u Baltimore

The Hood…

Portland

The real Hood….

Laryngeal Trauma

Paul W. Flint, MD

Otolaryngology – Head & Neck SurgeryOregon Health & Science University

5th Edition 2010

Guri Sandhu, MBBS, FRCSConsultant OtolaryngologistImperial College Healthcare NHS Trust, Charing Cross Hospital

Key Points

u Laryngeal trauma is rare although life threateningu Multiple etiologies: blunt, penetrating, intubation

caustic, thermal, radiation u Evaluation and Airway managementu Timing of interventionu Sequelae

Bhojani, RA - J Trauma 2005

Overall incidence is stable

Blunt trauma withincreased mortality

Blunt trauma more likely to require tracheotomy

Mechanics of injury impacted by age and degree of calcification

Blunt trauma:

Signs & Sx’s of external laryngeal trauma

u Hoarseness 28 (85%)u Dysphagia 17 (52%)u Pain 14 (42%)u Dyspnea 7 (21%)u Hemoptysis 6 (18%)

Luutilainen MActa Oto-Laryngologica 2007

n=33

Evaluation

u Airwayu Endoscopyu Imagingu Classification

Sandhu in Cummings OHNS 2010

Developing the Airway Response TeamOperational, Safety, and Educational Initiative.

Lauren Berkow, ACCMNasir Bhatti, OHNSRenee Cover, ORMJeffery Dodd-O, ACCMDavid Effron, Gen SurgElliot Haut, Gen SurgCarol Heiser, ACCMEugenia Heitmiller, ACCMPeter Hill, EDThomas Kirsch, EDChristina Lundquist, ACCMLynette Mark, ACCMDavid Tunkel, Peds OHNS

Imaging

Secure airway

Assess C-spine

Schaefer-Fuhrman classification of laryngeal traumau Group 1 Minor endolaryngeal hematomas or lacerations

No detectable fractureu Group 2 Edema, hematoma, minor mucosal disruption without exposed cartilage

Non-displaced fractureVarying degrees of airway compromise

u Group 3 Massive edema, large mucosal lacerations, exposed cartilageDisplaced fracture(s)Vocal cord immobility

u Group 4 Same as group 3 but more severe with:Severe mucosal disruptionDisruption of the anterior commissureUnstable fracture, 2 or more fracture lines

u Group 5 Complete laryngotracheal separation

Ann ORL 1982; J Trauma 1990

Approach to assess need for surgical intervention

u Laryngeal Framework

u Laryngeal Mucosa

u Vibratory Apparatus

u Laryngotracheal junction

Sandhu in Cummings OHNS 2010

Approach to assess need for surgical intervention

u Laryngeal Framework– Stable

No fracturesA single non-displaced fracture

– UnstableA single displaced fracture>1 fracture lineCricoid fracture

– Potentially non-viableFramework comminution with devitalized cartilage fragments

Sandhu in Cummings OHNS 2010

Approach to assess need for surgical intervention

u Laryngeal Framework– Stable

No fracturesA single non-displaced fracture

– UnstableA single displaced fracture>1 fracture lineCricoid fracture

– Potentially non-viableFramework comminution with devitalized cartilage fragments

Sandhu in Cummings OHNS 2010

Approach to assess need for surgical intervention

u Laryngeal Mucosa– Intact / Minimally injured

No mucosal injuries; Small submucosal hematomaLinear laceration with no exposed cartilage

– InjuredJagged / multiple linear lacerations Exposed cartilageLarge hematoma(s)

– Massively injured

Devitalized and/or significant loss of mucosa

Sandhu in Cummings OHNS 2010

16 yo female with history of fall

Neck tenderness and subcutaneous emphysema

Sandhu in Cummings OHNS 2010

Concomitant injuries with laryngeal trauma

Injury (%)u Open Neck Injury 18u Maxillofacial Fractures 18u Intracranial Injuries 17u Cervical Spine Fracture 13u Chest Injury 13u Other Facial Injury 10u Skull Fracture 7u Open Pharyngeal Injury 4

Jewett, Arch Otol-HNS 1999

Management

u Acute trauma

Sandhu in Cummings OHNS 2010

17 yo HS student struck in neck with lacrosse stick

PainHoarseness

Approach to assess need for surgical intervention

u Vibratory Apparatus– Intact– Injured

Anterior commissureVibrating edge of the vocal cord(s)Arytenoid dislocation

Sandhu in Cummings OHNS 2010

47 yo female

Touring racing stalls in Dubai

Horse bite to the neck

Tracheotomy performed urgentlyNo definitive repair

Approach to assess need for surgical intervention

u Laryngotracheal junction– Intact– Any degree of laryngotracheal separation

Sandhu in Cummings OHNS 2010

Management – penetrating trauma

u External– Penetrating

» Stab wound

» Emergent cricothyrotomy» Projectile

u Bullet– Low velocity– High velocity

Tracheotomy/cricothyrotomy - acute

u Hemorrhageu Decannulation or tube obstructionu False passageu Laceration of laryngeal framework

Cricothyroidotomy

laryngeal trauma

“Slash”Cricothyroidotomy

necessitates earlyearly endoscopic evaluation and repair

Voice outcome following laryngeal trauma

u Results from SchaeferGroup Voice outcome Airway outcome

Good Fair Poor Good Fair Poor1 20 0 0 20 0 02 38 3 0 40 1 03 18 3 0 21 0 04 22 10 0 31 0 2

u Results from Luutilainen et al2 12 4 0 16 0 03 7 6 0 13 0 04 1 3 0 4 0 0

Cummings OHNS 2010

Mechanisms of trauma

u Internal– Foreign body– Iatrogenic

» Endoscopic» Intubation» Radiation therapy

– Thermal» Ingestion, inhalation

– Caustic» Acid vs. Alkali

Intubation Injuries - delayed

u Granulomau Chondritisu Laryngeal stenosis

– glottic, subglotticu Tracheal stenosis

Mechanisms of Trauma

u Internal– Foreign body– Iatrogenic

» Endoscopic» Intubation» Radiation therapy

– Thermal» Ingestion, inhalation

– Caustic» Acid vs. Alkali

Prolonged intubationdefined by hours

-Weymuller

Mechanisms of Trauma

u Internal– Foreign body– Iatrogenic

» Endoscopic» Intubation» Radiation therapy

– Thermal» Ingestion, inhalation

– Caustic» Acid vs. Alkali

Electro-cautery inducedfire during tracheotomy

Acute

1 week

Management

u Sequelae

Long term sequelae

u Vocal fold motion impairment– Paralysis– Dislocation– Joint fixation

u Stenosis

S/P MVR

Posterior glotticfibrosis

Posterior cricoid split with graft

Posterior graft in position

Post op examPre op exam

Posterior cricoid split & rib graft

23 yo female with poly traumasecondary to MVA

Tracheotomy in the field

Unable to decannulate

Multiple endoscopic procedures

Stent left in place for 2 weeks

Decannulated

Intubation Injuries - Contributing factors

u Technique– visualization vs. blind, laryngeal blade

u ETT– size, duration, material

u Vent pressure, ETT fixation

Intubation Injuries - Contributing factors

u Patient activity - motionu Unconscious patientu NG tube, GERu Obesity, DM, nutritional status...

Intubation Injuries - Prevention

u Preop laryngoscopy?u Smallest tube, shortest durationu Anti-reflux regimenu Avoid rigid NGT

Intubation Injuries - Prevention

u Monitor vent/cuff pressuresu Early trach in high risk patientsu Endoscopic assessment

– steroid injection may be beneficial

Key Points

u Laryngeal trauma is rare although life threateningu Multiple etiologies: blunt, penetrating, intubation

caustic, thermal, radiation u Evaluation and Airway managementu Timing/sequence of interventionu Sequelae

Find Aoki slides

Laryngeal Stenosis

56 yo male s/pchemo-XRT for T3 N2b SCCA

Laryngeal Paralysis

Vocal fold polyp

Subglottic stenosis

Endoscopic resectionand placement of T-tube through trach site

Trach stenosis due to chronic intubation

Intubation Injuries - delayed

u Tracheomalaciau TE fistulau Intranasal synechiau Sinusitis

Intubation Injuries - acute

u Dental injuryu Soft tissue trauma

– nasal, oral, pharyngeal, hypopharyngealu Vocal fold contusion, lacerationu Vocal fold motion impairment

70 yo maleintubated 7 days S/P CABGwith NGT

69 yo female prolongedintubation S/P CABG

Mechanisms of Trauma

u ExternalBlunt

» Hanging» Clothesline injury» Sports Injury» Motor Vehicle Accident

u Internal

Penetrating» Stab wound» Emergent cricothyrotomy» Projectile

BulletLow velocityHigh velocity

Management

u ExternalBluntPenetrating

Post cricoid split – endoscopic view