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Laryngeal trauma
This document discusses laryngeal trauma. The larynx functions to protect the airway and enable phonation. Laryngeal trauma is rare, usually resulting from motor vehicle accidents, strangulation, or penetrating injuries. Injuries can range from minor bruising to fractures or separation of the laryngeal framework. Treatment involves securing the airway, usually through intubation or tracheostomy. Minor injuries are managed conservatively while more severe injuries involving exposed cartilage or vocal fold immobility require surgical exploration and repair. Endolaryngeal stents may be used in very severe cases to support the laryngeal structure during healing.
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Laryngeal trauma
- 1.
- 2. Larynx isa well protected structure in the neck Functions: airway ,tracheobronchial protection & 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
- 4. Laryngeal traumais rare < 1 % of all traumas Incidence is low < 1 / 30,000 ER visits Males > females Older persons more predisposed to communited fractures attributed to calcification Associated injuries Intracranial : 13% Cervical spine fracture : 8% Oesophageal injury : 3%
- 5. BLUNT INJURIES :CLOTHESLINE CRUSHING HANGING STRANGULATION PENETRATING INJURIES INHALATIONAL/INGESTION INJURIES IATROGENIC INJURIES
- 6. 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
- 7. 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
- 8. 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
- 10. Penetrating injuries Bouncesthe laryngeal skeleton enters thyrohyoid membrane bleeding of paraglottic space Airway obstruction Enters cricothyroid membrane Air escapes into soft tissues Surgical emphysema
- 11. 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
- 12. 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
- 13. This canlead to pre-epiglottic space bleeding & posterior displacement of epiglottis Calcified thyroid cartilage gets shattered resulting in communited fracture
- 15. Cricoid cartilage Invariablyassociated 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
- 16. Inhalational injuries Hotair/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
- 17. Iatrogenic injuries Intubation: Mucosal laceration / crico arytenoid dislocation / injury to lingual,hypoglossal , superior laryngeal , recurrent laryngeal nerve (neuropraxia) Prolonged intubation Tracheostomy : Injury to cricoid / recurrent laryngeal nerve
- 18. 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
- 20. EXAMINATION Incasesof cricotracheal separation the airway may be maintained via a cutaneous laceration 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
- 21. Any penetratinginjury 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
- 22. Plain x-ray ofcervical spine : To exclude hyoid bone fracture & concurrent cervical spine fracture Chest x-ray To rule out mediastinal emphysema / puenomothorax
- 23. CT SCAN Mainlyfor 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/cricothyroid joint,assessment of c-spine
- 24. CT reserved forfor patients 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.
- 25. Direct laryngoscopy Doneunder 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
- 27. GROUP SYMPTOMS SIGNSMANAGEMENT Group I Minor airway symptoms Minimal hematoma Small laceration No fractures Observation Humidified air Head end elevation +/- Steroids Group II Airway compromise Oedema/hematoma Minor mucosal disruption No cartilage exposure Direct laryngoscopy Oesophagoscopy +/- Tracheostomy +/- steroids Group III Airway compromise Oedema Mucosal tears Exposed cartilage Vocal cord immobility Tracheostomy Direct laryngoscopy Oesophagoscopy Exploration/repair No stent needed Group IV Airway compromise Massive oedema Significant mucosal tear Exposed cartilage Vocal cord immobility Tracheostomy Direct laryngoscopy Oesophagoscopy Exploration/repair Stent required
- 28. Securing theairway- 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
- 29. Conservative management GroupI & 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
- 30. 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
- 31. Open surgicalexploration & 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
- 32. Subplatysmal apronflap 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)
- 33. Displace fracturesof the cartilages are reduced ◦ Stabilized using stainless steel wires, nonabsorbable suture or miniplates. ◦ Small fragments of cartilage with no intact perichondrium are removed to prevent perichondritis. Anterior commissure- suspend the anterior true vocal cords to the outer perichondrium of the thyroid cartilage Close the thyrotomy ◦ Nonabsorbable suture, wires or miniplates
- 35. Anterior glotticinjuries : 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
- 36. 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
- 37. Types of stents Endotrachealportex 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
- 39. Stent shouldbe 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
- 40. 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 postcricoid mucosa 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 subglottic stenosis
- 41. Formation ofprofuse 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
- 42. Common inclothesline 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.
- 43. Immediate onsetaphonia, hemoptysis, respiratory distress, cervical subcutaneous emphysema Open neck wound : distal stump : intubated No neck wound : emergency tracheostomy Repair : within 24hrs
- 44. Primary re- anastamosisfrom 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
- 45. Incidence :4-13% : adults, 0.5 -61% in neonates Mc cause : prolonged intubation
- 46. • Endotracheal intubationinjuries 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
- 47. Epithelial erosion andulceration Ischemic necrosis Mucosal injury Mucosal ischemia Capillary perfusion pressure
- 48.
- 49. Minor epithelial erosion: primary epithelialization Extensive ulceration secondary intention healing with granulation tissue Granuloma Contracted scar tissue
- 50. Endotracheal tube liesin the posterior larynx : Applies pressure on 3 sites 1. Arytenoids : vocal process: medial surface 2. Posterior glottic mucosa in the interarytenoid region 3. Cricoid cartilage
- 51. • Physical trauma: difficult/ repeated intubations • Duration of inutbation : 1. 7 days : adults 2. Infants : longer 3. Neonates : weeks • State of larynx • Movement of tube : coughing, swallowing, bucking during anesthesia, transmitted ventilator movement Mucociliray mechanism : reduced : 1. Presence of tube 2. Stasis of secretions 3. Trauma from suctioning 4. Bacterial contamination Gastroesophageal reflux : chemical irritation : increased local injury Nasogastric tube
- 52. 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
- 53. 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 extubation unsuccesful 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
- 54. Severe injuries: deep ulceration : tracheostomy Continued intubation > 7 days : tracheostomy
- 55. Early non specific: 1. Hyperemia 2. Edema 3. Surface ulceration 4. Granulation Edema 1. In the loose tissue of ventricle : protrusion 2. In vocal folds perists : reinkes edema 3. Edematous swelling in the submucosa of criccoid cartilage
- 56. 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 interarytenoid adhesions
- 57. Ulceration Causedby 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
- 58. Misc injuries Laceration Bleeding into vocal cords Arytenoid dislocation Perforation Cricoid ulceration: sinus/ fistula : both NG tube and ET tube presence
- 59. Chronic changes after extubation RapidresolutionSevere stenosis
- 60. 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
- 61. Co2 laserexcision 1. Less removal: proliferation and recurrence 2. Excessive removal : exposure of perichondrium and recurrence
- 62. b/l granulations onvocal process fall together adhere and heal to one another If not removed Mature Interarytenoid bands
- 63. Vocal cordstethered together, abduction is limited : airway obstruction Misdiagnosed as b/l vocal cord paralysis
- 64. Partial or completecicatricial narrowing of endolarynx
- 65. 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
- 66. ◦ Infective (Tuberculosisof 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
- 67. CAUSE RESULT External laryngotrachealtrauma Penetrating injury Blunt injury Internal laryngotracheal trauma Endotracheal intubation Post tracheostomy Post radiotherapy Chemical,thermal burns Infection TB,Scleroma,fungal histoplasmosis Chronic inflammatory disease Sarcoidosis Collagen vascular diseases Wegener’s granulomatosis Relapsing polychondritis Neoplastic disease Benign : squamous papillomas,chondromas Malignant : squamous cell ca,lymphoma,sarcoma
- 68. External trauma Disruption of cartilagenous framework Hematomaand mucosal laceration Resorption of hematoma Cartilage loss Extensive deposition of collagen Scar contraction stenosis
- 69. Intubation trauma Ischemic necrosis ofmucosa because of ET tube Mucosal ulceration Perichondritis Cartilage resorption Healing with secondary intention Submucosal fibrosis Scar contraction
- 71. Cotton-Myer ◦ Basedon relative reduction of subglottic cross- sectional area ◦ Good for mature, firm, circumferential lesions ◦ Does not take into account extension to other subsites or length of stenosis
- 73. Posterior glotticstenosis : Bogdasarian & olson classification Type I : interarytenoid adhesion Type II : posterior commisure stenosis with scarring in interarytenoid plane & post cricoid lamina Type III :posterior commisure stenosis with unilateral cricoarytenoid ankylosis Type IV : posterior commisure stenosis with bilateral cricoarytenoid jt ankylosis
- 75. Evaluation History Idl + direct laryngoscopy Bronchoscopy Hrct of larynx and trachea
- 76. Timing ofrepair 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
- 77. Open repair: increasing airway obstruction requiring trach Cervical emphysema Exposed cartilage Extensive mucosal laceration Evidence of #/ dislocation
- 78. 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
- 79. Goal :to establish satisfactory airway,phonation & glottis closure Assessment of stenosis :location,vocal fold impairement,degree of functional impairement Management protocol : Re-establishment of stuctural support;grafts/cartilage Preservation of mucosa Judicious use of antibiotics,stents,skin grafts,cartilage & bone grafts to reduce granuloma formation & scarring
- 80. 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
- 81. 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 : cartilagenous framework deficient, maturation of scar contracture
- 82. Composed of teflon,cigar shaped Designed for laryngeal reconstuction in children Less irritation Granulation tissue may form in the base of epiglottis
- 83. Made ofSilicon 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)
- 84.
- 85. • Inert materialused • Prevent adhesion formation • Holds open the anterior commissure and the posterior commissure as reqd • Extend from cricoid membrane to 2-3 mm above posterior commissure • Placed endoscopically or through mini- cricothyroidotomy • Removed after 2-4 wks under GA
- 86. 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
- 87. External laryngealtrauma : 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
- 88. 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
- 89. External approach: If extends > 5mm into subglottis Ass with laryngeal inlet stenosis Endoscopic approach failed
- 90. 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
- 91. 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
- 92. 95% ofcases 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
- 93. Cartilaginous Stenosis Cricoidcartilage 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 cricoid stenosis ◦ Trapped first tracheal ring Soft-Tissue Stenosis Submucosal fibrosis Submucosal gland hyperplasia Granulation tissue
- 94. I. Endoscopic ◦Dilation ◦ Laser II. Open procedure ◦ Expansion procedure (with trach and stent or SS- LTR) Laryngotracheoplasty Laryngotracheal reconstruction
- 96. Grade IIIand IV stenoses require and open procedure
- 97. Anterior CricoidSplit (ACS) Posterior Cricoid Split (PCS) Combined ACS and PCS Four quadrant cricoid cartilage division
- 98. Described in1980 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
- 100.
- 101. Indications ◦ AnteriorSGS ◦ Anterior collapse Graft ◦ Elliptical ◦ Larger and thicker than posterior grafts ◦ Large external flange ◦ Perichondrium faces luminal surface ◦ Knots are external ◦ Vicryl suture
- 102. Indications ◦ PosteriorSGS ◦ 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)
- 103. Pts withpossible perforation : gastrograffin swallow/ 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.
- 104. Missed tearsrepresent 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.
- 105. caused bysevere hyperextension during acceleration/deceleration motor injuries. Signs: Hemiplegia, quadriplegia, CN deficits, change of sensorium, Horner’s syndrome (disturbance of stellate ganglion), neurogenic shock 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.