Laryngeal trauma

106
LARYNGEAL TRAUMA

Transcript of Laryngeal trauma

Page 1: Laryngeal trauma

LARYNGEAL TRAUMA

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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

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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%

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BLUNT INJURIES : CLOTHESLINE

CRUSHING

HANGING

STRANGULATION

PENETRATING INJURIES

INHALATIONAL/INGESTION INJURIES

IATROGENIC INJURIES

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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

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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

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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

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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

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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

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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

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This can lead to pre-epiglottic space bleeding & posterior displacement of epiglottis

Calcified thyroid cartilage gets shattered resulting in communited fracture

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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

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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

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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

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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

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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

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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

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Plain x-ray of cervical spine :

To exclude hyoid bone fracture & concurrent cervical spine fracture

Chest x-ray

To rule out mediastinal emphysema / puenomothorax

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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

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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.

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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

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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

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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

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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

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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

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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

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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)

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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

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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

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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

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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

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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

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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

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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

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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.

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Immediate onset aphonia, hemoptysis, respiratory distress, cervical subcutaneous emphysema

Open neck wound : distal stump : intubated

No neck wound : emergency tracheostomy

Repair : within 24hrs

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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

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Incidence : 4-13% : adults, 0.5 -61% in neonates

Mc cause : prolonged intubation

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• 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

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Epithelial erosion and ulceration

Ischemic necrosis

Mucosal injury

Mucosal ischemia Capillary perfusion pressure

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Cartilage necrosis

Perichondritis

After 96hrs

Stromal necrosis

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Minor epithelial erosion :

primary epithelialization

Extensive ulceration

secondary intention healing

with granulation tissue

Granuloma

Contracted scar tissue

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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

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• 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

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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

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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

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Severe injuries : deep ulceration : tracheostomy

Continued intubation > 7 days : tracheostomy

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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

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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

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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

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Misc injuries

Laceration

Bleeding into vocal cords

Arytenoid dislocation

Perforation

Cricoid ulceration: sinus/ fistula : both NG tube and ET tube presence

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Chronic changes

after extubation

Rapid resolutionSevere stenosis

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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

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Co2 laser excision

1. Less removal: proliferation and recurrence

2. Excessive removal : exposure of perichondrium and recurrence

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b/l granulations on vocal

process fall together adhere

and heal to one another

If not removed

Mature

Interarytenoid bands

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Vocal cords tethered together, abduction is limited : airway obstruction

Misdiagnosed as b/l vocal cord paralysis

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Partial or complete cicatricial narrowing of endolarynx

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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

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◦ 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

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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

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External trauma

Disruption of

cartilagenous

framework

Hematoma and

mucosal

laceration

Resorption of

hematoma

Cartilage loss

Extensive

deposition of

collagen

Scar contraction

stenosis

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Intubation trauma

Ischemic necrosis

of mucosa because

of ET tube

Mucosal ulceration Perichondritis

Cartilage

resorption

Healing with

secondary

intention

Submucosal

fibrosis

Scar contraction

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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

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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

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Evaluation

History

Idl + direct laryngoscopy

Bronchoscopy

Hrct of larynx and trachea

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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

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Open repair : increasing airway obstruction requiring trach

Cervical emphysema

Exposed cartilage

Extensive mucosal laceration

Evidence of #/ dislocation

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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

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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

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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

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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

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Composed of teflon, cigar shaped

Designed for laryngeal reconstuction in children

Less irritation Granulation tissue

may form in the base of epiglottis

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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)

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Montgomery tube

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• 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

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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

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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

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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

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External approach :

If extends > 5mm into subglottis

Ass with laryngeal inlet stenosis

Endoscopic approach failed

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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

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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

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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

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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

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I. Endoscopic ◦ Dilation

◦ Laser

II. Open procedure◦ Expansion procedure (with trach and stent or SS-

LTR)

Laryngotracheoplasty

Laryngotracheal reconstruction

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Grade III and IV stenoses require and open procedure

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Anterior Cricoid Split (ACS)

Posterior Cricoid Split (PCS)

Combined ACS and PCS

Four quadrant cricoid cartilage division

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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

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Posterior cricoid split

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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

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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)

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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.

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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.

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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.

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