airway & carbonstained sputum Mx: - secured airway & fluid resuscitation Injury from caustic ingestion Typically in childhood ( from various household products ) In adults => suicidal attempt(hydrocarbons : more common ) alkali : liquefaction necrosis of muscle, collagen, and lipids and creates an injury that worsens with time acids : coagulation necrosis of the superficial tissues S&S direct contact larynx during ingestion Limited injury to supraglottic area due to .reflex closure of the glottis Associated with oral, pharyngeal, and esophageal injuries Mx 24 hours for airway observation : GOAL-safe airway & cardiovascular resuscitation Presence of facial or body burns and soot in the oral cavity and finding at endoscopy of laryngeal edema predict the need for airway intervention Endotracheal intubation plays an even lesser role

If patients are to undergo microlaryngoscopy, tracheobronchoscopy, or esophagoscopy, the procedure should be performed within 24 hours of injury. The upper aerodigestive tract should be irrigated in cases of caustic injury to remove any residual substances Further treatment depends on the nature and extent of injuries found and the consequences of healing and scarring Caustic and thermal injuries can cause laryngeal and tracheal airway strictures

(severity is greater than that of strictures associated with postintubation laryngotracheal stenosis) DIAGNOSIS Classic symptoms:Hoarseness, laryngeal pain, dyspnea, dysphagia ***Severe compromised laryngeal lumen : aphonia & apnea tracheotomy => Need

Other symptoms:Aspiration : immobility of one or both vocal folds

Signs Laryngeal tenderness :to differentiate acute from old deformity Skin changes: contusions or abrasions from blunt injury, line pattern from strangulation injury,entrance and exit wound from penetrating injury Loss of thyroid cartilage prominence Stridor : relate to location of the lesion Subcutaneous emphysema&massive pneumomediastinum Hemoptysis : injury to upper aerodigestive system ( difficult to differentiate from facial trauma ) Vocal-fold immobility Laryngeal hematoma Laryngeal edema

Laryngeal lacerations

*** Laryngeal trauma is often associated with concomitant cervical and intracranial injuries and frequently occurs as part of multisystem polytrauma.

Investigation FOL : Evaluate endolaryngeal anatomy for Pts with stable airway Size & location of hematoma / lacerations Motion of arythenoid & TVC Airway patency? Exposed cartilage?

IDL : Not proper Rigid esophagoscopy : The best for examine hypopharynx & esophagus after R/O C-spine injury Plain films : Identify fractures but only two dimensions,Visualize the entire Cspine to avoid missing C-spine injury

case
CT scan Noninvasive manner for evaluate the laryngeal framework most useful method for evaluating laryngeal trauma CT scan can be deferred only in those patients with a history of relatively minor trauma to the neck, no laryngeal tenderness or surgical

emphysema, stable airway, and the finding of minimal laryngeal injuries on flexible laryngoscopy*** CT to identify. To assess the extent of laryngeal injury To confirm indirect or fiberoptic laryngoscopic findings To detect cartilage fractures that are not clinically apparent To assess poorly visualized areas( subglottic and anterior commissure regions) To identify associated cervical injuries

Management Goal To preserve life by maintaining the airway To preserve voice,swalowing quality

Emergency Care Primary survey : ABCD Airway & Breathing Cardiac resuscitation & control of hemorrhage Stabilization of neural and spinal injuries

Secondary survey :Investigation& Specific Mx for organ injuries Tracheotomy is more effective ( To prevent airway damage ) Intubation in this setting is hazardous Attempted ETT on a traumatized larynx : iatrogenic injury BUT intubation can be done 1. Under direct visualization by experienced personnel with a small ETT 2. If endolaryngeal mucous membrane is intact& laryngeal skeleton is minimally displaced ***A child with laryngeal injury Difficult to perform tracheotomy & O2 sat drop more quickly After successful bronchoscopy , tracheotomy can be done as needed

bronchoscope

Treatment Decision Making : Medical VS Surgical treatment Approximately 40% of patients with laryngeal trauma can be managed conservatively, and in those patients who require surgical treatment, the extent of the original injury correlates with the long-term outcome.

Medical treatment For 1. Edema 2. Small hematoma with intact mucosal coverage 3. Small lacerations without exposed cartilage 4. Single nondisplaced thyroid cartilage fractures in stable larynx Voice rest Systemic steroids : if presenting within 24 hours of injury Elevate head Humidified air Antibiotics laryngeal mucosa has been breached Antireflux measures Avoid NG tube

***Uncertain blunt trauma : observe for signs of progressive airway compromise at least 24 hrs Surgical treatment FOR. group 3,4,5 1. 2. 3. 4. 5. 6. Lacerations involving the free margin of the vocal fold Large mucosal lacerations Exposed cartilage Multiple and displaced cartilage fractures Avulsed or dislocated arytenoid cartilages Vocal fold immobility

Surgical treatment Tracheotomy Endoscopy Exploration Thyrotomy Closure of laceration Insertion of stents Grafting Fixation of fractures

Timing Early exploration : (Better outcome & more effective) Lower post-op infection rate Quicker healing Less granulation tissue& scarring We aim to repair all laryngeal injuries within 12 hours of presentation and are reluctant to accept delays beyond 24 hours. Delayed exploration Edema : Easy to repair ? In C-spine or traumatic brain injury pts Delays in treatment can lead to granulation and scar tissue formation, which can progress to laryngeal stenosis, a difficult surgical problem to correct.

Direct laryngoscopy, Bronchoscopy, esophagoscopy should be done before surgery

injury

Thyrotomy

Closure of laceration :Meticulous technique by 5-0 or 6-0 absorbable suture material Exposed cartilage must be covered to prevent granulation tissue and fibrosis Failure to do : grafting and healing by secondary intention (chance for scar formation) Grafting Loss of tissue is large & exposed cartilage Donor site1.Mucous membrane => most closely resembles normal endolaryngeal epithelium 2.Dermis :Split-thickness skin Insertion of stents To maintain internal configuration of larynx(normal scaphoid shape of the anterior commissure) & prevent stenosis I/C

Stent 3
Anterior commissure disruption Multiple & displaced cartilage fracture Multiple & severe endolaryngeal laceration

After placement of a stent , Anterior commissure is reconstituted by suturing TVC to outer perichondrium

Remove in 10-14 d. : risk of infection, Granulation tissue formation ORIF: screw suturematerial, stainless steel wire, titanium miniplate and

VOCAL CORD IMMOBILITY Cricoarytenoid joint dislocation :endoscopic manipulation and reduction Recurrent laryngeal nerves injury : Only if a complete palsy exploration of the affected nerve

*** Cricoarytenoid joint mobility can be assessed preoperatively, but definitive assessment of joint mobility requires microlaryngoscopy and instrumentation (passive mobility test) Cricotracheal Separation Precarious airway Loss of cricoid support High risk of injury to RCN Late development of SGS Mx : -Tracheotomy +/- Bronchoscope - Avoid ETT - Cricotracheal anastomosis & mucosal repair (Intact cricoid cartilage) 1. Repair with the posterior anastomosis, using a combination of 3-0 absorbable and nonabsorbable sutures, and works toward the anterior trachea 2. All knots are extraluminal, and the sutures are run through the submucosal plane 3. Avascular and damaged tissue is resected

4. If there is an associated crush injury to the trachea, a temporary soft polymeric silicone stent may have to be placed in the lumen prior to anastomosis - Internal fixation +/- stenting (Fx of cricoid cartilage) PARTIAL OR TOTAL LARYNGECTOMY In cases of massive laryngeal injury with significant tissue loss , BUT rare Severed Recurrent Laryngeal Nerve Immediate nerve reapproximation under an operating microscope Nerve regeneration???,Prevent muscle atrophy, Maintain some strength of voice

Postoperative Care Strict voice rest for 48 to 72 hours NG tube should be inserted at the time of surgery and should remain until the safety of swallowing is confirmed Post-op antibiotics for 5 -7 days (if mucosal tear) Elevate head Ambulate as soon as possible Remove stent in2 wk after surgery(mucosal tear),3 wk (anterior commissure disruption ) Tracheostomy tube care Decannulation as soon as the stent is removed Antacids & H2-blockers : to prevent reflux Regular endoscopic examinations :granulation tissue is removed to prevent long-term scarring In patients with cricotracheal separation, the neck is kept in flexion for 7 days postoperatively to prevent traction on the anastomosis

Follow-up : continue at least 1 year To assess true vocal fold function return To assess development of SGS COMPLICATION Granulation tissue Prevent by covering all exposed cartilage Avoid stents when possible Careful excision Laryngeal stenosis Excision with mucosal coverage Stenting selected cases Laryngotracheoplasty Tracheal resection with reanastomosis

Vocal-fold immobility Observe Vocal-fold injection Thyroplasty-type vocal-fold medialization Arytenoidectomy and vocal-fold lateralization for bilateral paralysis Outcome depend on Extent of the original injury Quality of subsequent repairs Group 1 -2 : excellent recovery without Group 3 -5 : good result if early repair surgery