Professional Documents
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Laryngeal Trauma 20080722
Laryngeal Trauma 20080722
R3 李建樂
Epidemiology
Overview
2
Anatomy
Overview
Clothesline Strangulation
All-terrain Low velocity
vehicle/Snow Mobile vs Initial hoarseness and
Tree Branch skin abrasion
Large energy to small Hyoid fracture = classic
area injury
Massive trauma, Subsequent edema/loss
frequently instant of airway
death/ asphyxiation
Crushed Larynx
Tracheal Separation
Bilateral RLN injury
6
Penetrating Injury
Classification
Gunshot Wound
range and velocity
Knife/slash Wound
Cleaner, less peripheral damage
7
Inhalation/ Ingestion
Classification
Inhalation Ingestion
Hot air/Smoke/Steam Mucosal Burns
Initial erythema and Pediatric: household
carbon sputum items
Followed by marked Adult: lye or
edema hydrocarbons
Early airway control Direct damage while
prior to fluid ingesting or
resuscitation regurgitation
Alkali generally worse
than acid
Glottic reflex limits injury to supraglottis 8
Iatrogenic
Classification
Intubation
Larynx/Pharynx laceration or abrasion
Arytenoid dislocation
Neuropraxia of lingual, hypoglossal, SLN or RLN
Prolonged Intubation
Generally change to tracheotomy in 7-10 days (earlier with
inhalation injury)
Tracheotomy
Cricoid/RLN injury
9
10
Traumatic Emergencies Involving
the Pediatric Airway Classification
David L. Mandell, MD
11
Pediatric Patient
Classification
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 b/c lack of fxs
Circumferential area less = vulnerable to submucosal
changes = More often life-threatening
Rigid bronchoscopy followed by tracheotomy
over the bronchoscope
12
Symptom & Sign
Investigation
Hemoptysis
Voice changes, hoarseness
Difficulty in swallowing
Neck pain
Air-bubble from neck wound
Deformity of thyroid cartilage
Subcutaneous emphysema
Stable Condition
Investigation
15
Investigation
16
Dilemmas
Investigation
23
Surgical Exploration/Repair
Management
Aim
Airway patency
External anatomy restoration
Internal functional anatomy
Neck exploration
Midline thyrotomy for endolaryngeal injury
Hemostasis, remove clot or debridement
Meticulous repair of lacerations
Cover cartilage
Reduce fxs – wire or plate
Relocate arytenoids
Flaps for tissue loss
24
Reduction of Fractures
Management
Wire/Suture
Plating
Miniplates vs. absorbable
Offers immediate rigid fixation
Well tolerated in situ
Better strength in animal studies
25
Management
plate
26
Soft Tissue Repair
Management
Cover cartilage
Grafts if needed (mucosa, STSG)
Disrupt mucosa and expose cartilage lead to
granulation tissue
27
Stents
Management
28
Stents
Management
Types of stents
Endotracheal tube (COVER THE TOP END TO PREVENT ASPIRATION)
Finger cots filled with gauze or foam
Polymeric silicone stents
29
Pediatric
Management
30
Post operation
Management
Antibiotics
Anti-reflux
Elevate Head
Tracheotomy Care
Stent removal
Decannulate
31
Complication
Aspiration/Dysphagia/Odynophagia
Dysphonia, Vocal Fold immobility
Wait 6-12 months before intervention if RLN
Fistula
Unable to decannulate
Granulation Tissue/Obstruction
Pre-op delayed diagnosis
Post-op
Subglottic stenosis
Dilation, Excision
Cricoid split, Resection
32
Management
RLN Injury
Attempt primary repair, but only expect tone
Tracheal separation
Reapproximate cartilages
Severe trauma
Consider partial/total laryngectomy
33
Prognosis
Mortality 10-30%
Higher Risk in
Blunt Trauma (63%)
Need for emergency airway
Higher risk of poor voice/airway from
blunt trauma
34
Classification
35
Management
36
Management
37
Pediatric Patient
Classification
38
39
Classification
40
Classification
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
41
Reference
42
Thank you
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