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LARYNGOTRACHEAL TRAUMA
INTRODUCTION
Laryngotracheal trauma commonest occur after road traffic accidents. Laryngeal fractures may well be missed because effort will be direct towards securing the airway and other injuries (head, chest, abdomen etc). Severe effects on airflow - Poiseuilles law
sharp
cartialge is still largely cartilaginous When hit vertebrae, the laminae are spread outwards Fracture occurs down the prominence Epiglottis may be detached causing obstruction Artyenoids are pushed against the vertebrae, may become swollen or disarticulated
cartilage is largely ossified Compressing force against the vertebrae will shatter the thyroid cartilage Disorganize the cords, epiglottis and arytenoids Causing flattening of neck
DIAGNOSIS
Easy to miss Always suspect in patient with multiple injuries Symptoms:
Look for
surgical emphysema, stridor, Cervical bruising, Loss of thyroid prominence, Loss of normal neck outline
Mirror examination or flexible laryngoscopy may show edematous, haemorrhagic arytenoids, mucosal tears and disorganized vocal cords DL should be done in suspected cases, but may exacerbate the effect of injury
INVESTIGATIONS
air
CT scan
TREATMENT
Secure airway
Intubation/
tracheostomy
Supportive
Oxygen Steroids Humid
to have no requirement of permanent tracheostomy tube, no dypsnea and normal daily activities Minimal debridement Usually involves open exploration and repair, reduction and fixation
Fractures of hyoid
Remove
CAUSES
Apart
Tracheostomy,
Partial
laryngectomy,
Granulomatous
Management:
Should not attempt for surgery until 18 months has passed from the initial injury Aim to get rid of tracheostomy tube and preserve a good voice Should assess the length of neck and cervical trachea available for mobilization Most patients should already have a tracheostomy, they should be informed the possibility of failure to wean off Stenosis due to systemic illness usually have poor results
Supraglottic
Excising
only the scarred area and leave the normal functioning vocal cords Mucosa is quilted down to avoid a dead space Another choice will be permanent tracheostomy
Glottic stenosis
may be removed and cords stitched in the desired position or the cords wired laterally approach, exicsing the web and closing the larynx over a McNaught Keel made of silastic excised, refashioned and fixed over a solid stent inlay of silicone for 8 weeks
to 4cm of trachea can be excised Free the tracheal stump and drop the larynx by dividing the suprahyoid muscles
Cricoid stenosis
The
only complete ring in respiratory tract Procedures trying to build out the ring have not been very sucessful Among the method available , the choice is to excise the cricoid apart from a plate on which the arytenoid lies. Free the trachea and larynx dropped down to join the cricothyroid remnant Risk of RLN injury
To operate or not?
Patient
with no tracheostomy could be advise for non operative management due to possibility of inducing scarring leading to a tracheostomy Patient with tracheostomy should be encourage since this is about 50% chance, he/she may wean off the tracheostomy tube.
CONCLUSION
High clinical suspicious of laryngeal injury in patient with multiple trauma Always look for underlying causes in patient with chronic laryngeal stenosis Aware of different operative management in laryngeal injury/ stenosis
THE END