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4TH TRAUMA SYMPOSIUM
MANAGEMENT OF LARYNGEAL INJURIES
IN
NECK TRAUMA
Dr. M. Naim Manhas
E.N.T. Specialist
King Abdul Aziz Hospital-Makkah
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trauma symposium—WHY?
Since the increase in incidence of trauma patients
For last two decades, because of increase in number of cars on roads
Natural disasters, local warfare activity
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trauma symposium—WHY?
Increased the number of trauma patients after the world war-2
Since the increase in number of trauma patients and revolution in medical technology
Providing sophisticated intensive care units leading to manage severe trauma patients
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trauma symposium—WHY?
This set up has given birth to a new speciality
“ TRAUMATOLOGY”
Many countries have come up with independent “trauma centres”
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“purpose of symposium”
Short comings of last symposium
Introduction of new protocol to
minimize the post traumatic complication
Recommedation laid in last
symposium
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BLUNT
•Neck injuries
PENETRATING
IATROGENIC
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Blunt injuries of neck
Bruises over the neck
Hematoma
Surgical emphysema
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Blunt injuries of neck
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Laryngeal injuries
dysphonia
Subcutaneous
emphysemahemoptysis hematoma
Airway
obstruction
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diagnosis of airway injury
Physical
examination
Imaging
studies
Endoscopic
examination
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management
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problematic
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Emergency airway management
Awake fiberopticintubation
Awake orotrachealintubation
Surgical airway
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pediatric consideration
Larynx more superior (c4)
Mandibular protection
Generally more soft tissue and less cartilage damage
Circumferential area is less
Vulnerable to submucosal changes
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Pediatric airway
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caution
• Not to be used as effectivness is decresed
• When the anatomy is distorted
Laryngeal mask airway
• Should be avoided until the airway is secured
• If necessary surgical airway
Neuromuscular blockade
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laryngeal trauma(neck-injury)
Airway stable
• Flexable fiberoptic laryngoscopy
• Normal endolarynx observation
Mild abnormality
• C.T. scan normal / Abnormal
• Non displaced,non angulated thyroid cartilage fracture
Mucosa and cartilage displaced
• Tracheotomy or intubation
• Direct laryngoscopy and esophagoscopy
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laryngeal trauma(neck-injury)
Impending airway
• tracheotomy
• Direct laryngoscopy and esophagoscopy
obstruction
• Hematoma, small laceration but endolarynx intact
• observation
• Isolated fracture displaced or angulated thyroid
• Cartilage but endolarynx intact
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surgical exploration
Significant voice alteration
Expanding hematoma / shock
Massive subcutaneous emphysema
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surgical exploration
Open exploration of neck with open reduction and internal fixation of fracture without thyrotomy
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laryngeal thyrotomy
Laryngeal cartilage stable,anteriorcommissureintact
ORIF- fractures
Repair mucosal laceration
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laryngeal thyrotomy
Laryngeal cartilage unstable,anterior commissuredisrupted,massive mucosal injuries
ORIF fractures, repair mucosal laceration and endolaryngealstent
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penetrating neck injuries
Neck zones
Zone -1 thoracic outlet
Cricoid cartilage to sternal notch
Zone-2 central
Cricoid to angle of mandible
Zone-3 skull base
Angle of mandible to base of skull
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Neck zone concept outdated
Location of skin wound not a reliable indicator of underlying injuries
Length of neck makes it impractical to divide into three short zones
Wounds often occur at border between zones and difficult to classify
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Epidemiology of penetrating neck injuries
40% of penetrating neck injuries do not involve important structures
Structures involved:-
-major vein: 15-25%
-major artery: 10-15%
-pharynx or esophagus: 5-15%
Larynx or trachea: 4-12%
Major nerves: 3-8%
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Debatable issue
Some 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 injury
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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----
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Indication of immediate surgical exploration
Exsanguinatinghemorrhage
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Guidelines
Pentrating neck wounds
Symptomatic/ asymptomatic
Angiography/ neck exploration
Endoscopy examination/angiog-
raphy/
Refractory shock or evolving stroke
Immediate neck exploration
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Esophageal injury--diagnosis
If missed leads to high morbidity and mortality
Contrast swallow study:-
Extravasation is diagnostic
Negative study is not reliable
50% of leak—missed with gastrograffin
25% of leaks missed with barium
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Recommendations
If gastrograffin study is negative then repeat with Barium
Avoid 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%
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latrogenic laryngeal injuries
The iatrogenic trauma(intubation related laryngeal injuries)
Has been neglected so far or has not been the topic for discussion,
As we all know that since the introduction of modern Intensive Care Units and introduction of
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latrogenic laryngeal injuries
Pvc biocompatable high volume and low pressure trans- laryngeal
Tubes has decreased the incidence of laryngeal complications after long term intubation.
Still the incidence of laryngeal injuries in our ICU is 15to 20 %
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Acute complication of intubation
Difficult anatomy
Excessive force
Inexperienced
doctor
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Endotrachealtubes
Upper limit size in
females :-7mm
Upper limit size in
males:-8mm
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Acute complication of intubation
Hematoma formation
Laceration
Avulsion
Scarring and granulomaformation
Dislocation of arytenoidcartilage
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Sequelae of prolonged intubation
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pathogensis
Non-specific hyperemia and edmadue to mucosal irritation
Edma often marked in the mucosa of the laryngeal ventricle
Prolapse or protrusion of the mucosa
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pathogensis
Edma within the submucosa in the subglottis
Delayed airway obstruction after extubation
Edma of true vocal cords persists, long after extubation as Reinkei’sedma---vocal cord dysfunction
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pathogenesis
Ulceration :- with varying degrees of granulation tissue formation
Common site susceptable site for irritation is mucosa overlying the vocal process
Prolapse of granulation in glottis after extubation airway obstruction REINTUBATION
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Sequelae of prolonged intubation
Posterior glottic stenosis both common adults and children
Deep ulceration occurs with chondritis of the arytenoid and cricoid cartilage
Heal by fibrosis formation of fibrous bands between arytenoidcartilages
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Sequelae of prolonged intubation
Abduction of the vocal cords are limited
Misdiagnosed as bilateral abductor paralysis
Peudolaryngealparalysis
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Sequelae of prolonged intubation
Sub-glottis stenosis in both adults and children
Children are more prone to mechanical trauma of subglottic region during intubation because of presence
Of loose tissue covering the cricoidcartilage and leads to edma formation.
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Sequelae of prolonged intubation
A mild edma in children in subglotticarea can lead to critical airwayobstruction
Sub glottic dimension in infants:- fullterminfant having less than 4 mm and premature infant having less than 3 mm
Cause symptomatic airway obstruction
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Prevention of postintubation injuries
Early detection of laryngeal injury and early anticipation of complication
Will reduce the incidence of complications.
Lot of controversies regarding the time for evaluation of larynx and tracheotomy
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Prevention of postintubation injuries
Time of intubation
More than 10 days and less than 10 days
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1
2
0
0.5
1
1.5
2
2.5
3
3.5
2
37% 71%
Prevention of postintubation injuries
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Prevention of postintubation injuries
On the basis of these complications it is recommended that patients
Intubated for 7 days should under go tracheotomy if extubation is not imminent
And length of intubation greater than 10 days should be avoided.
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Prevention of postintubation injuries
except
Infants Patients with burn injuries
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Result of recent studies done at university hospital Vall”Hebron-spain
• On 4th day of intubation1st laryngeal examination
• On 7th day of intubation
• Extubation was done –if unsuccessful then tracheotomy done
2nd laryngeal examination
• One month after extubation
• Or after tracheotomy
3rd laryngeal examination
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Result of serial laryngeal examinations
findings 1st laryngeal examination
2nd laryngeal examination
3rd laryngeal examination
normal 7.8% 10% 26.6%
edma 84% 43.3% 13.3%
preflap 42% 16% 26.6%
flap 13% 30% 26.6%
granuloma 5.2% 13.3% 0
ulceration 0 46.6% 33.3%
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conclusion
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conclusion
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