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DODDY SUMARDHIKA
• 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
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
• Clothesline Injury
Riding Motor Cycle
Stationary Object
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Blunt Trauma
• Manual Strangulation
• Hanging Static Force
Low Velocity
Airway Compromised 12
Penetrating Trauma
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•Rigid bronchoscopic intubation followed by
tracheotomy
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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
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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
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Emergency Care
Adult airway
• Tracheotomy under local anesthesia,
or rigid bronchoscopic intubation
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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
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Diagnosis
• Unstable
– Tracheotomy and neck
exploration
• Stable patients
– Flexible fiberoptic
laryngoscopy in the
ER
• CT scan, direct
laryngoscopy,
bronchoscopy and
esophagosopy
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Ct Scan
• CT allows: Hematoma
– Evaluation of the
laryngeal skeletal Fracture
framework Anterior Lamina
– Noninvasive
avoiding
unnecessary SQ emphysema
operative
explorations
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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
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• 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
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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
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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
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Laryngotracheal separation
Precarious airway
Subglottic stenosis
Nonabsorbable sutures
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COMPLICATION
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SEVERITY OF THERMAL INJURY
Temperature
Material inhaled
42
AIRWAY
Middle airway
Lower airway
43
TRACHEOSTOMY A MULTIPROFESSIONAL HANDBOOK 2004
EVALUATION
Early diagnosis
44
ENDOSCOPIC CRITERIA FOR DIAGNOSIS
INHALATION LARYNGEAL INJURY
Mucosal edema
Necrosis
Ulceration
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
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.
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EVALUATION
Hystory
Diagnosis thermal injury confirm endoscopy
Lateral neck film
Management :
Intra venous fluid
Steroid
NGT
Nebulized epinephrin
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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
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EVALUATION
Continue progress
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MANAGEMENT
Intravenous fluid
Antibiotic
Steroid
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UNIQUE CHEMICAL INHALATION
INJURY
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CRACK COCAIN
commons.wikimedia.org
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EFFECTS CRACK COCAIN
commons.wikimedia.org 57
EVALUATION AND MANAGEMENT
58
INTERNAL INJURIES
Mechanical injuries :
• Intubation
• Endoscopy
• Foreign body extaction
• Suctioning
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CAUSED INTUBATION INJURIES
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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