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Blunt and penetrating trauma to the larynx and upper airway
Operative Techniques in Otolaryngology (2007) 18, 140-143
Blunt and penetrating trauma to the larynx and upper airway Todd Preston, MD, Fred G. Fedok, MD, FACS From the Department of Surgery, Division of Otolaryngology–Head and Neck Surgery, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania. KEYWORDS Larynx; Laryngeal trauma; Laryngeal fractures; Laryngeal emergencies; Stridor
Larynx and upper airway trauma are uncommon but potentially devastating injuries. These injuries may rapidly progress with lethal consequences. In the United States, the incidence of laryngeal trauma is estimated to be between 1 in 5,000 to 1 in 137,000 emergency room visits. The most common etiology of airway trauma is a blunt force impact to the anterior neck. With penetrating wounds there may be associated tissue loss, injury to the nearby carotid sheath structures, or injury to the esophagus and pharynx. There is an overall mortality of 40% for blunt injuries and 20% for penetrating injuries. Evaluation and treatment are directed at preserving life and maintaining and restoring laryngeal function. © 2007 Elsevier Inc. All rights reserved.
Larynx and upper airway trauma are uncommon but potentially devastating injuries. These injuries may rapidly progress to lethal consequences in a somewhat unpredictable fashion. In the United States, the incidence of laryngeal trauma is estimated to be between 1 in 5,000 to 1 in 137,000 emergency room visits.1,2 The most common etiology of airway trauma is a blunt force impact to the anterior neck.1 Laryngeal trauma also occurs by penetrating injuries to the neck, carrying a greater degree of urgency for control of the patient’s airway as the amount of tissue injury is usually greater than that occurring by blunt force impact.3,4 With penetrating wounds, there may be associated tissue loss, injury to the nearby carotid sheath structures, or injury to the esophagus and pharynx.4 Care must be taken not to overlook the extent of injury during evaluation and management as the size of the external wound may not reflect the overall degree of injury. There is an overall mortality of 40% for blunt injuries and 20% for penetrating injuries.5
Address reprint requests and correspondence: Fred G. Fedok, MD, FACS, Otolaryngology–Head and Neck Surgery, H091, Penn State Milton S. Hershey Medical Center, 500 University Drive, PO Box 850, Hershey, PA 17033-0850. E-mail address: [email protected]. 1043-1810/$ -see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.otot.2007.05.005
Initial evaluation and treatment Patients should be evaluated in accordance with basic trauma principles, as delineated by the American College of Surgeons’ Advanced Trauma Life Support protocol.6 There should be special attention paid to the evaluation of the airway in patients with a history of trauma to the anterior or anterolateral regions of the neck. A significant injury should be suspected in patients with hoarseness, shortness of breath, pain, or a globus sensation. Physical examination findings include the presence of subcutaneous air, a change of the contour of the thyroid cartilage, hematoma, hemoptysis, and the presence of lacerations or ecchymosis. The physical examination of the patient who is suspected of having significant laryngeal injury should include an examination of the endolarynx. Depending on the clinical situation, this can be done via fiberoptic laryngoscopy. This can also be performed during the establishment of a definitive airway. For patients with an unstable airway, priority must be given to the establishment of a definitive one by performing a tracheotomy.2 This typically should be done with a minimum of sedation as sedation may decrease the patient’s ability to cough and may lead to aspiration or respiratory collapse. In most cases, cricothyroidotomy should be avoided as this may complete a partial cricotracheal separation injury, leading to the loss of the airway.2 In stable patients with normal anatomic landmarks, a trial of endotracheal intubation may be cautiously performed under direct fiberoptic visualization.3
Preston and Fedok
Trauma to the Larynx and Upper Airway
Figure 1 Noncontrasted axial computed tomography scan demonstrating a left paramedian fracture of the thyroid cartilage, with significant amounts of air present within the soft tissues of the neck.
Imaging Typically, computed tomography without contrast may be performed to establish the extent and location of injury and provide information for definitive treatment planning7,8 (Figure 1). In cases of suspected great vessel injury, however, contrast may be added to investigate these injuries. It also may reveal occult injuries in the case of penetrating wounds or foreign bodies.3
Definitive treatment For patients with type I injuries consisting of a greenstick fracture or a nondisplaced fracture of the thyroid cartilage and
Figure 2
141 without significant mucosal tear, conservative treatment may be considered, consisting of observation for at least 24 hours with continuous oxygen saturation monitoring.3,4,8 This group of patients may be managed with the administration of cool air or supplemental oxygen and treated with a brief course of IV steroids, antibiotics, H2 blockers, and a soft diet.3,4,8 Type II injuries consist of patients with a linear fracture of the thyroid cartilage and, without evidence of significant endolaryngeal injury, should be explored via an open approach to best expose, reduce, and fixate the fractured airway skeleton. This can be done through a horizontal skin incision at the level of the cricothyroid membrane, with the creation of subplatysmal soft-tissue flaps. The lateral limits of these soft-tissue flaps may be extended to explore the pharynx, esophagus, and carotid sheath structures. Exposure of the thyroid cartilage then proceeds in a subperichondrial plane (Figure 2). Once exposure of the fracture is complete, titanium plates are used to rigidly fixate the fracture segments.1 It is thought that the use of plate and screw fixation produces better fracture stabilization, especially during speaking and swallowing and in younger, more pliable cartilage. Some authors recommend the use of a 4-hole miniplate (Figure 3) or titanium mesh stabilization over a fracture.1 The use of low-profile plates of 1.3 mm or 1.5 mm is generally recommended.1 After completion of this stabilization, the wound is irrigated and closed in layers over a drain, with careful approximation of the perichondrium. For type III injuries, including significant injury to the endolaryngeal mucosa, involvement of the anterior commissure, or extensive comminution of the thyroid cartilage, open exploration by laryngofissure is indicated. This exposure is performed in the same way as described above but includes a vertical thyrotomy made in midline, extending through the entire thyroid cartilage (Figure 4). Via this approach, the entire endolarynx can be exposed, evaluated, and treated. Through this exposure, evacuation of
Subperichondrial dissection showing the exposed thyroid cartilage fracture.
142
Operative Techniques in Otolaryngology, Vol 18, No 2, June 2007
Figure 3
Fixation of thyroid cartilage fracture using 4-hole plate and screw technique.
hematomas and repair of significant lacerations should be performed. Coverage of all exposed cartilage should be performed through primary repair if possible or via advancement flaps by using 5-0 or 6-0 absorbable suture.3,4
Figure 4
Discussion and controversies Large areas of exposed cartilage should be avoided because of the risk of granulation or subsequent scar and synechiae
Surgical thyrotomy with exposure of the airway lumen.
Preston and Fedok
Trauma to the Larynx and Upper Airway
143
Figure 5 Schematic depicting the placement and securing of soft endolaryngeal stent as might be used in the management of extensive endolaryngeal laceration or grafting. (A) Anchoring suture placement through stent before closure of thyrotomy. (B) The positioning of anchoring sutures through skin and secured over buttons. (All to be removed several weeks after primary operation.)
formation. Free grafts consisting of buccal mucosa, dermis, or split-thickness skin grafts may be used where mucosal advancement is impossible but may themselves lead to the increased formation of granulation tissue. Thyroid cartilage loss and fractures with comminution should generally be corrected or supported because of the risk of a poor voice or difficulty with decannulation. Correction of loss of skeletal support may be performed with autogenous cartilage grafts, alloplastic stents, or titanium mesh. Some authors recommend simply using titanium mesh to span gaps, thus stabilizing the cartilage without the use of stents and their associated risk of granulation tissue formation.1 Injuries at the level of the cricoid ring may be repaired by using mesh, permanent suture,7 or keel placement. Stents may be placed at the level of the thyroid cartilage for additional support and to stabilize soft-tissue grafts. It is recommended that stents placed for the correction of loss of skeletal support be left in place for 14 days, and for the support of grafts, 8 days.4 Longer periods of time may promote granulation formation. Stents are secured in place by passing at least 2 transcutaneous permanent sutures through the stent and securing it over skin buttons (Figure 5). Some authors also recommend placing additional superior and inferior sutures for additional security.3 Stents should be designed to be easily removed using endoscopic techniques.
The above principles of evaluation and treatment are designed to give an overview of safe and effective treatments for both preserving life and maintaining and restoring function in patients suffering from blunt and penetrating injury to the larynx.
References 1. de Mello-Filho FV, Carrau RL: The management of laryngeal fractures using internal fixation. Laryngoscope 110:2143-2146, 2000 2. Bent JP 3rd, Silver JR, Porubsky ES: Acute laryngeal trauma: a review of 77 patients. Otolaryngol Head Neck Surg 109:441-449, 1993 3. Schaefer SD, Stringer SP: Laryngeal Trauma (ed 3). Philadelphia, PA, Lippincott, Williams and Wilkins, 2001 4. Lucente FE, Mitrani M, Sacks SH, et al: Penetrating injuries of the larynx. Ear Nose Throat J 64:406-415, 1985 5. Atkins BZ, Abbate S, Fisher SR, et al: Current management of laryngotracheal trauma: case report and literature review. J Trauma 56:185190, 2004 6. American College of Surgeons: American College of Surgeons ATLS Guidelines (ed 7). Chicago, IL, American College of Surgeons, 2007 7. Richardson JD: Outcome of tracheobronchial injuries: A long-term perspective. J Trauma 56:30-36, 2004 8. Butler AP, Wood BP, O’Rourke AK, et al: Acute external laryngeal trauma: Experience with 112 patients. Ann Otol Rhinol Laryngol 114: 361-368, 2005
Blunt and penetrating trauma to the larynx and upper airway Todd Preston, MD, Fred G. Fedok, MD, FACS From the Department of Surgery, Division of Otolaryngology–Head and Neck Surgery, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania. KEYWORDS Larynx; Laryngeal trauma; Laryngeal fractures; Laryngeal emergencies; Stridor
Larynx and upper airway trauma are uncommon but potentially devastating injuries. These injuries may rapidly progress with lethal consequences. In the United States, the incidence of laryngeal trauma is estimated to be between 1 in 5,000 to 1 in 137,000 emergency room visits. The most common etiology of airway trauma is a blunt force impact to the anterior neck. With penetrating wounds there may be associated tissue loss, injury to the nearby carotid sheath structures, or injury to the esophagus and pharynx. There is an overall mortality of 40% for blunt injuries and 20% for penetrating injuries. Evaluation and treatment are directed at preserving life and maintaining and restoring laryngeal function. © 2007 Elsevier Inc. All rights reserved.
Larynx and upper airway trauma are uncommon but potentially devastating injuries. These injuries may rapidly progress to lethal consequences in a somewhat unpredictable fashion. In the United States, the incidence of laryngeal trauma is estimated to be between 1 in 5,000 to 1 in 137,000 emergency room visits.1,2 The most common etiology of airway trauma is a blunt force impact to the anterior neck.1 Laryngeal trauma also occurs by penetrating injuries to the neck, carrying a greater degree of urgency for control of the patient’s airway as the amount of tissue injury is usually greater than that occurring by blunt force impact.3,4 With penetrating wounds, there may be associated tissue loss, injury to the nearby carotid sheath structures, or injury to the esophagus and pharynx.4 Care must be taken not to overlook the extent of injury during evaluation and management as the size of the external wound may not reflect the overall degree of injury. There is an overall mortality of 40% for blunt injuries and 20% for penetrating injuries.5
Address reprint requests and correspondence: Fred G. Fedok, MD, FACS, Otolaryngology–Head and Neck Surgery, H091, Penn State Milton S. Hershey Medical Center, 500 University Drive, PO Box 850, Hershey, PA 17033-0850. E-mail address: [email protected]. 1043-1810/$ -see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.otot.2007.05.005
Initial evaluation and treatment Patients should be evaluated in accordance with basic trauma principles, as delineated by the American College of Surgeons’ Advanced Trauma Life Support protocol.6 There should be special attention paid to the evaluation of the airway in patients with a history of trauma to the anterior or anterolateral regions of the neck. A significant injury should be suspected in patients with hoarseness, shortness of breath, pain, or a globus sensation. Physical examination findings include the presence of subcutaneous air, a change of the contour of the thyroid cartilage, hematoma, hemoptysis, and the presence of lacerations or ecchymosis. The physical examination of the patient who is suspected of having significant laryngeal injury should include an examination of the endolarynx. Depending on the clinical situation, this can be done via fiberoptic laryngoscopy. This can also be performed during the establishment of a definitive airway. For patients with an unstable airway, priority must be given to the establishment of a definitive one by performing a tracheotomy.2 This typically should be done with a minimum of sedation as sedation may decrease the patient’s ability to cough and may lead to aspiration or respiratory collapse. In most cases, cricothyroidotomy should be avoided as this may complete a partial cricotracheal separation injury, leading to the loss of the airway.2 In stable patients with normal anatomic landmarks, a trial of endotracheal intubation may be cautiously performed under direct fiberoptic visualization.3
Preston and Fedok
Trauma to the Larynx and Upper Airway
Figure 1 Noncontrasted axial computed tomography scan demonstrating a left paramedian fracture of the thyroid cartilage, with significant amounts of air present within the soft tissues of the neck.
Imaging Typically, computed tomography without contrast may be performed to establish the extent and location of injury and provide information for definitive treatment planning7,8 (Figure 1). In cases of suspected great vessel injury, however, contrast may be added to investigate these injuries. It also may reveal occult injuries in the case of penetrating wounds or foreign bodies.3
Definitive treatment For patients with type I injuries consisting of a greenstick fracture or a nondisplaced fracture of the thyroid cartilage and
Figure 2
141 without significant mucosal tear, conservative treatment may be considered, consisting of observation for at least 24 hours with continuous oxygen saturation monitoring.3,4,8 This group of patients may be managed with the administration of cool air or supplemental oxygen and treated with a brief course of IV steroids, antibiotics, H2 blockers, and a soft diet.3,4,8 Type II injuries consist of patients with a linear fracture of the thyroid cartilage and, without evidence of significant endolaryngeal injury, should be explored via an open approach to best expose, reduce, and fixate the fractured airway skeleton. This can be done through a horizontal skin incision at the level of the cricothyroid membrane, with the creation of subplatysmal soft-tissue flaps. The lateral limits of these soft-tissue flaps may be extended to explore the pharynx, esophagus, and carotid sheath structures. Exposure of the thyroid cartilage then proceeds in a subperichondrial plane (Figure 2). Once exposure of the fracture is complete, titanium plates are used to rigidly fixate the fracture segments.1 It is thought that the use of plate and screw fixation produces better fracture stabilization, especially during speaking and swallowing and in younger, more pliable cartilage. Some authors recommend the use of a 4-hole miniplate (Figure 3) or titanium mesh stabilization over a fracture.1 The use of low-profile plates of 1.3 mm or 1.5 mm is generally recommended.1 After completion of this stabilization, the wound is irrigated and closed in layers over a drain, with careful approximation of the perichondrium. For type III injuries, including significant injury to the endolaryngeal mucosa, involvement of the anterior commissure, or extensive comminution of the thyroid cartilage, open exploration by laryngofissure is indicated. This exposure is performed in the same way as described above but includes a vertical thyrotomy made in midline, extending through the entire thyroid cartilage (Figure 4). Via this approach, the entire endolarynx can be exposed, evaluated, and treated. Through this exposure, evacuation of
Subperichondrial dissection showing the exposed thyroid cartilage fracture.
142
Operative Techniques in Otolaryngology, Vol 18, No 2, June 2007
Figure 3
Fixation of thyroid cartilage fracture using 4-hole plate and screw technique.
hematomas and repair of significant lacerations should be performed. Coverage of all exposed cartilage should be performed through primary repair if possible or via advancement flaps by using 5-0 or 6-0 absorbable suture.3,4
Figure 4
Discussion and controversies Large areas of exposed cartilage should be avoided because of the risk of granulation or subsequent scar and synechiae
Surgical thyrotomy with exposure of the airway lumen.
Preston and Fedok
Trauma to the Larynx and Upper Airway
143
Figure 5 Schematic depicting the placement and securing of soft endolaryngeal stent as might be used in the management of extensive endolaryngeal laceration or grafting. (A) Anchoring suture placement through stent before closure of thyrotomy. (B) The positioning of anchoring sutures through skin and secured over buttons. (All to be removed several weeks after primary operation.)
formation. Free grafts consisting of buccal mucosa, dermis, or split-thickness skin grafts may be used where mucosal advancement is impossible but may themselves lead to the increased formation of granulation tissue. Thyroid cartilage loss and fractures with comminution should generally be corrected or supported because of the risk of a poor voice or difficulty with decannulation. Correction of loss of skeletal support may be performed with autogenous cartilage grafts, alloplastic stents, or titanium mesh. Some authors recommend simply using titanium mesh to span gaps, thus stabilizing the cartilage without the use of stents and their associated risk of granulation tissue formation.1 Injuries at the level of the cricoid ring may be repaired by using mesh, permanent suture,7 or keel placement. Stents may be placed at the level of the thyroid cartilage for additional support and to stabilize soft-tissue grafts. It is recommended that stents placed for the correction of loss of skeletal support be left in place for 14 days, and for the support of grafts, 8 days.4 Longer periods of time may promote granulation formation. Stents are secured in place by passing at least 2 transcutaneous permanent sutures through the stent and securing it over skin buttons (Figure 5). Some authors also recommend placing additional superior and inferior sutures for additional security.3 Stents should be designed to be easily removed using endoscopic techniques.
The above principles of evaluation and treatment are designed to give an overview of safe and effective treatments for both preserving life and maintaining and restoring function in patients suffering from blunt and penetrating injury to the larynx.
References 1. de Mello-Filho FV, Carrau RL: The management of laryngeal fractures using internal fixation. Laryngoscope 110:2143-2146, 2000 2. Bent JP 3rd, Silver JR, Porubsky ES: Acute laryngeal trauma: a review of 77 patients. Otolaryngol Head Neck Surg 109:441-449, 1993 3. Schaefer SD, Stringer SP: Laryngeal Trauma (ed 3). Philadelphia, PA, Lippincott, Williams and Wilkins, 2001 4. Lucente FE, Mitrani M, Sacks SH, et al: Penetrating injuries of the larynx. Ear Nose Throat J 64:406-415, 1985 5. Atkins BZ, Abbate S, Fisher SR, et al: Current management of laryngotracheal trauma: case report and literature review. J Trauma 56:185190, 2004 6. American College of Surgeons: American College of Surgeons ATLS Guidelines (ed 7). Chicago, IL, American College of Surgeons, 2007 7. Richardson JD: Outcome of tracheobronchial injuries: A long-term perspective. J Trauma 56:30-36, 2004 8. Butler AP, Wood BP, O’Rourke AK, et al: Acute external laryngeal trauma: Experience with 112 patients. Ann Otol Rhinol Laryngol 114: 361-368, 2005