Michelle Mekky, MA, CCC-SLP, BRS-S
Speech-Language Pathologist
Memorial Hermann Hospital & Children’s Memorial Hermann
Hospital
PurposeEducate the SLP on the medical
diagnosis, medical treatment, and ultimate rehabilitation of voice and swallowing following airway/laryngeal trauma.
Nelson Review Article• Why this article
• Lack of clinical research on this patient population in the SLP literature
Laryngeal Anatomy
Anatomy continued
Mechanism of Injury• Blunt Trauma-fractures/dislocation• Penetrating Trauma• Intubation Trauma• Thermal and Chemical Trauma
Blunt Trauma• Larynx is relatively well-protected• Lateral shielding by
sternocleidomastoid muscle• Posterior protection from cervical
vertebrae• Anterior protection by mandible
Examples of Blunt Trauma
Ex. of Blunt Trauma (cont)
Internal Trauma
Fractures and Dislocations• Midline or paramedian are most
common• Comminution & complex fractures
do occur• Surgical Management: ORIF &/or
tracheostomy• Use of stents
Laryngeotracheal Separation
• Severe airway compromise• Many die at the scene of the accident, unless
mucosal attachment remains• Tracheostomy performed ASAP • Intubation in the field may do more harm
than good• Bilateral recurrent nerve injury and subglottic
stenosis are common complications• Ultimate surgical intervention is sometimes a
total laryngectomy
Penetrating Trauma• Car accidents• Knifes• Bullets (handgun versus shotgun)• Other accidents: falling on sticks
or glass• Blast injuries
Vascular Injuries• Occur in 25-56% of penetrating
neck wounds• Most commonly to the carotid and
subclavian arteries-most common cause of death
• 20-30% of penetrating neck wounds result in laryngeal, tracheal, or esophageal injuries
Intubation Trauma• Prolonged intubation leads to
trauma in 4-13% of cases• Larger endotracheal tubes cause
more trauma• History of smoking or ETOH
consumption can be very drying to the mucosa
• GERD/LPRD
Intubation trauma caused by:
• Abnormal anatomy (~10% of the population)
• Difficult laryngescopy• Multiple intubations/extubations• Skill of person placing (resident vs.
attending)• Emergent versus Elective
When trachs are placed• In most hospitals tracheostomies
are performed after 10-14 days of endotracheal intubation
• If multiple trips to the OR are required
• Policies vary greatly between the different ICUs
Reaction to Intubation• Within 48 hours of intubation
granulation tissue begins to form• Mucosal ulceration is usually
present
Immediate Laryngeal Complications
• Glottic or subglottic edema• Mucosal laceration• Dislocation of the arytenoids• Avulsion of the epiglottis• Vocal cord paralysis
When to refer to ENT post intubation/extubation
• Hoarse voice greater than 48 hours
• Sore throat greater than 48 hours• Dysphagia• Odynophagia• Stridor
Management of Arytenoid Dislocation
• Needs to occur by ENT with 24-48 hours of identification
• Can sometimes be treated by direct endoscopy
Treatment of Avulsion of the Epiglottis
• Open repair• Laser excision
True VC Paralysis• May occur as result of intubation &/or
extubation• Brandwein et al. discovered that the anterior
branch of the recurrent laryngeal nerve is vulnerable to compression between the inflated cuff of the ETT, the lateral projection of the abducted arytenoids, and the thyroid cartilage.
• Cord is usually lying in the paramedian position
Late injuries of Intubation• Intubation granuloma• Cricoarytenoid ankylosis (fibrosis)• Glottic webs• Subglottic stenosis
Avoiding Late Injuries of Intubation
• Limiting amount of time the pt is intubated• Using the smallest ETT which will permit
adequate respiratory support• Using low-pressure cuffs• Careful fixation of the tube to limit
movement during assisted ventilation• Use of steroids and antibiotics• Early recognition/tx of such laryngeal
injuries
Intubation Granuloma• Forms when blood supply is poor• Area is exposed to potential contamination• Steroids is a medical tx• Antibiotics to promote healing of the
mucosa• Late presentations: voice changes,
globus, repetitive medical course of tx• Sometimes permanent
Glottic Web• Can result from simultaneous
denudation of both VFs near the anterior commissure
• When they heal together they produce a web
• Probably occurs more often as a complication or surgery rather than from intubation
Picture of Glottic Web
Medical tx of Glottic Webs• Surgical placement of anterior
tantalum keel• Endoscopic management with a
laser or mechanical lysis-followed by placement of an internal Teflon keel
Subglottic Stenosis• Definition: narrowing of the
subglottic space above the inferior margin of the cricoid cartilage and below the level of the glottis
• Can be anterior, posterior, or complete
Subglottic Stenosis (cont)• Grade I - Obstruction of 0-50% of
the lumen obstruction• Grade II - Obstruction of 51-70% of
the lumen• Grade III - Obstruction of 71-99% of
the lumen• Grade IV - Obstruction of 100% of
the lumen (ie, no detectable lumen)
Picture of Subglottic Stenosis
Tx of Subglottic Stenosis• Tracheostomy• Open reduction• Cricotracheal resection• Medical management of GERD/LPRD
if in the patient’s known history• Steroids/Antibiotics• Grafting
Consequences of Self-Extubation
• Edema• Possible vocal cord damage• Cartilage dislocation
Thermal and Chemical Trauma
• Inhalation of hot gases (caustic or not) cause trauma
• Stabilize the airway• Sudden edema is of primary
concern
Long term Injuries • Loss of mucosal integrity• Infection• Chondritis (inflammation of
cartilage)• Fibrosis
What the MD looks for:• Cough• Carbon particles• Blood in the sputum• Voice change• Stridor• Dyspnea (shortness of breath)
Course of Treatment• At least admitted for observation• Difficult to determine if
tracheostomy is indicated
Medical Management of the Airway
• Oral intubation after spine is clear• Rarely a cricothyroidotomy is
performed for an emergent airway when a trach cannot be completed
• Must be revised to a tracheostomy ASAP (within a few hours)
Role of the SLP• Aphonia/Hoarseness• Aspiration/Penetration• Avulsed/Amputated Epiglottis• Edema• Unilateral VC paresis/paralysis• Bilateral VC paralysis• Hearing Loss
Aphonia/Hoarseness• Get dx from ENT• Medical management is the best
course of tx for bringing back voicing
• Facilitate communication with a communication board and/or written communication systems
Aspiration/Penetration• Determine if postural changes are
helpful during MBS/FEES• MUST take into account fatigue on ability
to perform maneuvers (respiration and structural)
• May try: supraglottic swallow, super-supraglottic swallow, head down, or head rotation.
• Diet Modification is usually necessary with or without enteral access
Avulsed/Amputated Epiglottis
• May lead to initial odynophagia with all oral intake
• Chin down or super-supraglottic swallow may be a helpful to try during MBS/FEES
Edema• Vocal rest• Medical Management
– Steroids– Anti-inflammatories
Unilateral VC Paresis/Paralysis
• Many patients with unilateral paresis recover in the first 7-10 days post trauma
• Those with paralysis usually overcompensate with the good cord in 1-3 weeks
• Temporary tx’s by ENT: fat injection• Permanent tx’s by ENT: medialization
laryngoplasty or thyroplasty
Bilateral Vocal Cord Paralysis
• Causes– Paralysis (neurological)– Fixation of the cricoarytenoid joints– Both
Tx of Bilateral VC Paralysis• Usually trached and NOT a candidate
for a speaking valve• Written
communication/Communication board/electrolarynx during acute hospital stay
• If permanent with no recovery to either cord then: Speech generating device with or without electrolarynx
Hearing Loss• Reported cases of acoustic trauma SN HL
following blunt neck trauma• Segal et. al suggests it could be due to
sheer forces acting on the cervical spine that transition to the inner cranium
• Other theories suggest a neuromuscular mechanism, a neuro-vascular mechanism, or a mechanical vascular obstruction
• Tinnitus/Balance difficulties
Hearing Loss (cont)• Audiological/ENT referral is
appropriate• Referral to physical therapy may
be indicated• Speech tx for aural rehabilitation
Thoughts for the Future• Research in voice recovery s/p
airway trauma• Research in swallowing function
s/p airway trauma