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Cricotracheal disruption owing to strangulation
Cricotracheal disruption owing to strangulation A report of two cases with successful surgical repair Two patients with cricotracheal disruption resulting from accidental strangulation of the neck were treated. The first patient had severe respiratory obstruction. In the second patient, afascial tube maintained airway continuity between the separated larynx and trachea, and she had no difficulty breathing. A preoperative diagnosis of tracheal injury was based on the findings of respiratory obstruction, bloody secretions in the endotracheal tube, and subcutaneous emphysema in the neck. In both cases, an endotracheal tube was easily passed and entered the distal tracheal lumen. This relieved the respiratory obstruction in the first case and allowed administration of general anesthesia and control of ventilation during the operation. Prompt repair with cricotracheal anastomosis was followed by excellent results in both cases.
S. S. Gill, M . D . , C. M. Singh, M . D . , Ph.D., and F. C. Eggleston, M . D . , Ludhiana, Punjab, India
V-^ricotracheal disruption occurs most commonly during the decelleration type of automobile accidents, 1 - 4 when the neck of the victim strikes the steering wheel or the dashboard. Occasionally, cricotracheal disruption results when the neck strikes against a wire cable or the edge of a platform or receives a direct b l o w . 4 , 5 We have treated 2 patients with cricotracheal disruption resulting from accidental strangulation. Women in India carry, as a part of their dress, a length of cloth " c h u n n i " that goes across the neck and over the shoulders with the ends hanging down on the back. In each case, the ends of the chunni were caught in a poweroperated rotating machine and resulted in strangulation injury. Case reports CASE 1. A 25-year-old woman was admitted to the emergency room of the Brown Memorial Hospital on Feb. 27, 1971. Her injury had occurred 10 hours earlier when the chunni was caught in a spinning machine. She was released by stopping the machine and cutting the cloth. She did not lose consciousness and gradually experienced increasing difficulty in breathing. When seen in the emergency room, From the Department of Thoracic Surgery, Christian Medical College and Brown Memorial Hospital, Ludhiana, Punjab, India. Received for publication Nov. 8, 1976. Accepted for publication Jan. 13, 1977. Address for reprints: S. S. Gill, M.D., Brown Memorial Hospital, Ludhiana, Punjab, India. 948
she had severe respiratory obstruction. Examination of the neck revealed extensive subcutaneous emphysema and the mark of strangulation. An endotracheal tube was easily passed, bloody secretions were sucked out, and the respiratory obstruction was relieved. A diagnosis of tracheal injury was based on the presence of respiratory obstruction, bloody secretions in the endotracheal tube, and subcutaneous emphysema in the neck. The patient was taken to the operating room. With the woman under general anesthesia, a transverse cervical incision was made. As soon as the platysma was incised, the endotracheal tube came into view. Further exploration revealed complete cricotracheal disruption; the trachea had retracted into the superior mediastinum and the endotracheal tube had entered its lumen. With the use of stay sutures, the trachea was pulled up. A tracheostomy tube was placed through its anterior wall and the patient ventilated through it. The endotracheal tube was removed, and the esophagus was examined carefully and found uninjured. Both recurrent laryngeal nerves were visible and intact. A cricotracheal anastomosis was done with interrupted stitches of 4-0 Prolene with the knots tied on the outside. The tracheostomy tube was left in place. The postoperative course was uneventful. On removal of the tracheostomy tube on the fifth postoperative day, she was able to breathe and talk normally. At bronchoscopic examination 2 weeks postoperatively, there was excellent healing of the anastomosis and no evidence of stenosis. She was examined 3 years later and had no complaints; the bronchoscope disclosed no abnormalities. CASE 2. A 35-year-old woman was admitted to Brown Memorial Hospital on Dec. 22, 1973. Six hours earlier she had been accidentally strangled when the chunni was caught in a fodder chopper. She was released by stopping the machine and cutting the cloth. She did not lose consciousness
Volume 73 Number 6 June, 1977
Cricotracheal
disruption
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Fig. 1A. Case 2. A fascial tube maintained continuity between the separated larynx and trachea. Because of this, the patient had no difficulty breathing.
Fig. IB. Incising the fascial tube revealed complete cricotracheal separation. The endotracheal tube had entered the tracheal lumen.
and had no difficulty breathing. At examination she was breathing quietly and her voice was hoarse. She had subcutaneous emphysema and mark of strangulation in the neck. A diagnosis of tracheal injury was based on the presence of subcutaneous emphysema in the neck. A nasotracheal tube was passed with the use of local anesthesia without difficulty. General anesthesia was induced, and a transverse cervical incision was made. Separating the infrahyoid muscles in the midline disclosed a ballooned fascial tube (Fig. 1 A). The endotracheal tube could be palpated through it. The larynx was felt at the upper end and the trachea at the lower end. Incising the fascial tube (Fig. IB) revealed complete cricotracheal disruption. The endotracheal tube had bridged the gap and entered the tracheal lumen below. Repair was accomplished with the same technique as used in Case 1 (Fig. 1C). The patient had an uncomplicated postoperative course and, on removal of the tracheostomy tube, had a normal voice and airway. A lateral roentgenogram of the neck taken 4 months postoperatively showed no anastomotic stenosis (Fig. ID). The patient has been observed for one year and continues to be well.
tracheal membrane. The trachea retracts down owing to elasticity of the intercartilagenous ligaments producing cricotracheal separation of several centimeters. The mechanism of injury in the cases reported here was similar. Strangulation occurred from behind, and the tight cloth pulled upward and backward on the prominent thyroid and cricoid cartilages against the cervical spine that was simultaneously hyperextended. As in the first case, a patient may have severe respiratory obstruction. As in Case 2, the fascial tube may maintain airway continuity, and the patient may have no initial difficulty breathing. Subcutaneous emphysema in the neck, hemoptysis, and the strangulation mark point to the tracheal injury. If breathing is obstructed, the obstruction must be relieved immediately. We were surprised at the ease with which it was possible to perorally intubate the separated trachea. This was also possible in the case reported by Ashbaugh. 3 It appears that the trachea, although separated from the larynx by several centimeters, still maintains its alignment. If an endotracheal tube cannot be passed, a tracheostomy should be done. The trachea may have retracted behind the sternum, from where it can be pulled up and intubated.
Comment Cricotracheal disruption is an uncommon but serious injury. It usually results from the application of a sudden blunt force directed upward and backward against the lower border of the cricoid. 6 The same force, by causing hyperextension of the cervical spine, stretches the trachea and thereby facilitates rupture of the crico-
If breathing is not obstructed, the bronchoscope should be employed to confirm the diagnosis. In addi-
9 50
Gill, Singh,
The Journal of Thoracic and Cardiovascular Surgery
Eggleston
Fig. 1C. After minimal debridement to provide clean edges, cricotracheal anastomosis was done. Tracheostomy below the anastomosis is not shown.
Fig. ID. Air tracheogram done 4 months postoperatively shows an excellent result.
tion, the larynx and vocal cords can be examined. Since bronchoscopy can precipitate respiratory obstruction, all should be in readiness for a tracheostomy. As the esophagus may also be injured, an esophagoscopic examination may be useful. Alternatively, the esophagus should be carefully examined at time of repair. Cricotracheal disruption is easily corrected by prompt cricotracheal anastomosis with excellent results. Tracheostomy below the anastomosis was done in both cases because of the possibility of associated injury of the recurrent laryngeal nerves. Shaw and associates 4 pointed out that definitive repair should not be postponed to a later date, because then restoration of the airway is much more difficult and the result is not as good. Awareness of this complication of strangulation should prompt its early diagnosis and treatment.
REFERENCES 1 Ogura, J.: Management of Traumatic Injuries of the Larynx and Trachea Including Stenosis, J. Laryngol. Otol. 85: 1259, 1971. 2 McNeill, K.: Injuries of the Larynx and Trachea, J. Laryngol. Otol. 85: 1262, 1971. 3 Ashbaugh, D. G.: Traumatic Avulsion of the Trachea Associated With Cricoid Fracture, J. THORAC. CARDIOVASC. SURG. 69: 800,
1975.
4 Shaw, R. R., Paulson, D. L., and Kee, J. L., Jr.: Traumatic Tracheal Rupture, J. THORAC. CARDIOVASC. SURG.
42: 281, 1961. 5 Chodosh, P. L.: Cricoid Fracture With Tracheal Avulsion, Arch. Otolaryng. 87: 461, 1968. 6 Harris, H. H.: Management of Injuries to the Larynx and Trachea, Laryngoscope 82: 1924, 1972.
S. S. Gill, M . D . , C. M. Singh, M . D . , Ph.D., and F. C. Eggleston, M . D . , Ludhiana, Punjab, India
V-^ricotracheal disruption occurs most commonly during the decelleration type of automobile accidents, 1 - 4 when the neck of the victim strikes the steering wheel or the dashboard. Occasionally, cricotracheal disruption results when the neck strikes against a wire cable or the edge of a platform or receives a direct b l o w . 4 , 5 We have treated 2 patients with cricotracheal disruption resulting from accidental strangulation. Women in India carry, as a part of their dress, a length of cloth " c h u n n i " that goes across the neck and over the shoulders with the ends hanging down on the back. In each case, the ends of the chunni were caught in a poweroperated rotating machine and resulted in strangulation injury. Case reports CASE 1. A 25-year-old woman was admitted to the emergency room of the Brown Memorial Hospital on Feb. 27, 1971. Her injury had occurred 10 hours earlier when the chunni was caught in a spinning machine. She was released by stopping the machine and cutting the cloth. She did not lose consciousness and gradually experienced increasing difficulty in breathing. When seen in the emergency room, From the Department of Thoracic Surgery, Christian Medical College and Brown Memorial Hospital, Ludhiana, Punjab, India. Received for publication Nov. 8, 1976. Accepted for publication Jan. 13, 1977. Address for reprints: S. S. Gill, M.D., Brown Memorial Hospital, Ludhiana, Punjab, India. 948
she had severe respiratory obstruction. Examination of the neck revealed extensive subcutaneous emphysema and the mark of strangulation. An endotracheal tube was easily passed, bloody secretions were sucked out, and the respiratory obstruction was relieved. A diagnosis of tracheal injury was based on the presence of respiratory obstruction, bloody secretions in the endotracheal tube, and subcutaneous emphysema in the neck. The patient was taken to the operating room. With the woman under general anesthesia, a transverse cervical incision was made. As soon as the platysma was incised, the endotracheal tube came into view. Further exploration revealed complete cricotracheal disruption; the trachea had retracted into the superior mediastinum and the endotracheal tube had entered its lumen. With the use of stay sutures, the trachea was pulled up. A tracheostomy tube was placed through its anterior wall and the patient ventilated through it. The endotracheal tube was removed, and the esophagus was examined carefully and found uninjured. Both recurrent laryngeal nerves were visible and intact. A cricotracheal anastomosis was done with interrupted stitches of 4-0 Prolene with the knots tied on the outside. The tracheostomy tube was left in place. The postoperative course was uneventful. On removal of the tracheostomy tube on the fifth postoperative day, she was able to breathe and talk normally. At bronchoscopic examination 2 weeks postoperatively, there was excellent healing of the anastomosis and no evidence of stenosis. She was examined 3 years later and had no complaints; the bronchoscope disclosed no abnormalities. CASE 2. A 35-year-old woman was admitted to Brown Memorial Hospital on Dec. 22, 1973. Six hours earlier she had been accidentally strangled when the chunni was caught in a fodder chopper. She was released by stopping the machine and cutting the cloth. She did not lose consciousness
Volume 73 Number 6 June, 1977
Cricotracheal
disruption
94 9
Fig. 1A. Case 2. A fascial tube maintained continuity between the separated larynx and trachea. Because of this, the patient had no difficulty breathing.
Fig. IB. Incising the fascial tube revealed complete cricotracheal separation. The endotracheal tube had entered the tracheal lumen.
and had no difficulty breathing. At examination she was breathing quietly and her voice was hoarse. She had subcutaneous emphysema and mark of strangulation in the neck. A diagnosis of tracheal injury was based on the presence of subcutaneous emphysema in the neck. A nasotracheal tube was passed with the use of local anesthesia without difficulty. General anesthesia was induced, and a transverse cervical incision was made. Separating the infrahyoid muscles in the midline disclosed a ballooned fascial tube (Fig. 1 A). The endotracheal tube could be palpated through it. The larynx was felt at the upper end and the trachea at the lower end. Incising the fascial tube (Fig. IB) revealed complete cricotracheal disruption. The endotracheal tube had bridged the gap and entered the tracheal lumen below. Repair was accomplished with the same technique as used in Case 1 (Fig. 1C). The patient had an uncomplicated postoperative course and, on removal of the tracheostomy tube, had a normal voice and airway. A lateral roentgenogram of the neck taken 4 months postoperatively showed no anastomotic stenosis (Fig. ID). The patient has been observed for one year and continues to be well.
tracheal membrane. The trachea retracts down owing to elasticity of the intercartilagenous ligaments producing cricotracheal separation of several centimeters. The mechanism of injury in the cases reported here was similar. Strangulation occurred from behind, and the tight cloth pulled upward and backward on the prominent thyroid and cricoid cartilages against the cervical spine that was simultaneously hyperextended. As in the first case, a patient may have severe respiratory obstruction. As in Case 2, the fascial tube may maintain airway continuity, and the patient may have no initial difficulty breathing. Subcutaneous emphysema in the neck, hemoptysis, and the strangulation mark point to the tracheal injury. If breathing is obstructed, the obstruction must be relieved immediately. We were surprised at the ease with which it was possible to perorally intubate the separated trachea. This was also possible in the case reported by Ashbaugh. 3 It appears that the trachea, although separated from the larynx by several centimeters, still maintains its alignment. If an endotracheal tube cannot be passed, a tracheostomy should be done. The trachea may have retracted behind the sternum, from where it can be pulled up and intubated.
Comment Cricotracheal disruption is an uncommon but serious injury. It usually results from the application of a sudden blunt force directed upward and backward against the lower border of the cricoid. 6 The same force, by causing hyperextension of the cervical spine, stretches the trachea and thereby facilitates rupture of the crico-
If breathing is not obstructed, the bronchoscope should be employed to confirm the diagnosis. In addi-
9 50
Gill, Singh,
The Journal of Thoracic and Cardiovascular Surgery
Eggleston
Fig. 1C. After minimal debridement to provide clean edges, cricotracheal anastomosis was done. Tracheostomy below the anastomosis is not shown.
Fig. ID. Air tracheogram done 4 months postoperatively shows an excellent result.
tion, the larynx and vocal cords can be examined. Since bronchoscopy can precipitate respiratory obstruction, all should be in readiness for a tracheostomy. As the esophagus may also be injured, an esophagoscopic examination may be useful. Alternatively, the esophagus should be carefully examined at time of repair. Cricotracheal disruption is easily corrected by prompt cricotracheal anastomosis with excellent results. Tracheostomy below the anastomosis was done in both cases because of the possibility of associated injury of the recurrent laryngeal nerves. Shaw and associates 4 pointed out that definitive repair should not be postponed to a later date, because then restoration of the airway is much more difficult and the result is not as good. Awareness of this complication of strangulation should prompt its early diagnosis and treatment.
REFERENCES 1 Ogura, J.: Management of Traumatic Injuries of the Larynx and Trachea Including Stenosis, J. Laryngol. Otol. 85: 1259, 1971. 2 McNeill, K.: Injuries of the Larynx and Trachea, J. Laryngol. Otol. 85: 1262, 1971. 3 Ashbaugh, D. G.: Traumatic Avulsion of the Trachea Associated With Cricoid Fracture, J. THORAC. CARDIOVASC. SURG. 69: 800,
1975.
4 Shaw, R. R., Paulson, D. L., and Kee, J. L., Jr.: Traumatic Tracheal Rupture, J. THORAC. CARDIOVASC. SURG.
42: 281, 1961. 5 Chodosh, P. L.: Cricoid Fracture With Tracheal Avulsion, Arch. Otolaryng. 87: 461, 1968. 6 Harris, H. H.: Management of Injuries to the Larynx and Trachea, Laryngoscope 82: 1924, 1972.