Laryngotracheal Trauma Douglas J. Mathisen, M.D., and Hermes Grillo, M.D.

ABSTRACT Laryngotracheal trauma can be an imme- diately life-threatening injury. Failure to recognize such injuries and promptly secure an airway may have fatal consequences. Failure to recognize acute injuries or to observe the principles of management can lead to laryngo- tracheal stenosis.

We have seen 10 patients with acute injuries. Blunt trauma was responsible in 5, penetrating trauma in 4, and iatrogenic injury in 1. Esophageal transection was present in 1 patient. Thoracotomy was required in 2 patients with injury of the carina, and cervical exposure was adequate in 8. All patients underwent successful repair of the injuries.

Seventeen patients have been treated for delayed traumatic laryngotracheal stenosis. Vocal cord paralysis was apparent in 14. Concomitant esophageal injury was repaired in 4 patients. Eight patients required in- tralaryngeal procedures prior to repair of the laryngo- tracheal stenosis. All patients except 1 have a good airway, and 16 of the 17 have a good voice.

Laryngotracheal trauma may be life threatening. These injuries can occur in the most remote areas or in the busiest metropolitan setting. Emergency ward physi- cians, general surgeons, thoracic surgeons, anes- thesiologists, and otolaryngologists should be well versed in the manifestations and management of the injuries. Successful outcome demands prompt recogni- tion, skillful and expeditious management of difficult airways, complete evaluation of associated injuries, and careful planning of the proper treatment of each injury. Failure to accomplish each of these properly may result in death, multiple reoperations, or lifelong tracheostomy or gastrostomy.

Failure to recognize subtle presentations of these in- juries may allow cicatrization to occur and airway ob- struction to present days or months after the initial in- jury. Initial management of acute injuries may be palliative to secure an airway but not to restore con- tinuity. Failure of primary repair may occur because of the extent of the initial injury or failure to follow the principles of management of these injuries. In these situ- ations, restoring the airway and achieving a functional voice are still possible. Paralyzed vocal cords do not pre- clude attaining these goals.

From the General Thoracic Surgical Unit and Trauma Service, Massachu- setts General Hospital, and the Department of Surgery, Harvard Medical School, Boston, MA.

Presented at the Twenty-second Annual Meeting of The Society of Tho- racic Surgeons, Washington, DC, Jan 27-29, 1986.

Address reprint requests to Dr. Mathisen, Warren 1109, Massachusetts General Hospital, Boston, MA 02114.

Material and Methods We reviewed the charts of all patients undergoing tracheal operations for traumatic injuries to the airway. Ten patients were seen at our hospital for initial manage- ment of acute injuries. Seventeen patients were seen for delayed management. Follow-up was obtained from records and whenever possible by direct contact.

Acute Injuries Ten patients were seen with acute injuries to the airway. There were 8 men and 2 women ranging in age from 18 to 71 years. Although most of these injuries occurred as a result of blunt trauma, 4 were due to penetrating in- juries.

SIGNS AND SYMPTOMS. Subcutaneous emphysema was the most common finding. Hemoptysis was present in 4 patients, with hoarseness or inspiratory stridor in 1 each. Three patients were in acute respiratory distress requiring emergency procedures to secure the airway.

LOCATION. The laryngotracheal junction was the most frequently injured area. Two injuries involved the mid- dle part of the trachea, one of which was secondary to an endotracheal intubation and the other, the result of a gunshot wound. The two injuries of the lower trachea were the result of severe, sudden deceleration injuries, resulting in long tears of the membranous portion of the trachea involving the carina.

ASSOCIATED INJURIES. Blunt injuries to the chest wall (three) or head and neck were the most common associ- ated injuries. Recurrent laryngeal nerve injuries were present in 2 patients as a result of blunt trauma (unilat- eral in 1 and bilateral in the other). One patient had a false aneurysm of the innominate artery, and underwent successful repair of this and a 12-cm tear in the membra- nous portion of the distal trachea. Complete transection of the trachea and nearly total transection of the esopha- gus occurred in another patient after he was struck in the neck by an unseen chain while riding a motorcycle.

SURGICAL APPROACH. Eight patients underwent surgi- cal repair of the injuries through a generous collar inci- sion. Only 1 required a partial upper sternotomy for additional exposure. The 2 patients with tears in the distal membranous trachea extending to the carina were explored transthoracically.

SURGICAL PROCEDURE. All patients underwent de- finitive primary repair of the airway injuries. Absorbable suture material was used in every instance. Four pa- tients underwent simple suture repair. In 3 patients, the suture line was protected with a local muscle flap, usu- ally the detached sternohyoid muscle. One patient underwent a protecting tracheostomy because of exten- sive lacerations to the cricoid cartilage from a self- inflicted stab wound. Decannulation was successfully carried out eight days later.

254 Ann Thorac Surg 43:254-262, Mar 1987

255 Mathisen and Grillo: Laryngotracheal Trauma

Proximal Trachea, Larynx and Esophagus

Distal Trachea - and Esophagus

A B

Fig I . (A) Vinu of transected trachea and esophagus. (B) Esophag~ts closed in tum layers. (C) Strap mitscle ijiterposed fJetz(mvi the esoplin- Real and tracheal sittitre line. (D) Cornplrted repair.

Two patients required laryngeal stents and tracheos- tomies because of concomitant laryngeal injuries. De- cannulation was achieved without incident following re- moval of the laryngeal stents. One patient required the placement of a silicone T tube for a short time following removal of the laryngeal stent to allow granulations to resolve. The only other operative procedure required in these 10 patients was a Teflon injection into a paralyzed vocal cord. The patient who had a completely transected trachea and nearly total transection of the esophagus underwent a double-layer repair of the esophagus with 4-0 silk and a single-layer repair of the trachea with 4-0 Vicryl sutures. The proximally detached sternohyoid muscle was interposed between the two suture lines to prevent fistula formation (Fig 1).

Delayed Management There were 14 male and 3 female patients who were evaluated following management of laryngotracheal in- juries elsewhere. Their ages ranged from 9 to 35 years.

ETIOLOGY. Motor vehicle accidents with blunt trauma to the airway were the most common injuries in these patients. Five patients sustained "clothesline" injuries from striking unseen wires or chains. Only 1 patient sustained a penetrating injury.

LOCATION. The laryngotracheal junction or upper trachea was injured in 11 patients. The middle trachea was involved in 3 patients and the lower trachea, in 3.

ASSOCIATED INJURIES. All associated injuries had re- solved by the time these patients were evaluated except for those with esophageal injuries or vocal cord paraly- sis. Five patients had concomitant injuries of the esopha- gus. One patient had primary repair of the esophageal injury and required only dilation for subsequent steno- sis. Three patients were seen with tracheoesophageal fistula and 1, with the esophagus ending in a blind pouch proximally.

Vocal cord paralysis was identified at the time of

rld

C D

evaluation in 14 patients. Bilateral vocal cord paralysis was present in 7 patients; recovery of some function was documented in 1 of them. Unilateral vocal cord paralysis was present initially in 7 patients. Recovery of vocal cord function was documented at a later date in 2.

PRIOR INITIAL MANAGEMENT. Fourteen patients had been correctly diagnosed as having laryngotracheal in- juries. Four patients had had attempted primary repair of the injury, but delayed airway stenosis developed. Tracheostomy had been performed to establish a secure airway in 10 patients; no attempt at primary repair was made.

Diagnosis of laryngotracheal trauma had not been made initially in 3 patients, and symptoms of progres- sive airway obstruction developed 1 to 4 weeks later. Repair had been attempted in 1 and tracheostomy in another. One patient had had no procedure performed and was referred for evaluation when symptoms of tracheal stenosis developed.

The reasons for failure of primary repair were difficult to determine in most patients. The extent of the initial injury may have been responsible in 2 of the patients, and a combination of extent of injuries and technical failure was responsible in the other 3 patients.

ADDITIONAL SURGICAL PROCEDURES. Prior to definitive repair of laryngotracheal stenosis, 7 patients were thought to have inadequate laryngeal airways. This con- dition must be corrected prior to attempted repair of laryngotracheal stenosis. A variety of procedures were performed in these 7 patients to achieve a satisfactory laryngeal airway. These procedures were laryngofissure lysis of adhesions (3 patients), vocal cord lateralization (2), cricoarytenoid arthrodesis (2), and arytenoidectomy (1 patient).

These measures were successful in all but 1 patient who has required multiple procedures and still requires a tracheostomy to provide an adequate airway during vigorous physical activity. One patient with bilateral vocal cord paralysis required vocal cord lateralization postoperatively when it became apparent that he did not have an adequate glottic chink. Following definitive re- pair, 2 patients required debridement of granulation tis-

256 The Annals o f Thoracic Surgery Vol 43 No 3 March 1987

sue on a single occasion and 1 patient required a T tube for a short period.

One patient seen with a tracheoesophageal fistula re- quired cervical esophagostomy and gastrostomy. Acute inflammation was so severe that it precluded primary repair at that time. With adequate diversion of saliva, the inflammation subsided and the patient then under- went successful repair of tracheal stenosis and restora- tion of continuity of the esophagus.

INTERVAL FROM INJURY TO DEFINITIVE REPAIR. All but 1 patient had initially undergone surgical intervention in an attempt to either repair the injury or secure an air- way. All of these patients were given a sufficient time to allow inflammation and scarring to subside to facilitate definitive repair. The median interval from initial injury to repair was 5 months (range, 1 month to 11 months). The 11-month postponement of repair in I patient was done so that she could lose weight and so that the in- flammation could subside.

SURGICAL APPROACH. A low collar incision was used in 15 patients. Division of the upper sternum was required in 2 patients to gain additional distal exposure. Because of the location of the initial injury and previously at- tempted transthoracic repair of these injuries, a right thoracotomy approach was used in 2 patients.

SURGICAL PROCEDURE. All patients underwent resec- tion of the stenotic segment of the trachea and primary repair. In recent years, 4-0 Vicryl suture material has been used for the tracheal repair. In those patients in whom the cricoid cartilage was involved in the stenosis, the anterior half was resected and the distal trachea beveled to allow approximation of the trachea to thyroid cartilage in this area to enhance the diameter of the airway, as has been described for subglottic stenosis

Three patients were seen with tracheoesophageal fistulas and 1, with a blind pouch of the proximal esoph- agus. As mentioned, 1 patient with a tracheoesophageal fistula required cervical esophagostomy to allow the in- flammation to subside. He subsequently underwent suc- cessful repair. The other 2 patients with fistulas under- went single-stage repair of the esophagus and trachea, as has been described for repair of acquired tra- cheoesophageal fistula [2]. The fistula was debrided to viable tissue, and the esophagus was repaired in two layers with 4-0 silk. The patient with a blind pouch of the esophagus underwent a double-layer primary end-to- end anastomosis to the distal esophagus. In all patients requiring esophageal repair, a muscle flap, usually of proximally detached sternohyoid muscle, was inter- posed between the esophagus and trachea to prevent subsequent fistula formation (see Fig 1). All patients had successful reconstitution of the esophagus.

Results Acute Injuries All patients underwent successful primary repair of the injuries. Maintenance of an excellent airway has been achieved in all 10 patients. Delayed tracheal stenosis has

(Fig 2) (11.

not occurred in any patient to date. The 8 patients who did not have recurrent laryngeal nerve injuries have a normal voice. The 2 patients with recurrent nerve in- juries have very good, functional voices but they are somewhat husky. Follow-up on these 10 patients ranges from 7 months to 15 years.

Delayed M a nagemen t In all patients but 1, decannulation was performed suc- cessfully. These 16 patients have a good airway that does not limit them in their activities. Because of bilat- eral vocal cord paralysis, 1 patient has a necessarily fixed laryngeal airway, which will not allow vigorous physical activity. For this reason, he prefers a tracheostomy, used intermittently.

Ten patients were considered to have a good voice. Three of them had unilateral and 4, bilateral vocal cord paralysis. Six patients had a husky but very functional voice. Three of them had unilateral and 3, bilateral paralyzed vocal cords. Only 1 patient is considered to have been a failure with respect to voice. She had paraly- sis of one cord and paresis of the other, and continues to speak in only a whisper 4 years following repair. Median follow-up on these patients has been 30 months (range, 8 to 180 months).

Comment Damage by blunt cervical injury may occur in the airway at any level from the hyoid bone to the canna (3, 4, 20, 211. Motor vehicle accidents resulting in rapid decelera- tion that causes the passenger to strike the extended neck against the dashboard or steering wheel produce the majority of laryngotracheal injuries, as was the case with our patients. Direct injury to the laryngotracheal area compresses the airway against the vertebral bodies, thereby resulting in a crushing injury. Hyperextension of the neck causes an avulsion injury by pulling the larynx away from the distal trachea, which is restricted in its excursion by surrounding tissue and the left main- stem bronchus beneath the aortic arch. Striking the neck against an unseen wire or chain while riding a motorcy- cle or snowmobile accounts for a number of these injuries. Penetrating trauma from knife or gunshot wounds occurs much less frequently, although 5 of our patients sustained injuries in this manner.

These injuries produce a spectrum of signs and symp- toms. A high index of suspicion is imperative to avoid catastrophic consequences. Presentation may range from no visible external signs of trauma, to abrasion and contusion, to extensive laceration exposing cervical structures. Injuries to the distal trachea and canna may present with these findings in addition to pneumothorax associated with a large air leak in which the lung fails to reexpand completely after placement of a chest tube. The presentation may be more subtle with a pneumo- thorax responding to pleural suction and cessation of air leak. Subcutaneous or mediastinal emphysema may be the only finding in injuries to the distal trachea. The airway may appear to be completely patent or be absent

257 Mathisen and Crillo: Laryngotracheal Trauma

A B

E F

Fig 2. Operatizw repair ofanterolatcral stcnosis of the subgluttic larynx and upper trachea. (A) Anteroposterior v i m . ( B ) Lateral vie~ii showing the extent of disease involvement and the ultimate lines of transection. fC, D) Laryrix and trachea after removal of the specimm. Recurrant nerves have been left intact. Mucous mernbrane of larynx has been transected sharply at same level of division us cartilage. ( E ) Anteropostrrior and ( F ) lateral v i ~ w s of reconstruction. (G) Thyroid isthmus has been approximated to cover the anastomosis. Strap mus- cle, and occasionally thymus, is brought o7w to shield innominate artery from open area of anterior tracheal 7 i i d . Area is walled off for possible placemiwt of ~rUCht?fJStomy tube.

in an apneic patient. The combination of the type of accident and the signs or symptoms of hemoptysis, lo- calized pain, local contusion, subcutaneous emphy- sema, a change in voice, hoarseness, inspiratory stridor, or respiratory distress should alert the surgeon to the possibility of laryngotracheal injury.

Failure to recognize injuries acutely may lead to pro- gressive airway obstruction as cicatrization occurs and stenosis develops. The rapidity with which these in- juries present depends on the extent of the initial injury. In 3 of our patients, airway stenosis was recognized from 1 to 4 weeks following the injury.

G

D

Injuries of the magnitude sufficient to cause severe laryngotracheal damage may also cause injury to the esophagus, cervical spine, or vascular structures. If time and circumstances permit, each patient should be care- fully evaluated for these injuries. Cervical spine injuries may threaten the spinal cord and dictate the course of surgical management. Extension or flexion of the neck to perform intubation, bronchoscopy, or esophagoscopy or to relieve tension on the anastomosis must be avoided.

The cervical esophagus is frequently injured by acci- dents of this nature, as was the case in 6 of our patients [5-71. Contrast studies of the upper esophagus are help- ful but sometimes difficult to interpret. Esophagoscopy and direct inspection of the esophagus at the time of operation should be carried out when the possibility ex- ists that the esophagus is involved. Cervical spine in- jury obviously demands special caution and probably omission of esophagoscopy. Failure to recognize an esophageal injury may lead to mediastinal sepsis, tracheoesophageal fistula, and disruption of airway re- pair.

When the esophagus has been injured, it should be repaired with a meticulous double-layer repair. It is im- perative to interpose viable muscle, usually the detailed

258 The Annals of Thoracic Surgery Vol 43 No 3 March 1987

stemohyoid, to prevent subsequent fistula formation (see Fig 1). This is especially apparent in our 6 patients with esophageal involvement. Two patients had failed prior primary repair with development of tracheo- esophageal fistula when no muscle flap was used (1 patient had three attempts at closure). In none of our patients with tracheal and esophageal suture lines separated by muscle flaps have subsequent tracheo- esophageal fistulas developed.

Direct trauma to the vocal cords or recurrent laryngeal nerves may cause paralysis of one or both vocal cords. This was present in 2 of our patients seen with acute injuries and in 14 evaluated after the initial injury. The nerves may be either completely transected or avulsed. They may, however, be intact and not functioning be- cause of contusion. Subsequent recovery may follow, as was seen in 3 of our patients. No effort should be made to explore the traumatized wound to look for the recur- rent nerves. They are very difficult to identify in such injuries, and damage may be caused. This is also true when seeing patients for delayed management. Vocal cord paralysis does not preclude successful reconstitu- tion of the airway and achievement of a good functional voice. If procedures need to be done to enhance the glottic chink, they must be performed prior to repair of airway stenosis.

Vascular injuries may occur to the carotid artery, the innominate artery, or the aorta itself. One of our patients had a transection of the innominate artery. The tracheal injury was repaired first to allow adequate ventilation, and the patient then had successful repair of the vascu- lar injury. A careful search should be made for differen- tial pulses, localized bruits, or radiographic signs of aortic tears. Angiography is necessary to evaluate these injuries.

Radiological assessment of laryngotracheal injuries may be helpful. Plain roentgenograms of the neck may reveal distortion or disruption of the tracheal airway. Roentgenograms of the cervical spine, contrast studies of the esophagus, and tomograms of the larynx and trachea may be helpful in evaluating less emergent in- juries. Excessive time should not be spent in preopera- tive studies because an apparently stable airway may acutely obstruct.

Radiological evaluation of old injuries is invaluable in assessing the extent of injury. Details of the radiological assessment of the larynx and trachea have been de- scribed elsewhere (81.

The initial and most important problem in acute laryn- gotracheal injury is to secure a satisfactory airway. If partial airway obstruction is present, attempts at oral intubation or intubation over a flexible bronchoscope may be futile and may precipitate total obstruction.

Preparation for immediate tracheostomy must be made if intubation is attempted. In most instances, it is preferable to proceed directly to tracheostomy. On incis- ing the neck, the surgeon will encounter a contused or disrupted trachea. A divided trachea usually retracts into the mediastinum. The finger is used to locate the

divided end of the distal trachea. The trachea is grasped with a clamp and pulled into the operative field. An endotracheal tube is inserted to provide a controlled air- way. If primary repair is not contemplated, the end of the trachea should be secured to the skin as an end- tracheostomy. The proximal end should also be brought out as a stoma, or it should be oversewn and a drain left in place. A primary anastomosis can be accomplished months later after scarring and inflammation have sub- sided. Conservation of viable trachea is mandatory in this circumstance. A tracheostomy should never be placed through normal trachea.

Management of the airway in injuries to the distal trachea, carina, or proximal mainstem bronchi can be difficult. Double-lumen tubes should be avoided be- cause of the possibility of extending the injury. A long endotracheal tube can be positioned beyond the injury or into the appropriate mainstem bronchus to provide single-lung ventilation (Fig 3). This should be done very carefully with a flexible bronchoscope to serve as a guide and to check the final position. Great care must be taken not to extend the injury. A long, uncut endotracheal tube or preferably a more flexible Tovell tube with a proximal extension may allow the surgeon to manipu- late the tube into the appropriate bronchus at the time of operation (see Fig 3). A high-frequency ventilation catheter, if available, can be passed through an endotra- cheal tube and placed in proper position.

For those situations where a long endotracheal tube is not used or cannot be positioned properly, a sterile flex- ible endotracheal tube (Tovell tube) with appropriate connecting tubing can be used to intubate the opposite lung across the operative field. The connecting tubing is passed from the operating field to the anesthetist. Repair of the injury is done by intermittently removing the en- dotracheal tube and individually placing sutures. After all sutures are placed, the tube is removed, the airway approximated, and ventilation continued through the original endotracheal tube. If intubation and ventilation will be required, the endotracheal tube should be pulled back to a sufficient distance above the suture line. Ven- tilatory pressures should be kept as low as possible.

Special mention should be made of patients evaluated for delayed management. If stenosis is present but no tracheostomy, these patients should be handled as if the primary problem is tracheal stenosis. Anesthesia tech- niques have been described elsewhere [9] . We prefer to evaluate these patients bronchoscopically at the time of proposed operation, following complete radiological evaluation. We prefer rigid bronchoscopy because flex- ible bronchoscopy may occlude the airway or precipitate airway obstruction. Critical airway stenosis (less than 6 mm) may require dilation through a serious of increas- ingly larger rigid bronchoscopes or using Jackson di- lators with great caution through a rigid bronchoscope. This should be done with great care. Dilating the stenotic airway permits the anesthesiologist to intubate the patient and control the airway.

Once the airway has been stabilized, the extent of in-

259 Mathisen and Grillo: Laryngotracheal Trauma

jury to the airway and adjacent structures must be deter- mined. Exposure of the larynx and trachea is best achieved through a cervical incision. If distal exposure is needed, the upper third of the sternum can be divided. This was necessary in only 3 of our patients. If the trachea and esophagus have been divided, access to the retracted anterior mucosa of the esophagus is facilitated by placing traction on the larynx to pull it down and away from the esophagus to allow better exposure.

When trauma to the recurrent nerves is suspected, provision must be made to supply an airway at comple- tion of the repair. A small tracheostomy should be placed two rings below the level of the repair. The su- ture line should then be separated from the tracheos- tomy to prevent contamination with its danger of dehis- cence or late stenosis. This can usually be done by reapproximating the thyroid gland or using local muscle flaps (see Fig 2G). The tracheostomy should never be brought out through the suture line itself. Alternatively, a small, uncuffed endotracheal tube may be left in place at the end of the procedure. The patient should be re- turned to the operating room three to five days later and the tube removed so that the adequacy of the airway can be assessed. If there is an inadequate airway at that time, a small tracheostomy can be placed distal to the surgical repair. By this time, the anastomotic area should be sealed and the risk of contamination minimal. In most instances, a tracheostomy is preferable to prolonged en- dotracheal intubation.

Careful evaluation of the larynx is critical and should be done in conjunction with an otolaryngologist if pos- sible [lo-13, 191. Endoscopic examination of the larynx should be undertaken to look for exposed or fractured cartilages, damage to the vocal cords, or other signs indi-

cating damage to the larynx. Exposed cartilage should be covered with mucosa to diminish the likelihood of chon- dritis. This can usually be done by resuturing the mu- cosa that has been avulsed from the larynx and remains attached to the distal airway. Fractures should be re- duced and splinted, preferably over a mold, by an otolaryngologist competent in this type of reconstructive technique (see Fig 3). Attempts to reduce and hold com- plex laryngeal fractures by multiple sutures alone may result in stenosis and malformation of the larynx. The shattered larynx is most easily molded when the injury is fresh. A badly fragmented site of tracheal division may require debridement. Little laryngeal tissue, if any, should be sacrificed. A tracheostomy must be performed when a severe laryngeal injury is present.

Simple lacerations of the trachea should be repaired with absorbable 4-0 suture material using an interrupted technique. We have frequently reinforced these suture lines with local muscle flaps. Placement of a tracheos- tomy tube through a simple anterior laceration should be avoided unless prolonged intubation can be antici- pated, in which case the injury can be treated as a tracheal stoma and allowed to close when the tracheos- tomy tube is removed.

Extensive injuries to the trachea require debridement of ragged edges and devitalized tissue. Conservation of viable trachea is imperative. Careful end-to-end approxi- mation is done using interrupted absorbable 4-0 suture material. Small suction drains serve to remove accumu- lations of fluid. At completion of the operation, the pa- tient's neck is flexed and secured by a stitch from the chin to the chest. This will avoid unnecessary tension on the repair. Specific details of tracheal anastomosis have been described elsewhere [14].

Delayed repair of laryngotracheal injuries can often be complicated by many factors. Of prime importance, the patient should no longer require mechanical ventilation and associated injuries should have resolved. Careful radiological assessment is mandatory to determine the extent of injury and involvement of associated structures

260 The Annals of Thoracic Surgery Vol 43 No 3 March 1987

such as the esophagus. Careful functional assessment should be made of the laryngeal airway. The presence of paralyzed vocal cords does not preclude successful es- tablishment of a patent airway and useful voice [15]. A variety of procedures are available to provide an ade- quate airway and a useful voice [16, 17, 19). Laryngeal problems must be corrected prior to any attempted tracheal repair. A sufficient time should be allowed for healing and to be certain that late stenosis does not oc- cur. Failure to provide an adequate laryngeal airway will require a tracheostomy to be performed, which might jeopardize the repair. The larynx must be allowed sufficient time to heal so that it will be stable for a laryn- gotracheal anastomosis if that is necessary.

If associated injuries have resolved, careful evaluation of the extent of the injury is necessary. Measurements based on radiographic and endoscopic findings must be done to determine if adequate viable trachea exists to reestablish the airway. Inflammation and surrounding reaction should be minimal. A median of 5 months elapsed before definitive repair was undertaken in our patients. Silicone T tubes can be a useful alternative to tracheostomy tubes if additional time is required (see Fig 3) U81.

Once the decision to proceed has been made, a cervi- cal incision is employed, with division of the upper third of the sternum should additional exposure be required. Often the two ends of the trachea are separated, and the distal end retracts into the mediastinum. The dense scar joining the divided ends of trachea may make dissection difficult. The distal trachea in this case should be identified and circumferential dissection carried out at this point. Care should be used to avoid aspiration of blood into the tracheobronchial tree. The injured area should be resected to well-structured trachea. Repair can then be accomplished using an "open" technique with absorbable 4-0 sutures and removing the endotracheal tube as necessary to place sutures [14].

If previous repair has been attempted or extensive ini- tial injury has occurred, approximation may be difficult. A variety of techniques are available to achieve addi- tional length [14].

Injury to the cricoid cartilage or subsequent inflam- matory stenosis at this level may require resection of the anterior half of the cricoid. Care must be taken to re- move the posterior plate because of the risk of injuring the recurrent nerves. Removal of the cricoid in this oblique manner creates a larger subglottic airway (Fig 2A-C). The distal trachea is divided in a gentle curve on either side (Fig 2D). The midline of the thyroid cartilage is approximated to the midline of the peak of the "prow," which has been fashioned in the most proximal trachea (Fig 2E). The remainder of the repair is carried out in the standard manner (Fig 2F).

Delayed management of intrathoracic injuries encom- passes many of the principles previously mentioned for acute and chronic cervical tracheal injuries.

Acute laryngotracheal trauma can be successfully managed in the majority of patients by observation of

certain principles of management. They are as follows: proper airway management; evaluation of associated in- juries; avoidance of searching for recurrent nerves; sep- aration of tracheal and esophageal suture lines; conser- vation of viable trachea; avoidance of tracheostomy through repair; and flexion of neck to reduce tension. Delayed recognition or failure of primary repair, even in the presence of a paralyzed larynx and concomitant esophageal injury, can still be successfully managed in the majority of patients if certain principles are followed. These principles are the following: resolution of asso- ciated injuries; removal of mechanical ventilation; radiological evaluation; repair of larynx first; resolution of scarring and inflammation; separation of tracheal and esophageal suture lines; and general principles of tracheal surgery. It is also important to recognize that a paralyzed larynx does not preclude the reconstruction of the airway and voice. Every effort should be made in these patients to restore the airway and voice, thereby saving them the necessity for lifelong permanent trache- ostomy .

We thank the following surgeons for their contributions to the care of certain patients included in this report: Alan Hilgenberg, Edward Jacobs, Robert Lofgren, Ashby Moncure, and William Montgomery.

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261 Mathisen and Grillo: Laryngotracheal Trauma

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21. Urschel HC, Razzuk MA: Management of acute traumatic injuries of tracheobronchial tree. Surg Gynecol Obstet 136:113, 1973

Discussion DR. J. KENT TRINKLE (San Antonio, TX): It is customary to start a discussion by saying how much you enjoyed the paper. This is one of the few times I can say that and really mean it. Dr. Mathisen has done a nice job of analyzing a difficult group of patients, difficult because no two were alike. He is treating patients with acute injuries and patients with chronic injuries, some of them with prior attempts at reconstruction. In addi- tion, patients had various associated injuries involving a wide number of anatomical sites.

The authors' experience is weighted toward the patient with chronic injury and prior failed reconstruction. Our own experi- ence is primarily with the acute injury. This difference is due to referral patterns at each institution.

It is impossible to categorize these patients because of the wide variety of injuries, but I will emphasize some of the princi- ples that my colleagues and I have found helpful, particularly in the acute situation.

This type of operation needs a pro, not an amateur! Even though many of the patients arrive at 3:OO A.M., the surgeon ought to get out of bed and help the resident. This is a very difficult operation, and the initial care has a profound effect on the ultimate result.

Because Dr. Mathisen has outlined the signs and symptoms nicely, I won't go through those again. Most of the blunt in- juries occur to the driver of the vehicle, and there are generally some signs of external trauma.

It is often difficult to intubate patients with severe tracheolaryngeal injuries. We have found it helpful to thread the endotracheal tube over a fiberoptic bronchoscope, which serves as a guidewire. When the trachea or the tracheolaryngeal cleft is offset, this maneuver may be life saving. The broncho- scope is guided into the distal segment, and then the endotra- cheal tube is run over it.

All cartilage must be preserved and covered with mucosa at the initial operation. This prevents osteochondritis and nasty reconstructive problems. Laryngeal injuries need to be stented and packed with a distal tracheostomy. We try to avoid trache- ostomy except in the patient with a laryngeal injury. It is possi- ble to get by with only an endotracheal tube but there will be a nasty reconstructive problem later if the larynx is not stented.

Virtually all laryngotracheal injuries can be repaired through a collar incision except for distal tracheal lesions. These are easier to repair through a right thoracotomy, particularly the longitudinal blowout of the membranous portion of the trachea

or the straddle injury where a mainstem bronchus is cleaved off the trachea

We approach subglottic stenosis with a Z-plasty of the cricoid rather than the patch technique described by the authors.

These are very difficult patients. The principles 1 just outlined will help in managing these problems and perhaps obviate the need for difficult late reconstruction.

DR. DAVID s. MULDER (Montreal, Que, Canada): I, too, com- mend the authors for drawing our attention to this very rare but difficult problem.

I will address the topic of the airway management. My col- leagues and 1 have seen 20 patients in the acute phase, and the predominant mechanism of injury has been blunt trauma re- lated to athletic injuries. For example, 1 patient was a hockey goalkeeper who received a puck in the larynx. There was an obvious deformity, and the patient had an airway problem on the ice. How do you manage this problem? There is some con- troversy in the literature. Our colleagues in otolaryngology be- lieve that one should not intubate this patient but proceed im- mediately to a tracheostomy.

We have learned from Dr. Trinkle's experience, and based on an adverse experience with a corridor tracheostomy, we have adopted his technique of intubating the airway in all of these patients. We think that this has greatly facilitated control of the airway and has improved results. It also prevents a tracheos- tomy in a very minor laryngeal or upper airway injury.

In examination of our 20 patients with acute injuries, we looked at the variables contributing to morbidity, the morbidity primarily relating to the airway and to voice function. In our experience, delayed diagnosis was an important factor in at least 7 of the 15 patients, and most of these patients (8 of 15) had serious hypotension, very often precipitating an immediate intubation. Twelve of 15 patients had multisystemic trauma. This in itself masked the airway injury and contributed to a delay in diagnosis. We now advocate using Dr. Trinkle's tech- nique on extubation as well. We found a complete transection of the airway in 1 patient.

Dr. Mathisen, if you saw this injury tomorrow, what tech- nique would you favor for the emergency management o f an airway? Is an endotracheal tube contraindicated? 1 would also appreciate your comments on the role of immediate intubation as a factor in delayed diagnosis.

DR. SAFUH ATTAR (Baltimore, MD): I join the previous discus- sants in congratulating Dr. Mathisen and Dr. Grillo for their excellent presentation. I will stress a couple of points that my associates and I have learned from a few cases; a case report illustrates these points.

A 17-year-old man was riding a motorcycle. He tipped over, and the motorcycle ran over his larynx. He was taken im- mediately to the emergency room of one of the outlying hospi- tals. The distal trachea, which was divided below the larynx, was intubated, and the other injuries were attended to. There were fractures of the tibia and fibula and other serious injuries resulting in shock. Ultimately the patient recovered from the other injuries. He was referred to us for repair of tracheal stenosis.

We had the ear, nose, and throat staff evaluate his larynx. He had bilateral laryngeal nerve paralysis; this was very important because if we had repaired the tracheal stenosis by resection without attention to the paralyzed recurrent laryngeal nerves, the outcome would have been catastrophic. Another point noted was the presence of an air column in the esophagus, which is usually not visualized. This suggested the presence of

262 The Annals of Thoracic Surgery Vol 43 No 3 March 1987

an occult fistula between the trachea and the esophagus, which was demonstrated by Gastrografin (diatrizoate meglumine and diatrizoate sodium solution) study.

Subsequently, we operated on the patient after repair of the larynx by a left arytenoidectomy to afford him an open airway. The tracheoesophageal fistula was excised, and the sterno- cleidomastoid muscle was inserted between the trachea and the esophagus to prevent recurrence; the trachea was repaired by resection. The patient regained function and was able to com- municate with people on the telephone. He has continued to do well 10 years postoperatively.

DR. F. G . PEARSON (Toronto, Ont, Canada): 1 have a few com- ments on a subset of patients in this presentation. These are patients with transection of the airway caused by blunt trauma at the cricotracheal level and associated with bilateral recurrent nerve palsy. 1 believe you report on 4 patients, 2 of whom were seen with acute injuries and 2, with delayed injuries. We have seen 7 such patients, and 6 of them had a complete and bilateral recurrent nerve palsy at the time of injury. Many years ago, Ogura from St. Louis advised that one arytenoid cartilage should be lateralized at the time of repair to avoid the possible problem of glottic obstruction postoperatively. In our 6 pa- tients, we did not lateralize an arytenoid cartilage at the time of operation, and it is of interest that there has been no need for a delayed laryngeal operation in any of these 6 patients over a follow-up of many years. In reading your manuscript, it ap- pears that 2 of your 4 patients had a lateral pinning of the arytenoid. I would appreciate your comment on this.

DR. MATHISEN: I thank all the discussants for their comments. 1 will respond to them in reverse order.

In regard to Dr. Pearson‘s comments, we certainly agree with his approach. The 2 patients that we saw with acute injuries did not have any lateralization of the arytenoids performed initially and subsequently have not required further procedures. The patients that we saw in a delayed fashion in whom laryngeal procedures were performed required lateralization of the cords because the evaluation performed preoperatively indicated that they would have had an inadequate glottic airway without it. Therefore that procedure was done prior to definitive repair of the laryngotracheal stenosis. I think that is an important point.

In regard to Dr. Attar’s comments and also Dr. Pearson’s, careful assessment of the larynx is absolutely crucial. Repair of a tracheal stenosis with an inadequate glottic airway would lead to a tragic series of events. Therefore the larynx must be as- sessed very carefully in patients seen with acute injuries and also those with delayed presentation.

We certainly agree with both the approach that Dr. Mulder described and the one Dr. Trinkle alluded to of using the flex- ible bronchoscope with an endotracheal tube threaded over it. I think one caution should be raised: if this is attempted, it ought to be done with everything set up to perform an immediate tracheostomy. Often, because of separation of the trachea or bleeding, it is difficult to visualize the separated trachea. The surgeon may acutely obstruct the airway and must be prepared to perform an immediate tracheostomy.

I think that Dr. Trinkle’s points about cooperation not only among the residents and staff but also among the anes- thesiologists and otolaryngologists are something that we have relied on greatly through the management of all these patients. We agree that a cooperative effort is necessary to achieve a successful outcome.