Case Report: Endoscopic Management of Penetrating Laryngeal Trauma · 2018. 10. 8. · Case Report:...
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Case Report: Endoscopic Management of Penetrating Laryngeal Trauma Julie P. Shtraks, MD; Ahmed M.S. Soliman, MD Dept. of Otolaryngology- Head & Neck Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA ABSTRACT INTRODUCTION CASE REPORT DISCUSSION Isolated laryngotracheal trauma is a rare clinical scenario. Penetrating laryngeal trauma is usually treated via open surgical techniques. We present a case of a patient who sustained a gunshot wound through the larynx with significant mucosal destruction from the blast injury who was managed completely endoscopically with an excellent clinical outcome. • External trauma to the laryngotracheal complex is rare • Accounts for <1% of trauma cases, 1/30,000 ED visits per year in the United States 1,2 • Blunt penetrating trauma is more common than penetrating, however penetrating laryngeal trauma is increasing • Knife, gunshot, and blast injuries account for majority of penetrating trauma in the U.S. 2 • Injury to the aerodigestive tract occurs in 5-15% of penetrating neck traumas 3 • Patients with massive edema, mucosal disruption, exposed cartilage, vocal fold immobility, or displaced laryngeal cartilage require surgical intervention 2 • Penetrating laryngeal trauma caused by gunshot results in blast injury and cartilage framework fractures • Usually requires open thyrotomy • We present a case of a patient who sustained a gunshot wound to the neck, resulting in blast injury, who was managed with endoscopic debridement and laryngeal stent • A 25 year old male presented to the Temple University Hospital Emergency Department after sustaining a gunshot wound to the left neck • He was orotracheally intubated in the trauma bay • CT angiogram of the neck demonstrated extravasation from the right external carotid artery and its proximal branches • He was taken emergently to the operating room IOR) by the Trauma service for neck exploration and control of hemorrhage • Otolaryngology was consulted intraoperatively • Direct laryngoscopy identified diffuse edema and ecchymosis of the supraglottic structures obscuring visualization of the vocal folds • 48 hours later, he was taken to the OR by Otolaryngology for tracheotomy and laryngeal cartilage repair • Microlaryngoscopy revealed extensive left sided supraglottic devitalized tissue involving the arytenoid, false vocal fold and ventricle • In blast injuries, the severity of the injury is directly related to the kinetic energy conveyed by the missile onto the laryngeal tissue 4 • Generally, civilian gunshot wounds are lower-velocity, though high- velocity handguns do contribute to civilian crime • We describe the case of a patient who presented to our institution after sustaining a penetrating zone II neck trauma resulting in blast injury to the endolarynx • The primarily supraglottic location of the injury and the relative sparing of the vocal folds lent itself well to endoscopic treatment and his excellent voice and airway outcome • The significant neck edema and extensive vascular repair required made neck exploration and open treatment more challenging and potential risky • This technique may be applicable for use in other patients who sustain blast injury to the neck both in civilian and military environments, and should be in the toolbox of otolaryngologists CONCLUSIONS Endoscopic management of endolaryngeal injury from penetrating laryngeal trauma is a feasible option in select patients with significant mucosal destruction resulting from blast injury to the neck • Devitalized tissue was removed with the laryngeal microdebrider Tricut® blade (Medtronic Inc., Minneapolis, MN) until healthy appearing tissue was seen • A soft endolaryngeal stent was fashioned from a sterile glove finger filled with Vaseline gauze was placed endoscopically • He returned to the OR 7 days later for stent removal at which time marked improvement in supraglottic edema and a patent glottic airway was seen • He was discharged home with his tracheotomy in place • He returned to the outpatient clinic one month after endoscopic repair and was using a Passy Muir valve without issues • On flexible laryngoscopy, his supraglottic and glottic airway was patent and his true vocal fold mobility was normal • He was decannulated 6 weeks after his initial injury Figure 1 A,B. (A) Axial CT scan at the level of the thyroid cartilage demonstrating the entry point of the bullet in the left neck with surrounding metallic bullet fragments; (B) Coronal CT scan showing extensive soft tissue swelling with subcutaneous emphysema and scattered bullet fragments. Figure 2 A-F. (A) Intra-operative view of extensive devitalized supraglottic tissue; (B) Devitalized tissue removed with laryngeal microdebrider Tricut blade (Medtronic Inc., Minneapolis, MN); ( C) Supraglottis after debridement of necrotic tissue; (D) Laryngeal stent removal; (E) Decannulation; (F) Outpatient laryngoscopy revealed a patent glottis with normal true vocal fold mobility REFERENCES 1. Jalisi S, Zoccoli, M. Management of Laryngeal Fractures—A 10-Year Experience. J Voice. 2011;25(4):473-9. 2. Schaefer SD. The acute management of external laryngeal trauma. A 27 year experience. Arch Otolaryngol Head Neck Surg. 1992;118(6):598-604. 3. Soliman AMS, Ahmad SM, Roy D. The Role of Aerodigestive Tract Endoscopy in Penetrating Neck Trauma. Laryngoscope. 2014; 124:S1-S9. 4. Holt GR, Kostohryz G. Wound ballistics of gunshot injuries to the head and neck. Arch Otolaryngol. 1983;109:313-318. A B C D E F
Transcript of Case Report: Endoscopic Management of Penetrating Laryngeal Trauma · 2018. 10. 8. · Case Report:...
CaseReport:EndoscopicManagementofPenetratingLaryngealTraumaJulieP.Shtraks,MD;AhmedM.S.Soliman,MD
Dept.ofOtolaryngology- Head&NeckSurgery,LewisKatzSchoolofMedicineatTempleUniversity,Philadelphia,PA
ABSTRACT
INTRODUCTION
CASEREPORT
DISCUSSION
Isolatedlaryngotrachealtraumaisarareclinicalscenario.Penetratinglaryngealtraumaisusuallytreatedviaopensurgicaltechniques.Wepresentacaseofapatientwhosustainedagunshotwoundthroughthelarynxwithsignificantmucosaldestructionfromtheblastinjurywhowasmanagedcompletelyendoscopicallywithanexcellentclinicaloutcome.
• Externaltraumatothelaryngotrachealcomplexisrare• Accountsfor<1%oftraumacases,1/30,000EDvisitsperyearintheUnitedStates1,2
• Bluntpenetratingtraumaismorecommonthanpenetrating,howeverpenetratinglaryngealtraumaisincreasing• Knife,gunshot,andblastinjuriesaccountformajorityof
penetratingtraumaintheU.S.2• Injurytotheaerodigestivetractoccursin5-15%ofpenetratingneck
traumas3• Patientswithmassiveedema,mucosaldisruption,exposedcartilage,
vocalfoldimmobility,ordisplacedlaryngealcartilagerequiresurgicalintervention2
• Penetratinglaryngealtraumacausedbygunshotresultsinblastinjuryandcartilageframeworkfractures• Usuallyrequiresopenthyrotomy
• Wepresentacaseofapatientwhosustainedagunshotwoundtotheneck,resultinginblastinjury,whowasmanagedwithendoscopicdebridementandlaryngealstent
• A25yearoldmalepresentedtotheTempleUniversityHospitalEmergencyDepartmentaftersustainingagunshotwoundtotheleftneck
• Hewasorotracheallyintubatedinthetraumabay• CTangiogramoftheneckdemonstratedextravasationfromtheright
externalcarotidarteryanditsproximalbranches• HewastakenemergentlytotheoperatingroomIOR)bytheTrauma
serviceforneckexplorationandcontrolofhemorrhage• Otolaryngologywasconsultedintraoperatively• Directlaryngoscopyidentifieddiffuseedemaandecchymosisofthe
supraglotticstructuresobscuringvisualizationofthevocalfolds• 48hourslater,hewastakentotheORbyOtolaryngologyfor
tracheotomyandlaryngealcartilagerepair• Microlaryngoscopyrevealedextensiveleftsidedsupraglottic
devitalizedtissueinvolvingthearytenoid,falsevocalfoldandventricle
• Inblastinjuries,theseverityoftheinjuryisdirectlyrelatedtothekineticenergyconveyedbythemissileontothelaryngealtissue4
• Generally,civiliangunshotwoundsarelower-velocity,thoughhigh-velocityhandgunsdocontributetociviliancrime
• WedescribethecaseofapatientwhopresentedtoourinstitutionaftersustainingapenetratingzoneIInecktraumaresultinginblastinjurytotheendolarynx
• Theprimarilysupraglotticlocationoftheinjuryandtherelativesparingofthevocalfoldslentitselfwelltoendoscopictreatmentandhisexcellentvoiceandairwayoutcome
• Thesignificantneckedemaandextensivevascularrepairrequiredmadeneckexplorationandopentreatmentmorechallengingandpotentialrisky
• Thistechniquemaybeapplicableforuseinotherpatientswhosustainblastinjurytotheneckbothincivilianandmilitaryenvironments,andshouldbeinthetoolboxofotolaryngologists
CONCLUSIONSEndoscopicmanagementofendolaryngealinjuryfrompenetratinglaryngealtraumaisafeasibleoptioninselectpatientswithsignificantmucosaldestructionresultingfromblastinjurytotheneck
• DevitalizedtissuewasremovedwiththelaryngealmicrodebriderTricut®blade(MedtronicInc.,Minneapolis,MN)untilhealthyappearingtissuewasseen
• AsoftendolaryngealstentwasfashionedfromasterileglovefingerfilledwithVaselinegauzewasplacedendoscopically
• HereturnedtotheOR7dayslaterforstentremovalatwhichtimemarkedimprovementinsupraglotticedemaandapatentglotticairwaywasseen
• Hewasdischargedhomewithhistracheotomyinplace• Hereturnedtotheoutpatientcliniconemonthafterendoscopic
repairandwasusingaPassyMuirvalvewithoutissues• Onflexiblelaryngoscopy,hissupraglotticandglotticairwaywas
patentandhistruevocalfoldmobilitywasnormal• He was decannulated 6 weeks after his initial injury
Figure1A,B.(A)AxialCTscanatthelevelofthethyroidcartilagedemonstratingtheentrypointofthebulletintheleftneckwithsurroundingmetallicbulletfragments;(B)CoronalCTscanshowingextensivesofttissueswellingwithsubcutaneousemphysemaandscatteredbulletfragments.
Figure2A-F.(A)Intra-operativeviewofextensivedevitalizedsupraglottictissue;(B)DevitalizedtissueremovedwithlaryngealmicrodebriderTricutblade(MedtronicInc.,Minneapolis,MN);(C)Supraglottisafterdebridementofnecrotictissue;(D)Laryngealstentremoval;(E)Decannulation;(F)Outpatientlaryngoscopyrevealedapatentglottiswithnormaltruevocalfoldmobility
REFERENCES1. JalisiS,Zoccoli,M.ManagementofLaryngealFractures—A10-Year
Experience.JVoice.2011;25(4):473-9.2. SchaeferSD.Theacutemanagementofexternallaryngealtrauma.A27year
experience.ArchOtolaryngolHeadNeckSurg.1992;118(6):598-604.3. SolimanAMS,AhmadSM,RoyD.TheRoleofAerodigestiveTractEndoscopyin
PenetratingNeckTrauma.Laryngoscope. 2014;124:S1-S9.4. HoltGR,KostohryzG.Woundballisticsofgunshotinjuriestotheheadand
neck.ArchOtolaryngol. 1983;109:313-318.
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