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LARYNGOTRACHEAL INJURIES ASSOCIATED WITH NECK TRAUMA

DR. NAIM MANHAS F.I.C.S., M.S.,M.B.B.S. E.N.T. SURGEON KING ABDUL AZIZ HOSPITAL MAKKAH

Diagnosis and management of E.N.T. trauma –an update (5thAnnual Trauma Symposium )

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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.

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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.

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Laryngo-tracheal injuriesLaryngeotracheal injury is rare 1 in every 5000 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 trauma

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Aim and objectives

Prevent long term

complications by early

diagnosis and proper

management

In association

with ER surgeons,

trauma surgeons

and Anesthesiol

ogists

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types of laryngeal trauma

Blunt

trauma

Iatrogenic trauma

Intubation injuries

Penetrating trauma

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Management

Management of laryngo-tracheal trauma is based on the extent of injury:-

Initial

evaluatio

n

Endoscopic

evaluatio

n

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Initial Evaluation

Securing the airway

•Intubation:- vocal cords are visible, no visible injuries

•Tracheotomy done under local anesthesia

Obtaining hemodynamic stability

•Controlling of bleeding

Immobilizing the cervical spine

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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.

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Initial Evaluation

Identified with physical examination or fiberoptic laryngoscopy

In case exploration of neck is carried

Direct laryngoscopy and bronchoscopy is performed

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Initial Evaluation

Oesophagoscopy is always performed

50% of patients with an airway injury also have associated oesophageal injury

Degree and type of injury is evaluated during endoscopic examination

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Classification of laryngeal injuries

supraglottis transglottis Cricoid/trachea

As per location

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Aim and objectives

Assessment of injury

Level of injury

Severity of injury

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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

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PRESENTATION

dyspnoea dysphagia dysphonia

odynophagiaRespiratory distress

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physical findingsSubcutaneous

•Emphysema

•Tenderness

Oedma

•Hematoma

•ecchymosis

Distoration •Or

•Loss of laryngeal landmarks

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Classification of laryngeal injury

Group 1

Group2

Group3

Group4

Group5

Minor endolaryngeal hematoma : Minimal airway compromise Endolaryngeal hematoma/oedma

associated with compromised airway/non-displaced fracture

Massive endolaryngeal edma with airway obstruction/mucosal tears with exposed cartilage/immobile vocal cords

Same as group3 with more than two fracture lines on imaging/massive dearangement of endolarynx

Laryngotracheal sepration3/30/2012

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MANAGEMENT

Grop 1& 2 are usually managed non surgically with humidied air,head of bed elevation,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 stent

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Aim and objectives

Restore the integrity of the larynx with regard

To phonation,airway and quality of life

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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 conflict

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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 hours

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Penetrating laryngeal injuries

hematomaMucosal tears or laceration

Cartilage fractures and dislocation

Laryngo-tracheal

disruption

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Classification of penetrating neck injuries

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Classification of penetrating neck 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 base

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Management of penetrating neck injuries

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.

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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:-

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Management of penetrating neck injuries

All patients with hemodynamic instability or airway compromise

Needs surgical exploration

Followed by panendoscopy

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Management of penetrating neck injuries

Injuries in Zone -1. and in Zone-3. of neck are difficult to examine clinically and surgically.

Imaging including angiography is often performed

Zone.1. injuries are subjected with preoperative arteriograhpy and gastrograffin swallow studies

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Management of penetrating neck injuries 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 imaging

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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.

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Surgical intervention laceration involving anterior commissure,

Injury to the free edge of the true vocal fold

Exposed cartilage /displaced or comminuted fracture

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Surgical intervention

Vocal fold immobility

Arytenoid cartilage dislocation

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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.

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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.

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Intubation injuries

The incidence of intubation injury has increased since

The critically ill patients are being sustained longer on

Ventilatory support because of introduction of sophisticated I.C.U.

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Intubation injuries

Scarring of laryngeal structures

Subglottic stenosis•Tracheal stenosis

Granulation tissue formation•Vocal fold paresis or•paralysis

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Intubation injuries

19%

42%

Intubation prolonged more than 7-10 days ,incidence of complications is from 14-19%.

The incidence of complications increases two-folds if intubation is prolonged more than two weeks.

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Fac

tors

determine the severity of intubation injures

Ana

tom

ical

var

iatio

n Difficult intubation or traumatic intubation.

Inexperienced intubation

Iatr

ogen

ic c

ause

s Oversized tubes

Excessive patient movement

Repeated self extubation

Overinflated tube cuffs

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presentation

High endotracheal cuff pressure

Progressive hoarsness of voice or airway obstruction from glottic or subglottic edma

Compressive neuropathies by direct pressure of cuff

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presentation

Dysfunctional vocal cords or paresis

Mucosal injury, result from movement of endotracheal tube,pressure necrosis

Granulation formation ,fixation of cricoarytenoid joint,web formation or stenosis

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Management

Post intubation granulation tissue resolve spontaneously after some times

Treatment includes a combination of voice therapy and antireflux medication

Surgical removal is only indicated when it leads to partial airway obstruction

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Management

Managemnt of stenosis depends on its 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 mucosa

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Management

Posterior laryngeal stenosis and cricoarytenoid joint fixation

Treated with repeated dilation through an endoscopic approach

In severe cases ,open approach through laryngofissure is done

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Management

In cases of failures or more severe cases

Arytenoidectomy or partial posterior cordotomy is done

Subglottic or tracheal stenosis approached with endoscopic laser incision and dilation

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Management

More severe stenosis require laryngotracheal reconstruction or

Vocal fold paralysis with persistent dysphonia or significant aspiration

segmental resection with primary anastomisis

Vocal fold augmentation

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ManagementBilateral vocal fold immbolity present with stridor and airway obstruction

Relieved by partial posterior cordectomy,arytenoidectomy or arytenoid lateralization procedure

In severe cases needs tracheostomy

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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.

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THANK YOU

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