Airway Trauma IAC 2000

Airway Trauma

Ruben Peralta, MDWilliam E. Hurford, MD

Descriptions of penetrating neck injuries were first reported in theEdwin Smith papyrus approximately 5000 years ago.1 According to deFourmestranx, successful management of a penetrating vascular injury inthe neck was first documented in 1952. Ambroise Pare reportedly saved aman who had been injured in a duel and presented with a laceratedcommon carotid artery and internal jugular vein. The patient survived buthad aphasia and a hemiplegia.2,3 In 1803, Fleming was successful in ligat-ing the common carotid artery in a sailor who had attempted suicide bycutting his neck.2,4 In 1811, Abernathy, treating a patient who had beengored by a bull, ligated the lacerated left common and internal carotidarteries. The patient subsequently developed acute hemiplegia and didnot survive.2,4

Hugh Munro of Scotland documented the treatment of penetratingwounds of the trachea as early as 1792. He believed that longitudinaltracheal lacerations could be held together by straps. He reported that themost common tracheal injuries were transverse between two cartilagesand that these wounds could be sutured over a stent, with the patient’sneck remaining in a flexed position while the wound was allowed to heal.5

In 1873, Seuvre6 reported the first case of traumatic bronchial rupture ina patient with a right main bronchus avulsion. Sanger7 performed the firstsuture repair of a bronchial laceration in 1945. The first successful pri-mary repair of a bronchial rupture caused by blunt trauma was reportedin 1947 by Kinsella and Johnsrud.8

With the development of improved diagnostic facilities, reduced timefrom injury to definitive therapy, and advanced therapeutic modalities,the mortality rate of patients with neck and airway injuries has steadilydeclined. The current mortality rate due to penetrating neck injuries isapproximately 2% to 6%, whereas mortality rates were reported to bearound 15% in the Vietnam war.9–14 Mortality rates from blunt and pen-etrating airway injuries remain much higher.

111

� Incidence

Blunt injury to the lower airway is uncommon. This is primarily due toanatomical protection by the mandible and sternum anteriorly, the spinalcolumn posteriorly, and the mobility and the elasticity of the upper airwayitself. The larynx or cervical trachea is injured in <1% of patients admittedto the hospital for blunt trauma.15 Angood and colleagues16 reported thatonly 16 patients with laryngeal injury and 4 patients with cervical trachealinjury were treated at the Montreal General Hospital over a 10-year pe-riod. Of 46 patients with blunt upper airway injuries reported by Cicalaand associates,17 11 (24%) died, and 4 (36%) of these deaths were pri-marily due to airway injury. Kelly and coworkers18 reported that 21% ofpatients with blunt airway injuries died in the first 2 hours after admissionto a hospital. The incidence of such injuries has increased over the past 3decades.19,20

Penetrating airway injuries in the neck are also relatively uncommon.Capan and colleagues21 reviewed 17 reports published between 1965–1989 describing acute cervical airway injuries. Approximately 300 patientswere identified, accounting for an average of <3 cases per year per report-ing center. Penetrating injuries of the neck involved the larynx in up to5%–15% of patients, with the patients who had carotid artery or digestivetract injuries being at least twice as likely to have airway injuries.22,23 Aboutone-third of airway injuries involved the larynx and two-thirds involved thecervical trachea.17

The sites of nonpenetrating upper airway injuries vary among pa-tients. Cicala and associates17 reviewing a series of blunt injuries to theupper airway, reported seven (35%) larynx injuries above the cricoid,three (15%) involving the cricoid cartilage, nine (45%) involving thecervical trachea, and one (5%) involving other sites. Trone and col-leagues24 reported the thyroid cartilage to be the most commonly frac-tured site in blunt and penetrating laryngeal injuries (47%), followed byarytenoid cartilage (24%) and cricoid cartilage (22%). The prevailing siteof tracheal transection is the junction of the cricoid with the tracheabecause the connective tissues in this area are relatively weak.

� Mechanism of Injury

The pattern of injuries is closely related to the mechanism of injury.The majority of laryngotracheal injuries are caused by blunt trauma.Other etiologies include inhalation of noxious or hot gas fumes; aspira-tion of foreign bodies; iatrogenic injuries such as those occurring duringdiagnostic procedures, endotracheal intubation, percutaneous tracheos-tomy or tracheostomy; and penetrating trauma.

112 � Peralta and Hurford

Inhalation Injury

The inhalation of extremely hot steam, gas, or other noxious fumeswill tend to primarily injure the larynx and cervical trachea, and, seldomly,will damage the lower airway. The resulting necrosis and scar formationnarrows and deforms the affected area. Early intubation or tracheostomyis essential in most cases, due to the rapid development of laryngealedema. Intubation and tracheostomy can produce additional injury to thepreviously damaged trachea.

Intubation Injury

Injuries resulting from endotracheal intubation have been the mostcommon indication for tracheal resection and reconstruction (Fig. 1). Ina study at Massachusetts General Hospital by Grillo,25 208 patients re-ceived operations to repair injuries resulting from tracheal intubation;185 had tracheostomy injuries and 23 had injuries from endotracheal

Figure 1. (A) Axial computedtomography (CT) scan at the levelof the thoracic inlet of a patientwith a laryngotracheal lacerationfollowing attempted cricothyrotomyshows that extensive subcutaneousemphysema is present. An endo-tracheal tube is present within thetracheal lumen. (B) CT scan at themidtracheal level of the samepatient shows that subcutaneousand mediastinal emphysema ispresent. Bilateral dependentconsolidations of the lungs andacute respiratory failure occurredsecondary to aspiration of gastriccontents.

Airway Trauma � 113

intubation, with 22 of the 23 being cuff injuries. Cuff injuries also ac-counted for approximately half of the injuries in the patients who hadtracheostomies. The percentage of laryngeal injuries due to intubation isunclear, but a prospective study by Kambic and Radsel26 reported it to beapproximately 0.1%.

The most frequent intubation injury is chronic cicatrix with stenosis(Fig. 2). Other injuries in the study by Grillo25 included nine patients with

Figure 2. An anteroposterior tomogram of the larynxand trachea demonstrates narrowing of the subglottictrachea (at arrow) consistent with a cicatrization andstenosis following endotracheal intubation.


tracheoesophageal fistula, eight with tracheal erosion by the tracheostomytube, and one with a trachea-innominate artery fistula. Bronchial rupturefollowing endotracheal intubation has been reported by Patel and associ-ates.27

High pressures within endotracheal tube cuffs, which were commonprior to the introduction of low-pressure, high-volume cuffs, are thoughtto be the etiology of most injuries following endotracheal intubation (seechapter by Dunn and Goulet). In a study by Thomas,28 consisting of 46patients treated between 1961 to 1972, it was observed that 22% of sur-viving patients who had cuffed tracheal tubes subsequently developedtracheal stenosis. Since the development of high-volume, low-pressurecuffs, the incidence of tracheal stenosis from this type of injury appears tohave decreased, but injuries continue to occur and continue to be themost common indication for tracheal resection and reconstruction.29 In-juries may occur even after a brief period of intubation.30 Endotrachealcuff injuries may be more common in children31 and when the tracheahas been injured by inhalation injury.32

Blunt Injuries

Most blunt injuries to the upper airway and chest are the result ofdirect blows, severe flexion/extension injuries, or crushing injuries to thechest.33 Frequently, the blunt injury is the result of a motor vehicle crash(MVC) in which the victim is pinned between the car seat and the steeringwheel or is ejected from the vehicle and pinned beneath the wreckage(Fig. 3).34 In a study by Sklar and coworkers35 involving 35 cases, 40%were the result of a MVC (of which 64% were ejected from and crushedby the vehicle when it rolled over them), 26% were due to the slippage ofcars from jacks, and 20% were secondary to industrial accidents.

Direct blows are most likely to injure the cartilages of the larynx,36

while flexion/extension injuries are most commonly associated with tra-

Figure 3. Photograph shows achest contusion and discolorationin an unrestrained driver followinga motor vehicle crash. The injuryresulted in bronchial disruption atthe level of the carina.


cheal tears or laryngotracheal separation.37 When the trachea is damagedfrom a crushing injury, it may be the result of the trachea becomingcompressed between the manubrium and the vertebral column. Bluntinjuries to the chest may produce vertical tears in the membranous por-tion of the trachea or bronchi, usually within 2.5 cm of the carina (Figs.4, 5).17,38,39

Penetrating Injuries

Although penetrating injuries can involve any portion of the airway,the trachea is the structure most commonly injured by stab wounds. Thelarynx is injured in approximately one-third of upper airway injuries, withthe cervical trachea accounting for the remaining two-thirds.17 Death inpatients with penetrating airway trauma is usually due to an associatedvascular injury and is rarely due to the airway injury itself.18

Figure 4. (A) Chest radiographdemonstrates a tracheal lacera-tion sustained following a dirtbike injury with extensivepneumomediastinum andsubcutaneous emphysema withinthe neck. (B) Axial computedtomography scan through thesuperior mediastinum revealsextensive mediastinal emphysemaand subcutaneous emphysema.There is a laceration of themembranous wall of the trachea.


Associated Upper Airway Pathology

Edema fluid can rapidly accumulate in the supraglottic and the sub-glottic submucosa. The resulting subglottic endolaryngeal swelling tendsto be circumferential, increasing the possibility of airway obstruction. Ver-tical spread of accumulated edema is limited by the conus elasticus.40 Airdissecting within the submucosal space can further reduce the luminaldiameter of the larynx and trachea. Air within the soft tissues (subcuta-neous emphysema) may produce epiglottic emphysema and narrowing ofthe supraglottic airway.39,41

Most submucosal edema and hematoma formation occurs within sev-eral hours after trauma.42 Consequently, it is unlikely that endolaryngealswelling will produce airway obstruction more than 6 hours after thetrauma. Straining, coughing, and speaking, however, can increase theamount of subcutaneous air and can produce intramural bleeding, whichcan worsen airway obstruction.

Multiple factors, including the magnitude and direction of force, theposition of the cervical spine at impact, the age of the patient, and theconsistency of the laryngotracheal cartilages and soft tissue, determinethe type of airway injury (such as laryngotracheal contusion, edema, he-matoma, laceration avulsion, and/or fracture and dislocation of the thy-roid, cricoid, or tracheal cartilages) that may occur.21 Older patients withcalcified cartilages presumably are more likely to be vulnerable to a laryn-geal fracture, although it may occur at any age. This theory regardingvulnerability due to age has never been formally proved, however, prob-ably because patients that sustain this type of injury tend to be younger

Figure 5. Chest radiograph reveals acomplete avulsion of the right mainstembronchus, resulting in pneumothorax andcomplete collapse of the right lung.


adults.43 A combination of soft tissue, supraglottic, glottic, and infraglotticinjuries in a single patient is common.

Associated Injuries

Injuries sufficient to result in severe laryngotracheal damage can alsoeasily damage the cervical spine, esophagus, and vascular structures. Atleast 10%24 and as many as 50%16 of patients with blunt airway traumahave concurrent cervical spine injuries. A cervical spine injury should beconsidered present in such injuries until proven otherwise.44 When per-forming endotracheal intubation, bronchoscopy, or esophagoscopy orwhen undertaking measures to ease pressure on a tracheal anastomosis,flexion or extension of the neck must be avoided until cervical spineinjuries are excluded. An existing cervical spine injury or neurologicalsymptoms will determine the timing and surgical management of associ-ated airway injuries.

Patients with blunt laryngotracheal trauma also commonly presentwith closed head injury. Airway obstruction from the injury can be mis-takenly thought to be a result of upper airway obstruction resulting fromcoma. Maxillofacial injuries are also common and, again, airway obstruc-tion may be blamed on the facial injuries. An emergency cricothyroid-otomy performed under such conditions may convert a partial airwayobstruction to a complete airway obstruction. Patients with penetratingtrauma are likely to have concurrent vascular, esophageal, and thoracicinjuries. Esophageal injury occurs in 25% of patients with penetratingairway injuries but may be missed until late in the patient’s hospitalcourse.18

Traumatic asphyxia is a syndrome that results from a crush injury,usually of short duration, to the chest. The condition is rare, with only 10cases identified in a 12.5-year period at the Shock Trauma Center of theUniversity of Maryland.35,45 Associated injuries are expected and includeinjuries to the chest wall, lung, and liver. Management is focused onprotection of the airway, ventilatory and vascular support, and treatmentof the associated injuries. The majority of patients with isolated traumaticasphyxia survive; morbidity and mortality are related primarily to associ-ated injuries and cerebral anoxia.

� Diagnosis

Physical Findings

Airway injuries produce a spectrum of signs and symptomatology.Presentation varies according to the mechanism of injury from no visiblesign of trauma, to visible sign of tissue destruction such as contusion and


subcutaneous emphysema, to extensive lacerations that expose vascularand airway structures. In 1965, Harris and Ainsworth46 reported using anevaluation system to classify the location, type, and severity of laryngotra-cheal injuries. This system was subsequently refined by Potter and cowork-ers.47

While a high index of clinical suspicion and a thorough history andphysical examination are imperative, reports suggest that at least 25% ofpatients with laryngotracheal trauma requiring surgery have no physicalevidence of such injury and may not display symptoms until 24 to 48 hoursafter trauma.48,49 In the series of upper airway injuries reported by Cicalaand associates,17 10 of 46 (22%) patients were not diagnosed from pre-senting signs and symptoms. Of these 10 patients, 5 were diagnosed bycomputed tomography (CT), 1 by laryngoscopy, 1 by bronchoscopy, 1during the induction of the anesthesia, and 1 at autopsy.

Patients may present with only subtle signs of airway injury. In diag-nosing laryngotracheal injury, one should take into consideration the typeof accident and be alert for signs or a combination of signs of localcontusion, subcutaneous emphysema, changes in the voice such as hoarse-ness or inspiratory stridor, respiratory distress, and hemoptysis. Subcuta-neous or mediastinal emphysema are sometimes the only factors presentin an injury to the distal trachea, and the airway otherwise appears sur-prisingly normal. It is imperative that the surgeon, if time and circum-stances allow, carefully and fully evaluates, each patient for signs of theseinjuries. Injuries to the distal trachea and carina may present with addi-tional findings, including subcutaneous emphysema and pneumothoraxwith a minimal to a large air leak in which the lung fails to reexpandcompletely after placement of a chest tube. Laryngoscopy, flexible andrigid bronchoscopy, and esophagoscopy can be performed to definitelydelineate the anatomy of the airway and associated injuries.

Failure to recognize injuries acutely may lead to progressive airwayobstruction as cicatrization occurs and stenosis develops. Delayed diagno-sis of laryngotracheal injuries is not unusual, especially when emergencyintubation is performed. In one series, delayed diagnosis was reported in37% (7 of 19) of patients who remained undiagnosed until they presentedwith airway stenosis 8 days to 3 years after the initial trauma.50 The out-come due to delayed diagnosis of associated injuries (i.e., esophagealperforation) can be devastating due to the development of life-threatening complications such as mediastinitis.

Radiological Assessment

A radiograph of the neck can reveal tracheal injuries.51 Angood andcolleagues16 reported that radiography alone was sufficient for diagnosing12 (60%) out of 20 patients with cervical airway trauma. The use of ra-


diographs of the esophagus or cervical spine and additional use of tomo-grams of the trachea and larynx can be very useful in discovering subtle,previously undetected injuries. While radiological studies can be veryhelpful, definitive airway management should not be delayed excessivelyby their use, since an apparently stable airway can rapidly progress to anacute airway obstruction. Additional radiological examinations that maybe indicated in selected patients include contrast-enhanced esophagealstudies, computed tomography, and magnetic resonance imaging. High-resolution helical CT scanning can permit three-dimensional reconstruc-tion of the airway (Fig. 6). Patients who are unable to lie supine becauseof airway symptoms or dyspnea, however, may not be able to tolerate

Figure 6. Helical computed tomography(CT) scans with reconstructed images canaccurately define airway pathology. Theseimages demonstrate a soft tissue massconsistent with a mucoepidermoid carcinomaof the trachea. The anatomy of lesionsassociated with airway trauma can besimilarly defined. (A) Helical CT scanreconstructed in through the tracheademonstrates a rounded soft tissue mass in thedistal trachea 3 cm above the carina andarising from the right lateral wall of thetrachea. (B) Sagittal reconstructiondemonstrates the soft tissue mass arising fromthe anterior wall of the distal trachea. (C)“Virtual bronchoscopic” image reconstructedfrom a helical CT demonstrates the soft tissuemass arising from the right anterolateral wallof the trachea.


prolonged radiological examinations. Use of intravenous sedatives duringimaging in these patients may lead to disastrous airway compromise and isnot advised.

� Airway Management

Many patients with upper airway injuries may be successfully managedusing traditional techniques to establish an airway.17,52 In a retrospectivereview of upper airway injuries reported by Cicala and associates,17 three-fourths (35/46) of the patients had no apparent airway managementproblems and were either observed without requiring endotracheal intu-bation (4 patients), intubated through an obvious airway defect (6 pa-tients), or endotracheally intubated using traditional techniques (25 pa-tients). The remaining patients required emergent tracheostomy, mostcommonly following blunt trauma.

Airway management in patients with neck trauma is based upon ahigh index of clinical suspicion for cricoid or cervical tracheal injuries.Attempts at endotracheal intubation in patients with unsuspected cricoidinjuries can be disastrous.17 Cricoid pressure or the attempted passage ofan endotracheal tube may dislocate a fractured cricoid cartilage and/orentirely disrupt a partial tracheal transection, producing complete airwayobstruction (Fig. 7).

The equipment and personnel required to perform an immediate

Figure 7. Intraoperative view of a tracheal transection shows the proximal and distal ends of thetrachea, which remain attached only by the posterior membranous wall and the soft tissuessurrounding the trachea. An endotracheal tube is present within the lumen of the trachea.


tracheostomy must be present prior to manipulation of an injured airway.Positive pressure ventilation can exacerbate air leaks and rapidly worsensymptoms from pneumothorax, pneumomediastinum, and air dissectingaround airway structures. Whenever possible, the patient should be per-mitted to breathe spontaneously. Rapid induction of anesthesia and neu-romuscular blockade can rapidly produce loss of the airway and the in-ability to provide positive pressure ventilation. Attempts at directlaryngoscopy or intubation over a flexible bronchoscope may be futilebecause of bleeding within the airway or distortion of anatomical struc-tures. The danger also exists that flexible bronchoscopy may occlude theairway or precipitate airway obstruction in patients with critical airwaystenosis.37 Under ideal circumstances, preoxygenation followed by awakeflexible bronchoscopy may permit evaluation of airway injuries and safeendotracheal intubation. Prior induction of general anesthesia, using apotent inhalation anesthetic such as sevoflurane, while maintaining spon-taneous ventilation, may be appropriate in some patients. This approachcan permit rigid laryngoscopy and rigid bronchoscopy while maintainingspontaneous ventilation. These techniques may be preferable when bleed-ing or debris obscure the airway, making fiberoptic examination impos-sible. If endotracheal intubation appears unwise and the patient is un-stable or the airway is lost, immediate tracheostomy is the only appropriatechoice. When the trachea itself is injured, it is preferable to conservenormal trachea by placing the tracheostomy through the damaged area.This will facilitate subsequent surgical repair of the trachea.37

� Anesthetic Considerations

Anesthesia and airway management for tracheal surgery has beendiscussed in detail in a recent issue of International Anesthesiology Clinics.53

Induction of general anesthesia using a potent volatile agent and sponta-neous ventilation is generally considered to be the safest technique toinduce anesthesia in patients with possible airway injuries.54,55 The use ofintravenous agents such as propofol, however, may be necessary if thepatient is confused or uncooperative. Once anesthetized, the airway maybe secured by passing a rigid bronchoscope or an endotracheal tube intothe distal airway and past the point of injury. An endobronchial intubationsometimes is necessary to accomplish this. Once an endotracheal tube hasbeen placed across or distal to the site of injury, controlled positive pres-sure ventilation can begin (Fig. 8). The use of neuromuscular-blockingagents should generally be avoided until the airway is secured. Positivepressure ventilation by mask may become impossible under such condi-tions, and may worsen subcutaneous emphysema. Immediate tracheos-tomy is then the only option. Cricothyrotomy may be useless if the cricoidcartilage or distal trachea is injured. The use of cardiopulmonary bypass to


provide emergency support after complete tracheal disruption has beendescribed.56

� Outcome

Morbidity

Patients who have suffered severe laryngotracheal injuries usually suf-fer some permanent airway or voice impairment and may have increaseddifficulties protecting the airway from aspiration of pharyngeal contents.These complications generally are due to scar contracture or excessgranulation tissue formation.37,57,58 Patients sustaining blunt neck traumatend to have more late complications, such as difficulties with phonationor scarring, than those with penetrating trauma.55,59 Schaefer60 reportedthat more severe laryngeal injuries are correlated with an increased like-lihood and severity of long-term sequelae. Late complications are morecommon when definitive treatment does not occur for more than 24hours after injury.37,44,57,58,61,62 Additional studies58,63,64 have reportedthat the quality of the voice and airway is highly, if not directly, related to

Figure 8. Intraoperative viewillustrates a complete trachealtransection secondary to a wire“clothesline” injury of the neck. Theairway is secured by temporaryintubation distal to the site of injury.


expedient repair of the injury. Reece and Shatney63 reported that delaysin repair increased the possibility of late airway stenosis, and Dedo andRowe65 concluded that a delay in diagnosis of 24 to 48 hours resulted inthe development of strictures for all affected patients.

Mortality

Mortality rates of patients with airway injuries are reported to be be-tween 15% to 30%18,19 and are usually the result of irreversible shock,massive aspiration of blood, related cervicothoracic vascular injuries, andinjured organs. Emergency management with failed intubation attemptsalso may produce airway obstruction and even death.66 Cicala and asso-ciates17 reported mortality rates of 24% (11 of 46) for upper airway inju-ries. Causes of death were exsanguination in 5 (45%) patients, airwayproblems in 4 (36%), brain injury in 1 patient (9%), and sepsis in 1patient (9%). The mortality rate for gunshot wounds producing airwayinjury was 35%, for blunt trauma was 25%, and for stab wounds to theupper airway was 22%.17

� Summary

Traumatic airway injuries fortunately are rare. While sometimes inju-ries are obvious and initial management straightforward, frequently thediagnosis is difficult. Prompt diagnosis of airway injuries requires a highindex of clinical suspicion, complemented by judicious use of endoscopyand radiological imaging. Initial management can be complicated by as-sociated head, neck, and thoracic injuries. Importantly, a patient’s airwaycan be lost because of injudicious use of sedation or failure to be properlycautious during attempts at airway management and endotracheal intu-bation. Mortality rates and the incidence of late complications remainhigh and have been related to delays in diagnosis and definitive treatment.

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Documents

Airway Trauma IAC 2000