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Trauma symposium 2012

presented in Clock tower
Masjid Haram
Makkah
April-2012

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Trauma symposium 2012

  1. 1. 3/30/2012 Dr.Naim Manhas 1
  2. 2. Diagnosis and management ofE.N.T. trauma –an update(5thAnnual Trauma Symposium )3/30/2012 Dr.Naim Manhas 2
  3. 3. Aim and objectives Traumatology has become an important medical subject as we all know that trauma related patients have increased since last two decades. Before major injuries were seen only in world wars, but now the percentage of trauma patients have increased due to increase in vehicular accidents , day to day military conflicts in many countries.3/30/2012 Dr.Naim Manhas 3
  4. 4. Aim and objectives The trauma system was created when it was discovered that more lives could be saved by taking critically injured patients to specialized trauma centre for immediate care.3/30/2012 Dr.Naim Manhas 4
  5. 5. Laryngo-tracheal injuriesLaryngeotracheal injury is rare 1 in every5000 trauma cases Laryngeal injuries in 30-70% of penetrating neck injuries Its rarity notwithstanding, it is second to only intracranial injury as the most common cause of death among patients with head and neck trauma3/30/2012 Dr.Naim Manhas 5
  6. 6. Aim and objectives Prevent long term In association with complications by ER surgeons, early diagnosis trauma surgeons and proper and management Anesthesiologists3/30/2012 Dr.Naim Manhas 6
  7. 7. types of laryngeal trauma Iatrogenic trauma Intubation injuries3/30/2012 Dr.Naim Manhas 7
  8. 8. Management Management of laryngo-tracheal trauma is based on the extent of injury:- Initial Endoscopic evaluation evaluation3/30/2012 Dr.Naim Manhas 8
  9. 9. Initial EvaluationSecuring the Obtaining Immobilizing theairway hemodynamic cervical spine stability• Intubation:- vocal cords are visible, no • Controlling of visible injuries bleeding• Tracheotomy done under local anesthesia 3/30/2012 Dr.Naim Manhas 9
  10. 10. paediatric patients In contrast to adults pediatric patients are unlikely to cooperate with a tracheotomy while awake. Paediatric airway is secured with rigid bronchoscopy while maintaining spontaneous respiration before tracheotomy is performed.3/30/2012 Dr.Naim Manhas 10
  11. 11. Initial EvaluationIdentified with physicalexamination or fiberopticlaryngoscopy In case exploration of neck is carried Direct laryngoscopy and bronchoscopy is performed3/30/2012 Dr.Naim Manhas 11
  12. 12. Initial EvaluationOesophagoscopy is alwaysperformed 50% of patients with an airway injury also have associated oesophageal injury Degree and type of injury is evaluated during endoscopic examination3/30/2012 Dr.Naim Manhas 12
  13. 13. Classification of laryngealinjuries As per locationsupraglottis transglottis Cricoid/trachea3/30/2012 Dr.Naim Manhas 13
  14. 14. Aim and objectives Assessment of injury Level of injury Severity of injury3/30/2012 Dr.Naim Manhas 14
  15. 15. BLUNT TRAUMA Thyroid cartilage fracture:- Multiple fractures in calcified laryngeal cartilage as compared to one site fracture in cartilaginous larynx Mucosa disruption oedma Arytenoid dislocation Laryngeal ligaments tear 3/30/2012 Dr.Naim Manhas 15
  16. 16. PRESENTATION dyspnoea dysphagia dysphonia Respiratory odynophagia distress3/30/2012 Dr.Naim Manhas 16
  17. 17. physical findings Subcutaneous Oedma Distoration • Or • Emphysema • Hematoma • Loss of laryngeal • Tenderness • ecchymosis landmarks3/30/2012 Dr.Naim Manhas 17
  18. 18. Classification of laryngeal injury Group 1  Minor endolaryngeal hematoma :  Minimal airway compromise Group2  Endolaryngeal hematoma/oedma associated with compromised airway/non-displaced fracture  Massive endolaryngeal edma with Group3 airway obstruction/mucosal tears with exposed cartilage/immobile vocal cords Group4  Same as group3 with more than two fracture lines on imaging/massive dearangement of endolarynx Group5  Laryngotracheal sepration 3/30/2012 Dr.Naim Manhas 18
  19. 19. MANAGEMENTGrop 1& 2 are usually managed nonsurgically with humidied air,head of bedelevation,voice rest Serial fiberoptic examinations Streroids:- only usefull if given within first few hours after injury Group 3 & 4 :- immediate surgical repair and may involve the use of stent3/30/2012 Dr.Naim Manhas 19
  20. 20. Aim and objectives Restore the integrity of the larynx with regard To phonation,airway and quality of life3/30/2012 Dr.Naim Manhas 20
  21. 21. penetrating neck injuries Neck wounds that extend deep to the platysma are considered penetrating injuries. Incidence of penetrating neck injuries has increased since world war II because of rise in violent crimes. The main cause of penetrating neck injury in this country is accidental, while as internationally usually related to violent crimes as well as military conflict3/30/2012 Dr.Naim Manhas 21
  22. 22. penetrating neck injuries Injuries to vascular system----20-56% Laryngeal, tracheal and oesophageal injuries—20-30% Mortality rates from oesophageal injuries were found to increase from 11 to 17% after a delay in diagnosis of only 12 hours3/30/2012 Dr.Naim Manhas 22
  23. 23. Penetrating laryngealinjuries Cartilagehemato Mucosal fractures Laryngo- tears or and tracheal ma dislocation laceration disruption3/30/2012 Dr.Naim Manhas 23
  24. 24. Classification of penetratingneck injuries3/30/2012 Dr.Naim Manhas 24
  25. 25. Classification of penetratingneck injuries zone 1. - • Extends from sternal notch to the cricoid zone 2. • Extends from cricoid to angle of mandible zone 3. • Extends from the mandible to the skull base3/30/2012 Dr.Naim Manhas 25
  26. 26. Management of penetrating neckinjuries Remarkable number of changes in the treatment protocol has been made because of development of new technologies, it may be from non-operative management to routine exploration to selective exploration. Penetrating neck injuries remain challenging as there are a number of important structures in a small area. 3/30/2012 Dr.Naim Manhas 26
  27. 27. Management of penetrating neck injuries Since the introduction of sophisticated ancillary tests and accurate identification of localizing signs and symptoms the surgical exploration of penetrating neck trauma is now done on selective basis:-3/30/2012 Dr.Naim Manhas 27
  28. 28. Management of penetrating neck injuriesAll patients with hemodynamicinstability or airwaycompromise Needs surgical exploration Followed by panendoscopy3/30/2012 Dr.Naim Manhas 28
  29. 29. Management of penetrating neckinjuriesInjuries in Zone -1. and in Zone-3. of neck are difficult to examine clinically and surgically.Imaging including angiography is often performedZone.1. injuries are subjected with preoperative arteriograhpy and gastrograffin swallow studies3/30/2012 Dr.Naim Manhas 29
  30. 30. Management of penetrating neckinjuries Zone 3. injuries are studied with arteriograhphy and all facilities for embolization should be available in case injury is found. Zone 2. surgical exploration is done even without imaging3/30/2012 Dr.Naim Manhas 30
  31. 31. Asymptomatic patients The management of asymptomatic patients remains controversial but according to the recent retrospective studies made by “Sarkar et al” and “Ramasamy et al” of British military causalities from Iraq and Afghanisthan who sustained penetrating neck injuries, it was observed that percentage of negative exploration was reduced by selective exploration.3/30/2012 Dr.Naim Manhas 31
  32. 32. Surgical intervention lacerationinvolving anteriorcommissure, Injury to the free edge of the true vocal fold Exposed cartilage /displaced or comminuted fracture 3/30/2012 Dr.Naim Manhas 32
  33. 33. Surgical intervention Vocal fold immobility Arytenoid cartilage dislocation3/30/2012 Dr.Naim Manhas 33
  34. 34. Reduction of laryngeal fractures Fixation of even minimally displaced or ingulated fractures are important for maintaing the geometry of larynx. Good results are obtained by using miniplates as compared to previously used stainless-steel wires or absorable sutures.3/30/2012 Dr.Naim Manhas 34
  35. 35. Role of stent Use of stent is controversial because of increased risk of infection and granulation formation. Recommended only where inadequate fracture fixation is done to give structural stability. Prevent synechiae formation when used in presence of severe soft tissue disruption or lacerations involving anterior commissure.3/30/2012 Dr.Naim Manhas 35
  36. 36. 3/30/2012 Dr.Naim Manhas 36
  37. 37. Intubation injuriesThe incidence of intubation injuryhas increased since The critically ill patients are being sustained longer on Ventilatory support because of introduction of sophisticated I.C.U.3/30/2012 Dr.Naim Manhas 37
  38. 38. Intubation injuries Scarring of Subglottic Granulation laryngeal stenosis tissue structures • Tracheal formation stenosis • Vocal fold paresis or • paralysis3/30/2012 Dr.Naim Manhas 38
  39. 39. Intubation injuries  Intubation prolonged more than 7-10 days ,incidence of 19% complications is from 14- 19%. 30%  The incidence of 42% complications increases two-folds if intubation is prolonged more than two weeks.3/30/2012 Dr.Naim Manhas 39
  40. 40. Factors Oversized Iatrogenic causes tubes Difficult Anatomical variation determine intubation or Excessive the severity traumatic patient of intubation. movement intubation Inexperienced Repeated self injures intubation extubation Overinflated tube cuffs3/30/2012 Dr.Naim Manhas 40
  41. 41. presentationHigh endotracheal cuffpressure Progressive hoarsness of voice or airway obstruction from glottic or subglottic edma Compressive neuropathies by direct pressure of cuff3/30/2012 Dr.Naim Manhas 41
  42. 42. presentationDysfunctional vocal cords orparesis Mucosal injury, result from movement of endotracheal tube,pressure necrosis Granulation formation ,fixation of cricoarytenoid joint,web formation or stenosis3/30/2012 Dr.Naim Manhas 42
  43. 43. ManagementPost intubation granulationtissue resolve spontaneouslyafter some times Treatment includes a combination of voice therapy and antireflux medication Surgical removal is only indicated when it leads to partial airway obstruction3/30/2012 Dr.Naim Manhas 43
  44. 44. ManagementManagemnt of stenosis depends onits location and severity. Presence of thin web in the anterior glottis Surgically removed and stent is placed to prevent the reformation of web from opposed denuded mucosa3/30/2012 Dr.Naim Manhas 44
  45. 45. ManagementPosterior laryngeal stenosisand cricoarytenoid joint fixation Treated with repeated dilation through an endoscopic approach In severe cases ,open approach through laryngofissure is done3/30/2012 Dr.Naim Manhas 45
  46. 46. ManagementIn cases of failures or moresevere cases Arytenoidectomy or partial posterior cordotomy is done Subglottic or tracheal stenosis approached with endoscopic laser incision and dilation3/30/2012 Dr.Naim Manhas 46
  47. 47. ManagementMore severe stenosis requirelaryngotracheal reconstruction or segmental resection with primary anastomisis Vocal fold paralysis with persistent dysphonia or significant aspiration Vocal fold augmentation3/30/2012 Dr.Naim Manhas 47
  48. 48. ManagementBilateral vocal fold immbolitypresent with stridor and airwayobstruction Relieved by partial posterior cordectomy,arytenoidectomy or arytenoid lateralization procedure In severe cases needs tracheostomy3/30/2012 Dr.Naim Manhas 48
  49. 49. conclusion The initial goal in managing laryngeal trauma is to preserve life. Secondary goal is to prevent long term complication to the voice and airway. Intubation injuries can be prevented by proper intubation by experienced E.R. staff. Early tracheotomy in patients who need prolonged ventilatory life support.3/30/2012 Dr.Naim Manhas 49
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