Laryngeal trauma
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Transcript of Laryngeal trauma
LARYNGEAL TRAUMA
Larynx is a well protected structure in the neck
Functions: airway ,tracheobronchialprotection & phonation
Skeletal framework : hyoid,thyroid,cricoid Divided into supraglottis.glottis,subglottis Supraglottis –soft tissue Glottis-relies on external
support,cricoarytenoid jt mobility and neuromuscular coordinaton
Subglottis - cricoid
Laryngeal trauma is rare < 1 % of all traumas
Incidence is low < 1 / 30,000 ER visits
Males > females
Older persons more predisposed to communitedfractures attributed to calcification
Associated injuries
Intracranial : 13%
Cervical spine fracture : 8%
Oesophageal injury : 3%
BLUNT INJURIES : CLOTHESLINE
CRUSHING
HANGING
STRANGULATION
PENETRATING INJURIES
INHALATIONAL/INGESTION INJURIES
IATROGENIC INJURIES
ANTERIOR BLUNT INJURIES: Mc in motor vehicle accidents
During deceleration driver is thrust forward with neck hyperextended: without the protection of mandible, larynx can strike wheel/ dashboard : compressed
Clothesline injury : rider of vehicle : motorcycle or snowmobile: encounter a fixed horizontal object at neck, clotheline at neck, there is large amount of energy against small surface causing separation of cricoid from larynx or the trachea
Strangulation : initially abrasion of skin
12 - 24 hrs later edema of larynx leading to airway compromise
Penetrating injuries : gunshot or knife injuries
Gunshots at close range impart intense energy and are usually fatal
Long range : damage may be minimal
High velocity weapons : surrounding tissue damage is significant, wide debridement advisable
Penetrating injuries
Bounces the laryngeal skeleton
enters thyrohyoid membrane
bleeding of paraglottic space
Airway obstruction
Enters cricothyroid membrane
Air escapes into soft tissues
Surgical emphysema
Hyoid bone :
May be fractured
Can cause mild discomfort or painful swallowing
Rarely can lead to formation of bursa at the fractured ends which can be treated by excision
Thyroid cartilage & arytenoids
Commonly fractured due to the prominence of the thyroid cartilage in the neck
This injury depends on degree of calcification of the cartilage
Minimal injury – no fracture
If pushed backwards over cervical spine,thyroid ala is splayed apart to a more obtuse angle
This can lead to pre-epiglottic space bleeding & posterior displacement of epiglottis
Calcified thyroid cartilage gets shattered resulting in communited fracture
Cricoid cartilage
Invariably associated with thyroid fractures
Anterior part of the cricoid mostly fractured
Cricotracheal seperation
Final soft tissue injury,usually results in death at the roadside
Cricotracheal membrane is sheared off
Several tracheal rings may be damaged
Larynx pulled upwards & trachea is pushed to the retrosternal area
Inhalational injuries
Hot air/smoke/steam: glottis reflexely closes: limits the amount of thermal injury by stopping inhalation : injury supraglottic larynx.
Ass with burns in othr parts of the body
Initial erythema & blackish sputum
Marked oedema
Early airway management : marked edema of injured mucosa with loss of airway : inability to intubate
Ingestion injuries
Mucosal burns
Direct damage due to ingestion / regurgitation
Alkali worse than acids
Iatrogenic injuries
Intubation : Mucosal laceration / cricoarytenoid dislocation / injury to lingual,hypoglossal , superior laryngeal , recurrent laryngeal nerve (neuropraxia)
Prolonged intubation
Tracheostomy : Injury to cricoid / recurrent laryngeal nerve
Diagnosis
Symptoms : Change in voice ,Difficulty in breathing,Dysphonia,Dyspaghia,Pain,Cough
Hemoptysis
Stridor : b/l vc palsy/ surpaglottic/ glottic / subglottic edema
Skin : contusions, abrasions
open fractures
laryngocutaneous fistula
Palpation : Crepitance
tenderness : significant injury
Cervical spine should always be palpated
EXAMINATION
Incases of cricotracheal separation the airway may be maintained via a cutaneouslaceration tat connects the trachea: no attempt should be made to cover or compress or manipulate the wound : until surgeon ready for airway establishment
Subtle form of laryngeal dysfunction is aspiration: immobitly of vocal cords
Any penetrating injury should be examined for entry and exit wounds
Open wounds should not be explored with instruments, should not be probed
Endolaryngeal anatomy examined : fibreoptic in case of non intubated pts, very careful
Look for hematomas, movement of arytenoids or presence of any exposed cartilage
Plain x-ray of cervical spine :
To exclude hyoid bone fracture & concurrent cervical spine fracture
Chest x-ray
To rule out mediastinal emphysema / puenomothorax
CT SCAN Mainly for pts who can do well without any
surgical intervention
Pts requiring a open surgical repair or with exposed cartilage : does give much input
nonivasive Spiral ct scan- mainstay of post traumatic
laryngeal injury Quick (< 20secs) Can produce two dimensional ,reconstructed
images Detects mucosal oedema,fracture of
thyroid,disruption of cricoaryteniod/cricothyroidjoint,assessment of c-spine
CT reserved for forpatients in whom laryngeal injury is
supected from either history or physical
examination without any indications for surgery.
Noninvasive confirmation of laryngeal
injury without need for GA or laryngoscopy.
Presence of massive edema or hematoma :
direct laryngoscopy not helpful: CT provides
input.
Direct laryngoscopy
Done under GA
Look for 1) large mucosal laceration 2) exposed cartilage 3)laceration on the free edge of the vocal cords 4)vocal cord immobility 5)dislocated arytenoids 6) displaced fractures 6) other neck injuries
GROUP SYMPTOMS SIGNS MANAGEMENT
Group I Minor airway symptoms
Minimal hematomaSmall lacerationNo fractures
ObservationHumidified airHead end elevation+/- Steroids
Group II Airway compromise Oedema/hematomaMinor mucosal disruptionNo cartilage exposure
Direct laryngoscopyOesophagoscopy+/- Tracheostomy+/- steroids
Group III Airway compromise OedemaMucosal tears Exposed cartilageVocal cord immobility
TracheostomyDirect laryngoscopyOesophagoscopyExploration/repairNo stent needed
Group IV Airway compromise Massive oedemaSignificant mucosal tearExposed cartilageVocal cord immobility
TracheostomyDirect laryngoscopyOesophagoscopyExploration/repairStent required
Securing the airway-
Tracheostomy
Endotracheal intubation-indicated only when mucosa is intact,minimal laryngeal fracture
Endotracheal intubation may further damage the larynx
Paediatric pt –airway secured with rigid bronchoscopy,tracheostomy performed over bronchoscope
Follwing intubation/ trach : direct laryngoscopy to assess the extent of damage: hematomas, exposed cartilage, lacerations, movement of vocal cords
Conservative management Group I & II Clinical observation for 48hrs Head end elevation 30 degree Voice rest –minimize edema Humidified air-prevents crust formation &
improves ciliary function Corticosteroids Antibiotics Antireflux medication
Surgical management
All injuries involving the anterior commisure
Exposed cartilage
Multiple or displaced fracture of thyroid cartilage
Multiple fractures of cricoid cartilage causing
1. Vocal fold paralysis
2. Airway compromise to require intubation or trach
3. Injury to neck requiring exploration
Open surgical exploration & repair
Exploration within 24hrs –maximizes airway & phonation results
Hemostasis
Evacuation of hematoma
Reconstruction of the laryngeal framework
Coverage of de-epithelialized surfaces
Group II to IV required surgical intervention
Subplatysmal apron flap elevated till the hyoid bone
Laryngeal skeleton is exposed from the hyoid to sternal notch
Midline thyrotomy◦ May use a vertical fracture (2 to 3mm of midline)
Nondisplaced fractures◦ Suture outer perichondrium◦ Primary closure with nonabsorbable suture / wires
Mucosal lacerations◦ Meticulously repaired using fine absorbable sutures◦ Knots outside the laryngeal lumen (prevent
granulation)
Displace fractures of the cartilages are reduced◦ Stabilized using stainless
steel wires, nonabsorbable suture or
miniplates. ◦ Small fragments of
cartilage with no intactperichondrium are removed to prevent
perichondritis. Anterior commissure-
suspend the anteriortrue vocal cords to
the outer perichondrium
of the thyroid cartilage
Close the thyrotomy◦ Nonabsorbable suture,
wires or miniplates
Anterior glottic injuries :
Seen in vertical thyroid cartilage #
Ass with vocal fold laceration
Endolarynx approached through midline thyrotomy or thru thyroid #
Anterior commisure divided in midline
Mucosal laceration closed
Anterior free edges of false and true vocal cords sutured thru the anterior thyroid perichondrium
Keel used to reconstruct the anterior comm
Endolaryngeal stenting (group IV )◦ Disruption of the anterior commissure
◦ Massive mucosal injuries
◦ Comminuted fractures of the laryngeal skeleton
◦ Cases wher architecture of larynx not maintained by open fixation
Uses : ◦ Stability and prevent endolaryngeal adhesions
◦ Maintains the scaphoid shape of anterior commissure,essential for vocalization
◦ Support to laryngeal framework : movement : phonation/ swallowing
Types of stents
Endotracheal portex tube-
Most easily available
3.5cm long,upper end closed with sutures to prevent aspiration
Smooth clamps are placed to approximate true & false vocal cords
Finger cots filled with gelfoam /gauze
Stent should be placed such that it extends from false vocal cords to first tracheal ring
Stent secured by monofilament sutures through the laryngeal ventricle and cricothyroid membrane and tied to skin buttons.
Removed in a period of 10 to 14 days to prevent mucosal damage
Antibiotics – 5 to 7 days
Antireflux – proton pump inhibitors routinely used to prevent reflux which can cause mucosal damage & scarring.
Avoid nasogastric tubes as it erodes the postcricoidmucosa
Head end elevation
Early ambulation
Tracheostomy care
Removal of stents in 2 weeks followed by decannulation
Follow up-1yr for assessment of true vocal cord function & to monitor development of subglotticstenosis
Formation of profuse granulation tissue ; can be debulked endoscopically
Vocal cord immobility due to
• RLN injury- unilateral paralysis wait & watch for 6 months.Medializtion procedure considered if no voice return is noted
• Bilateral paralysis-arytenoidectomy / cordotomy
Subglottic /Tracheal stenois
Common in clothesline injuries., ligamentous inj
Cricotracheal separation is usually associated with cricoid fractures and avulsion of the mucosa from the anterior surface of the posterior cricoid plate.
high chance of asphyxiation and mortality.
Cricotracheal separation is highly associated with recurrent laryngeal nerve injury.
Immediate onset aphonia, hemoptysis, respiratory distress, cervical subcutaneous emphysema
Open neck wound : distal stump : intubated
No neck wound : emergency tracheostomy
Repair : within 24hrs
Primary re-anastamosis from posterior to anterior
Intact cricoid :only the mucous membrane needs to be repaired.
If cricoid is fractured:◦ internal fixation of
the cricoid cartilage done.
If > 2cm of tracheal loss : larynx mobilized
Complications-granulations, laryngeal and tracheal stenosis, glottic web
Incidence : 4-13% : adults, 0.5 -61% in neonates
Mc cause : prolonged intubation
• Endotracheal intubation injuries
1. Laryngeal mucosa
2. Soft tissues
3. Perichondrium
4. Cartilage
• most injuries : superficial irritation / minor ulceration : heal quickly
• More severe injuries : edema, granulation tissue / ulcerations
Epithelial erosion and ulceration
Ischemic necrosis
Mucosal injury
Mucosal ischemia Capillary perfusion pressure
Cartilage necrosis
Perichondritis
After 96hrs
Stromal necrosis
Minor epithelial erosion :
primary epithelialization
Extensive ulceration
secondary intention healing
with granulation tissue
Granuloma
Contracted scar tissue
Endotracheal tube lies in the posterior larynx :
Applies pressure on 3 sites
1. Arytenoids : vocal process: medial surface
2. Posterior glotticmucosa in the interarytenoidregion
3. Cricoid cartilage
• Physical trauma : difficult/ repeated intubations
• Duration of inutbation:
1. 7 days : adults2. Infants : longer3. Neonates : weeks • State of larynx• Movement of tube :
coughing, swallowing, bucking during anesthesia, transmitted ventilator movement
Mucociliray mechanism : reduced :
1. Presence of tube2. Stasis of secretions3. Trauma from
suctioning4. Bacterial
contaminationGastroesophageal reflux :
chemical irritation : increased local injury
Nasogastric tube
Tube characteristics
Tube sizing
Max : 8 mm in males and 7mm in females : inner dia
Upto 8yrs : uncuffed tube
Cuff pressure 8cm of H2O2
Patient factors◦ Poor tissue
perfusion (i.e. sepsis, organ failure, etc)◦ LPR◦ Abnormal larynx◦ Wound healing,
keloid
ENDOSCOPIC ASSESMENT
Nature of degree of trauma assessed by direct laryngoscopy and endoscopy
Assesment : 7 days : adultys, children after 1 -2 weeks, infants when attempted extubationunsuccesful
Continued intubation
1. Edema in vocal cords
2. Surface mucosal ulceration
3. Minor granulation tissue at vocal process
4. Absence of deep ulceration and perichondritis
Intubation injuries heal quickly without treatment
Severe injuries : deep ulceration : tracheostomy
Continued intubation > 7 days : tracheostomy
Early non specific :
1. Hyperemia
2. Edema
3. Surface ulceration
4. Granulation
Edema1. In the loose tissue of
ventricle : protrusion
2. In vocal folds perists : reinkes edema
3. Edematous swelling in the submucosa of criccoidcartilage
Granulation tissue: at the sites of ulceration by tube pressure on mucosa, perichondrium/ cartilage
Formed within 48hrs
Spontaneous resolution : after tube removal
Incomplete resolution : intubation granuloma
nodules
interarytenoidadhesions
Ulceration
Caused by pressure necrosis of the tube
Sites :
1. medial surface of aytenoids
2. Anterior surface of lamina of thyroid cartilage
3. Cricoarytenoid joints
Superficial ulcerations : epithelialization
Deep : scar tissue formation : stenosis
Misc injuries
Laceration
Bleeding into vocal cords
Arytenoid dislocation
Perforation
Cricoid ulceration: sinus/ fistula : both NG tube and ET tube presence
Chronic changes
after extubation
Rapid resolutionSevere stenosis
Intubation granulomas Healing incomplete :
perichondritis persists : granulation tissue remains localised : granuloma
U/L, can be B/L Yellow red goblular
mass, pedunculated at vocal process and medial surface of arytenoid
Can develop upto 8wks aftr extubation
50% resolve spontaneously
Co2 laser excision
1. Less removal: proliferation and recurrence
2. Excessive removal : exposure of perichondrium and recurrence
b/l granulations on vocal
process fall together adhere
and heal to one another
If not removed
Mature
Interarytenoid bands
Vocal cords tethered together, abduction is limited : airway obstruction
Misdiagnosed as b/l vocal cord paralysis
Partial or complete cicatricial narrowing of endolarynx
Establishing diagnosis◦ Laryngeal stenosis
Noisy breathing
Stridor
Phases: inspiratory, expiratory, biphasic
Wheezing
Recurrent : precepitating factors and aggravating factors
Infection, exercise
History of emergency intubation
Suggest higher possibility of intubation trauma due to repetition, stylet use and higher friction
Duration of mechanical ventilation (2-5/7: 0-2%, 5-10/7: 5-10%, >10/7: 12-14%)2,3, cuff pressure (laryngeal microcirculation critical P 30mmHg) 1
Tracheostomy (site, type of incision, tube biomechanics)4
Acute organophosphate poisoning: primary reason of intubation contributes to laryngotracheal stenosis
Dysphagia, change in quality of voice
◦ Infective (Tuberculosis of the larynx)
Prolonged history of fever, unintentional weight loss, cough, hemoptysis, change in quality of voice, neck swelling.
Contact with tuberculosis patients
◦ Immune mediated (Sarcoidosis, Rheumatoid arthritis, Pemphigus)
Onset and progression is usually gradual
Related symptoms: joint pain and deformity, skin lesions,
◦ Vocal fold immobility
Change in quality of voice
Aspiration symptoms
CAUSE RESULT
External laryngotracheal trauma Penetrating injuryBlunt injury
Internal laryngotracheal trauma Endotracheal intubationPost tracheostomyPost radiotherapyChemical,thermal burns
Infection TB,Scleroma,fungal histoplasmosis
Chronic inflammatory disease Sarcoidosis
Collagen vascular diseases Wegener’s granulomatosisRelapsing polychondritis
Neoplastic disease Benign : squamouspapillomas,chondromasMalignant : squamous cell ca,lymphoma,sarcoma
External trauma
Disruption of
cartilagenous
framework
Hematoma and
mucosal
laceration
Resorption of
hematoma
Cartilage loss
Extensive
deposition of
collagen
Scar contraction
stenosis
Intubation trauma
Ischemic necrosis
of mucosa because
of ET tube
Mucosal ulceration Perichondritis
Cartilage
resorption
Healing with
secondary
intention
Submucosal
fibrosis
Scar contraction
Cotton-Myer◦ Based on relative
reduction of subglottic cross-
sectional area◦ Good for mature, firm,circumferential lesions◦ Does not take into
accountextension to other subsites or
length of stenosis
Posterior glottic stenosis : Bogdasarian & olsonclassification
Type I : interarytenoid adhesion
Type II : posterior commisure stenosis with scarring in interarytenoid plane & post cricoidlamina
Type III :posterior commisure stenosis with unilateral cricoarytenoid ankylosis
Type IV : posterior commisure stenosis with bilateral cricoarytenoid jt ankylosis
Evaluation
History
Idl + direct laryngoscopy
Bronchoscopy
Hrct of larynx and trachea
Timing of repair initial management and airway establishment : evaluation of degree of laryngeal injury
Acute stenosis : open repair within first two weeks of injury
Chronic stenosis : repair elective
Open repair : increasing airway obstruction requiring trach
Cervical emphysema
Exposed cartilage
Extensive mucosal laceration
Evidence of #/ dislocation
Endoscopic repair
Acute stenosis secondary to granulation tissue after extubation
Mc used : CO2 laser
Adv of CO2 : delayed formation and maturation of collagen : allows time for reepithelialization before scar tissue formation
Minimal deep tissue injury
Precise control of hemostasis : preservation of mucosa
Goal : to establish satisfactory airway,phonation & glottis closure
Assessment of stenosis :location,vocal fold impairement,degree of functional impairement
Management protocol :
Re-establishment of stucturalsupport;grafts/cartilage
Preservation of mucosa
Judicious use of antibiotics,stents,skingrafts,cartilage & bone grafts to reduce granulomaformation & scarring
For repair : cartilage / bone grafts
Acute injuries : stabilization of fractures
Chronic : for structural support, luminal augmentation
Grafts :
1. Rib : mc used
2. Iliac crest : mc used
3. Hyoid
4. Epiglottis
5. Thyroid
6. Auricular
7. Septal cartilage
Uses : to approximate epidermal grafts and immobilize it
Support for cartilage and bone grafts
Separate opposing surfaces
Maintain lumen in a recontructed area
1-3 wks : mucosal healing
6-8 wks : to maintain laryngeal skeleton in position
Upto 14months : cartilagenousframework deficient, maturation of scar contracture
Composed of teflon, cigar shaped
Designed for laryngeal reconstuction in children
Less irritation Granulation tissue
may form in the base of epiglottis
Made of Silicon
Long central lumen & smaller lumen projecting from side at 90 degree/75 degree
Used in laryngotracheal reconstruction in stenosis
Can be left in place for > 12months
Advantage : pt can speak with T –tube
Disadvantage : more prone for crusting ( can be prevented by blocking the side lumen& proper suctioning)
Montgomery tube
• Inert material used• Prevent adhesion
formation• Holds open the anterior
commissure and the posterior commissure as reqd
• Extend from cricoidmembrane to 2-3 mm above posterior commissure
• Placed endoscopically or through mini-cricothyroidotomy
• Removed after 2-4 wks under GA
Supraglottic stenosis
Adhesions of epiglotttis to the hypopharyngeal walls : division of adhesion along long axis; submucosal excision of scar and primary mucosal closure
Horizontal web : vertical incision : scar excised
External laryngeal trauma : thyroid cartilage # and mucosal disruption
Endolaryngeal truama : intubation or surgical removal of mucosa : anterior edges : two opposing raw edges heal together : web
Management : endoscopic resection / MLS excision with laser
Keel placed
Keel :
Should be inert material
Length should be sufficient to extend from the cricothyroid membrane atleast 2-3mm above the anterior comissure
Anterior edge of keel should make 120 degree angle
The posterior wing should lie at the vocal processes and should not touch the posterior commisure
Removed after 2-4weeks
External approach :
If extends > 5mm into subglottis
Ass with laryngeal inlet stenosis
Endoscopic approach failed
Et intubation/ cricothyroid joint arthritis
Endoscopic repair : type I and II : simple division of web + finger cot stents for 2 weeks/ with laser
With arytenoid fixation : external approach
if b/l arytenoid fixation : removal of least mobile arytenoid, denuded surfaces covered with mucosal flaps , skin and mucosal grafts
Stenting for 2-3 weeks
Type IV : endoscopic laser arytenoidectomy
External approach : woodmans
arytenoidectomy
Posterolateral extralaryngeal
dissection through inf constrictor
Elevating pyriform fossa mucosa
and postcricoid area
Expose the arytenoid cartilage
Entire arytenoid removed except
the vocal process
95% of cases of SGS
90% due to long-term or prior intubation◦ Duration of intubation
◦ ETT size
◦ Number of intubations
◦ Traumatic intubations
◦ Movement of the ETT
◦ Infection
Cartilaginous Stenosis Cricoid cartilage
deformity◦ Normal shape Small for infant's size
◦ Abnormal shape Large anterior lamina
Oval (elliptic shape)
Large posterior lamina
Generalized thickening
Submucous (occult) cleft
Other congenital cricoidstenosis
◦ Trapped first tracheal ring
Soft-Tissue Stenosis
Submucosalfibrosis
Submucosalgland hyperplasia
Granulation tissue
I. Endoscopic ◦ Dilation
◦ Laser
II. Open procedure◦ Expansion procedure (with trach and stent or SS-
LTR)
Laryngotracheoplasty
Laryngotracheal reconstruction
Grade III and IV stenoses require and open procedure
Anterior Cricoid Split (ACS)
Posterior Cricoid Split (PCS)
Combined ACS and PCS
Four quadrant cricoid cartilage division
Described in 1980 as an alternative to tracheotomy in the management of acquired SGS in premature infants
Safe and effective (67-70% extubation rate) ◦ If stenosis isolated & moderate grade
◦ No other anatomic abnormalities prohibiting decannulation
◦ Pulmonary reserve must be adequate
Posterior cricoid split
Indications◦ Anterior SGS
◦ Anterior collapse
Graft◦ Elliptical
◦ Larger and thicker than posterior grafts
◦ Large external flange
◦ Perichondrium faces luminal surface
◦ Knots are external
◦ Vicryl suture
Indications◦ Posterior SGS◦ Glottic extension
Try to avoid complete laryngofissure
Graft◦ Elliptical◦ Thinner than anterior
graft◦ Width
.05 to 1.00 mm/yr of age up to 1 cm (Cotton, 1999)
Pts with possible perforation : gastrograffinswallow/ barium swallow
Best detected by combination of esophagoscopy and esophagram in symptomatic patients.
Close wounds in watertight 2 layer fashion.
After mucosal repair, muscle flap may be interposed, minimises the risk of TE Fistula
Small pharyngeal lesions above arytenoids can be treated with NPO and observation 5-7 days
All patients should be NPO for 5-7 days.
Missed tears represent most of delayed injuries : mediastinits
Neck exploration for patients who have air in soft tissues of neck
During neck exploration. NG tube can be pulled up to the level of the neck and methyelene blue infused to localise.
caused by severe hyperextension during acceleration/deceleration motor injuries.
Signs: Hemiplegia, quadriplegia, CN deficits, change of sensorium, Horner’s syndrome (disturbance of stellate ganglion), neurogenicshock
Evaluation: clinical examination and imaging –AP and lateral cervical radiography plain films and CT scan.
Management: Neurosurgery should be consulted for any surgical intervention. From the ENT standpoint, stability of cervical spine to be established.