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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

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Laryngeal Protection

Mandible
C-spine

Sternum

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Mechanism of Injury

Penetrating Inhalation/
trauma Ingestion

Blunt
Iatrogenic
trauma
Laryngeal
Injuries

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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.
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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:
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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.

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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.

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• Motor vehicle accidents

Rapid deceleration with neck hyperextended


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Blunt Trauma

• Clothesline Injury
Riding Motor Cycle

Stationary Object

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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

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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

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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

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

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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

• Antibiotics for laryngeal mucosa disruption


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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
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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.
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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.

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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
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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

 High risk injury recurrent


laryngeal nerve

 Subglottic stenosis

 Nonabsorbable sutures

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COMPLICATION

Subglottic stenosis Granuloma

Basic Otorhinolaryngology© 2006 Thieme

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SEVERITY OF THERMAL INJURY

Temperature

Material inhaled

Degradation natural protective


mechanism

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AIRWAY

Upper airway : common

Middle airway

Lower airway

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TRACHEOSTOMY A MULTIPROFESSIONAL HANDBOOK 2004
EVALUATION

Facial burn 66% thermal inhalation


injuries

Early diagnosis

Fiberoptic and direct laryngoscopy

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ENDOSCOPIC CRITERIA FOR DIAGNOSIS
INHALATION LARYNGEAL INJURY

Mucosal edema

Necrosis

Ulceration

Carbonized material or debris


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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)
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HOT LIQUID AND SOLID

LIQUIDS

Epiglotis common
Fatalities 6 hours post trauma
Death : asphyxia and massive
sloughing tongue and supraglottic
mucosa.
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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

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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

Esophageal and laryngeal endoscopy

Clinical finding thermal = chemical

Continue progress

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MANAGEMENT

Keep airway open

Intravenous fluid

Antibiotic

Steroid
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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

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CRACK COCAIN

commons.wikimedia.org
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EFFECTS CRACK COCAIN

commons.wikimedia.org 57
EVALUATION AND MANAGEMENT

Fiberoptic laryngeal endoscopy


Supportive
Intubation
Antibiotic
Intravenous hydration

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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