Dr. Naim Manhas presented at the 4th Trauma Symposium on the management of laryngeal injuries in neck trauma. The presentation covered diagnosis and treatment of blunt and penetrating neck injuries, as well as iatrogenic laryngeal injuries from intubation. Complications from prolonged intubation can include hematoma, laceration, scarring, and limitation of vocal cord abduction. Prevention techniques aim to minimize intubation time and use proper tube size and positioning. Exploration is recommended for penetrating injuries in neck Zone 2 and those showing symptoms.

1. 4TH TRAUMA SYMPOSIUMMANAGEMENT OF LARYNGEAL INJURIES IN NECK TRAUMA Dr. M. NaimManhas E.N.T. Specialist King Abdul Aziz Hospital-MakkahDr. Naim Manhas1

2. trauma symposium—WHY?2Dr. Naim Manhas

3. trauma symposium—WHY?3Dr. Naim Manhas

4. trauma symposium—WHY? 4Dr. Naim Manhas

5. “purpose of symposium”5Dr. Naim Manhas

6. 6Dr. Naim Manhas

7. Blunt injuries of neckBruises over the neckHematoma Surgical emphysema7Dr. Naim Manhas

8. Blunt injuries of neck8Dr. Naim Manhas

9. Laryngeal injuries9Dr. Naim Manhas

10. diagnosis of airway injury 10Dr. Naim Manhas

11. management11Dr. Naim Manhas

12. problematic12Dr. Naim Manhas

13. Emergency airway management13Dr. Naim Manhas

14. pediatric consideration14Dr. Naim Manhas

15. Pediatric airway15Dr. Naim Manhas

16. caution16Dr. Naim Manhas

17. laryngeal trauma(neck-injury)Dr. Naim Manhas17

18. laryngeal trauma(neck-injury)Dr. Naim Manhas18

19. surgical exploration19Dr. Naim Manhas

20. surgical explorationOpen exploration of neck with open reduction and internal fixation of fracture without thyrotomyDr. Naim Manhas20

21. laryngeal thyrotomyLaryngeal cartilage stable,anteriorcommissure intactORIF- fracturesRepair mucosal lacerationDr. Naim Manhas21

22. laryngeal thyrotomyORIF fractures, repair mucosal laceration and endolaryngeal stentLaryngeal cartilage unstable,anteriorcommissuredisrupted,massive mucosal injuriesDr. Naim Manhas22

23. penetrating neck injuriesNeck zonesZone -1 thoracic outletCricoid cartilage to sternal notchZone-2 centralCricoid to angle of mandibleZone-3 skull baseAngle of mandible to base of skullDr. Naim Manhas23

24. Neck zone concept outdatedDr. Naim Manhas24

25. Epidemiology of penetrating neck injuries40% of penetrating neck injuries do not involve important structuresStructures involved:--major vein: 15-25%-major artery: 10-15%-pharynx or esophagus: 5-15%Larynx or trachea: 4-12%Major nerves: 3-8%Dr. Naim Manhas25

26. Debatable issueSome surgeons have advocated mandatory exploration of all penetrating neck wounds on the basis that serious injury can exist in the absence of clinical findings. Others have advocated a selective approach operating only upon patients whose findings suggest a major vascular or visceral injuryDr. Naim Manhas26

27. penetrating neck injuries since zone 2nd has all the vital structures and any injury in this area needs immediate neck exploration in case patient is symptomatic.As per the studies it is difficult to make decisions regarding the exact zone for the injuries which are on border line, as the area of neck is small so the indications for immediate surgical exploration----Dr. Naim Manhas27

28. Indication of immediate surgical explorationDr. Naim Manhas28

29. GuidelinesDr. Naim Manhas29

30. Esophageal injury--diagnosisIf missed leads to high morbidity and mortalityContrast swallow study:-Extravasation is diagnosticNegative study is not reliable50% of leak—missed with gastrograffin25% of leaks missed with bariumDr. Naim Manhas30

31. RecommendationsIf gastrograffin study is negative then repeat with BariumAvoid gastrograffin in patients without gag / cough reflex or unprotected airway.( causes pneumonitis if aspirated)Endoscopy 50% of injuries can be missed , esp. if the patient is on ventilator.Combination of contrast study with esophagoscopy reduces missed injuries to 5%Dr. Naim Manhas31

32. latrogenic laryngeal injuriesDr. Naim Manhas32

33. latrogenic laryngeal injuriesDr. Naim Manhas33

34. Acute complication of intubationDr. Naim Manhas34

35. Dr. Naim Manhas35

36. Acute complication of intubationHematoma formationLaceration AvulsionScarring and granuloma formationDislocation of arytenoid cartilageDr. Naim Manhas36

37. Sequelae of prolonged intubationDr. Naim Manhas37

38. pathogensisDr. Naim Manhas38

39. pathogensisDr. Naim Manhas39

40. pathogenesisDr. Naim Manhas40

41. Sequelae of prolonged intubationDr. Naim Manhas41

42. Sequelae of prolonged intubationAbduction of the vocal cords are limited Misdiagnosed as bilateral abductor paralysisPeudolaryngeal paralysisDr. Naim Manhas42

43. Sequelae of prolonged intubationDr. Naim Manhas43

44. Sequelae of prolonged intubationDr. Naim Manhas44

45. Prevention of postintubation injuries Dr. Naim Manhas45

46. Prevention of postintubation injuries Time of intubationMore than 10 days and less than 10 daysDr. Naim Manhas46

47. Prevention of postintubation injuries Dr. Naim Manhas47

48. Prevention of postintubation injuries Dr. Naim Manhas48

49. Prevention of postintubation injuries Dr. Naim Manhas49

50. Result of recent studies done at university hospital Vall”Hebron-spainDr. Naim Manhas50

51. Result of serial laryngeal examinationsDr. Naim Manhas51

52. conclusionIntubation injury to the larynx is relatively common and all types of injury have been reported . In patients intubated for prolonged period ,certain types of injury can be expected. The surgeon asked to evaluate a patient for intubation injury should have a clear idea of the type of injury that may be encountered as well as through knowledge of the best methods of prevention and intervention.Dr. Naim Manhas52

53. conclusionIn many cases, the injury will resolve without incident, while in others the injury is irreversible. Frequently the process can be corrected with good results if the proper treatment is instituted.THANK YOU Dr. Naim Manhas53