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Endoscopic repair of pediatric traumatic laryngeal injury
International Journal of Pediatric Otorhinolaryngology 60 (2001) 243– 247 www.elsevier.com/locate/ijporl
Case report
Endoscopic repair of pediatric traumatic laryngeal injury David C. Bloom a,b,*, Daniela S. Carvalho a,c, Donald B. Kearns a,c a
Pediatric Otolaryngology, Children’s Hospital and Health Center, 3030 Children’s Way, Suite 402, San Diego, CA 92123 -4228, USA b Otolaryngology — Head and Neck Surgery, Na6al Medical Center San Diego, 34520 Bob Wilson Dri6e, Suite 200, San Diego, CA 92134 -2200, USA c Di6ision of Head and Neck Surgery, Uni6ersity of California, San Diego, 200 West Arbor Dri6e, San Diego, CA 92103 -8895, USA Received 11 April 2001; received in revised form 13 June 2001; accepted 17 June 2001
Keywords: Endoscopy; Laryngeal injury; Repair
1. Introduction
2. Case report
Acute laryngotracheal complex injury in childhood is rare. The reported incidence in the adult population is one in 30,000 emergency room visits [1]. The incidence in children is lower because of anatomic factors and behavioral differences [2]. Historically, acute laryngeal injuries have been treated by securing the airway and exploring the neck [3]. We report a case of bilateral avulsion of the leading edge of the true vocal cords from the anterior commissure of the larynx and a novel technique for endoscopic evaluation and repair of this injury.
A 10-year-old boy was brought via ambulance to the emergency department after a clothesline injury to the neck. He was found walking in a parking lot after riding his bicycle down a hill with a helmet on and striking a chain at full speed with his anterior neck. He was amnestic for the event but denied headache, nausea, vomiting, chest or abdominal pain. He was transported in C-spine precautions and presented to the emergency room with a respiratory rate of 20 with a room air oxygen saturation of 100%. His physical examination was remarkable for a hoarse voice, tenderness to palpation over the larynx and a 2.5 cm horizontal laceration under the chin. The remainder of his examination was normal. Flexible laryngoscopy demonstrated a bilateral avulsion of the leading edge of the true vocal cords from the anterior commissure of the larynx. A computed tomography (CT) scan of his larynx
The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government. * Corresponding author. Tel.: +1-619-532-9400; Fax: + 1619-532-6088. E-mail address: [email protected] (D.C. Bloom).
0165-5876/01/$ - see front matter © 2001 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 1 6 5 - 5 8 7 6 ( 0 1 ) 0 0 5 3 3 - X
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D.C. Bloom et al. / Int. J. Pediatr. Otorhinolaryngol. 60 (2001) 243–247
demonstrated intact laryngeal cartilages, and CT scan of his head demonstrated no intracranial anomalies. Microsuspension laryngoscopy, bronchoscopy and repair of laryngeal mucosal lacerations were performed. The Lindholm laryngoscope was placed in the valecula, and the larynx was visualized. The anterior three-quarters of both true
vocal cords were found to be avulsed off the thyroid cartilage at the anterior commissure and retracted back toward the arytenoid cartilages (Fig. 1). Examination of the subglottis demonstrated subglottic edema, but the remainder of the trachea and main stem bronchi were normal. An ethibond suture was passed from the skin of the anterior neck through the thyroid cartilage into
Fig. 1. (A) Intraoperative photograph and (B) schema of laryngotracheal injury demonstrating bilateral avulsion of the leading edge of the true vocal cords from the anterior commissure of the larynx.
D.C. Bloom et al. / Int. J. Pediatr. Otorhinolaryngol. 60 (2001) 243–247
245
Fig. 2. (A) Intraoperative photograph and (B) schema demonstrating use of suture to reapproximate true vocal cords and to reconstruct the anterior commissure.
the larynx at the level of the anterior commissure. It was passed though the anterior-most portion of the left true vocal cord and then delivered into the mouth. This was repeated on the right side and again delivered into the mouth. The two sutures were tied within the mouth and then pulled from the anterior neck until the laceration was closed and the vocal cords reapproximated to the
anterior commissure (Fig. 2). The external suture was tied over a sterile button at the skin. Gelfoam packing was placed over the mucosa, and a small endotracheal tube was placed. Postoperatively, the patient was placed on steroids, antibiotics, anti-reflux precautions and medication. Repeat endoscopic examination was performed 4 days later, at which point he was extubated without
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D.C. Bloom et al. / Int. J. Pediatr. Otorhinolaryngol. 60 (2001) 243–247
complications. He was seen in follow-up at 2 years after surgery, at which time he had a normal appearing larynx with a good voice.
3. Discussion Laryngotracheal injury in the pediatric population is rare and potentially life-threatening. The reported adult incidence is 1 in 30,000 or less than 1% of all blunt trauma injuries [1]. The incidence is lower in children. Children are involved in fewer assaults and motor vehicle accidents, with the majority of laryngeal trauma occurring because of falls, bicycle injuries, fixed-wire injury or motor vehicle accidents. The pediatric larynx is favorably located at the C-4 vertebral level, which is higher than the adult, and allows the mandible to partially shield the larynx from blunt trauma. The pediatric larynx is also relatively protected by the pliability of the cartilage and relative lack of ossification that makes it less likely to fracture. This increased pliability of the pediatric larynx can result in splaying outward of the thyroid cartilage without fracture during an anterior blow that causes avulsion of the vocal cords anteriorly [2]. This is the presumed pathophysiologic mechanism underlying the injury in this case. Any child with a neck injury may have a laryngeal injury. The presenting symptoms of acute laryngeal trauma consist of voice change, stridor, respiratory distress, dysphagia, odynophagia and hemoptysis. The typical signs include edema, crepitation, subcutaneous emphysema, loss of thyroid cartilage prominence, open neck wound and palpable cartilage fracture. Any patient with compromised ventilation and a history of neck trauma should have the airway secured endoscopically or surgically. If the patient is hemodynamically stable, the laryngotracheal complex can be evaluated with fiberoptic nasopharyngoscopy and computed tomography. Laryngeal injuries are classified into five groups [2] (Table 1). Nonsurgical management including observation, delivery of humidified air, and voice rest is reserved for group 1. The surgical options for laryngeal injuries in groups 2– 5 include endoscopy alone, endoscopy with exploration, and
endoscopy with exploration and stenting. Endoscopy alone is performed whenever any doubt exists to the degree of injury following physical examination, fiberoptic examination and computed tomography. Minor edema, hematomas and mucosal lacerations are treated with a secure airway and conservative therapy. Endoscopy with open exploration is considered for any of the following indications: (1) large mucosal laceration, (2) exposed cartilage, (3) multiple or displaced cartilaginous fractures, (4) vocal cord immobility, (5) fractured cricoid cartilage, (6) lacerations of the anterior commissure or free margin of a vocal cord, and (7) disruption of the cricoarytenoid joint [1]. Stenting is indicated for: (1) comminuted laryngeal fractures, (2) massive mucosal injuries, and (3) injuries that involved disruption of the anterior commissure [1]. Kurien and Zachariah recently reported a protocol for the management of pediatric laryngeal injury. While effective, their case series demonstrated several complications of open exploration of laryngeal injury, including subglottic and glottic stenosis [3]. We report a case of endoscopic repair of a traumatic anterior commissure injury. A low threshold for taking patients to the operating room for endoscopic evaluation will enable accurate evaluation of the extent of laryngeal injury and may enable repair of select laryngeal injuries. Endoscopic evaluation and repair of injuries inTable 1 Classification of laryngotracheal injury [2] Group
Characteristics
1
No detectable fracture; no mucosal lacerations; minor endolaryngeal hematoma; minimal airway compromise Endolaryngeal hematoma or edema with compromised airway; minor mucosal lacerations without exposed cartilage; nondisplaced fracture Massive edema with airway obstruction; mucosal lacerations with exposed cartilage; immobile vocal cord Same as group 3 with massive derangement of the endolarynx; more than two fracture lines on CT Laryngotracheal separation
2
3
4
5
D.C. Bloom et al. / Int. J. Pediatr. Otorhinolaryngol. 60 (2001) 243–247
cluding mucosal lacerations, and lacerations of the true vocal cord should be performed when technically feasible. This will allow early decannulation, provide for functional speech and normal deglutition, and decrease the number of required explorations and stents.
247
edge of the true vocal cords from the anterior commissure of the larynx provides an alternative to tracheotomy, stenting and exploration of the neck in the treatment of this severe laryngeal injury.
References 4. Conclusion Pediatric laryngotracheal complex injury is rare, requiring a high index of suspicion for diagnosis. Early endoscopic evaluation is essential for determining the extent of injury, assessing the need to secure the airway, and establishing plans for surgical interventions. Our method of endoscopic repair of bilateral avulsion of the leading
[1] J.P. Bent, J.R. Silver, E.S. Porubsky, Acute layrngeal trauma: a review of 77 patients, Otolaryngol. Head Neck Surg. 109 (3-1) (1993) 441 – 449. [2] D.T. Link, R.T. Cotton, The laryngotracheal complex in pediatric head and neck trauma: securing the airway and management of external laryngeal injury, Pediatr. Head Neck Trauma 7 (2) (1999) 133 – 143. [3] M. Kurien, N. Zachariah, External laryngotracheal trauma in children, Int. J. Pediatr Otorhinolarygol. 49 (2) (1999) 115 – 119.
Case report
Endoscopic repair of pediatric traumatic laryngeal injury David C. Bloom a,b,*, Daniela S. Carvalho a,c, Donald B. Kearns a,c a
Pediatric Otolaryngology, Children’s Hospital and Health Center, 3030 Children’s Way, Suite 402, San Diego, CA 92123 -4228, USA b Otolaryngology — Head and Neck Surgery, Na6al Medical Center San Diego, 34520 Bob Wilson Dri6e, Suite 200, San Diego, CA 92134 -2200, USA c Di6ision of Head and Neck Surgery, Uni6ersity of California, San Diego, 200 West Arbor Dri6e, San Diego, CA 92103 -8895, USA Received 11 April 2001; received in revised form 13 June 2001; accepted 17 June 2001
Keywords: Endoscopy; Laryngeal injury; Repair
1. Introduction
2. Case report
Acute laryngotracheal complex injury in childhood is rare. The reported incidence in the adult population is one in 30,000 emergency room visits [1]. The incidence in children is lower because of anatomic factors and behavioral differences [2]. Historically, acute laryngeal injuries have been treated by securing the airway and exploring the neck [3]. We report a case of bilateral avulsion of the leading edge of the true vocal cords from the anterior commissure of the larynx and a novel technique for endoscopic evaluation and repair of this injury.
A 10-year-old boy was brought via ambulance to the emergency department after a clothesline injury to the neck. He was found walking in a parking lot after riding his bicycle down a hill with a helmet on and striking a chain at full speed with his anterior neck. He was amnestic for the event but denied headache, nausea, vomiting, chest or abdominal pain. He was transported in C-spine precautions and presented to the emergency room with a respiratory rate of 20 with a room air oxygen saturation of 100%. His physical examination was remarkable for a hoarse voice, tenderness to palpation over the larynx and a 2.5 cm horizontal laceration under the chin. The remainder of his examination was normal. Flexible laryngoscopy demonstrated a bilateral avulsion of the leading edge of the true vocal cords from the anterior commissure of the larynx. A computed tomography (CT) scan of his larynx
The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government. * Corresponding author. Tel.: +1-619-532-9400; Fax: + 1619-532-6088. E-mail address: [email protected] (D.C. Bloom).
0165-5876/01/$ - see front matter © 2001 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 1 6 5 - 5 8 7 6 ( 0 1 ) 0 0 5 3 3 - X
244
D.C. Bloom et al. / Int. J. Pediatr. Otorhinolaryngol. 60 (2001) 243–247
demonstrated intact laryngeal cartilages, and CT scan of his head demonstrated no intracranial anomalies. Microsuspension laryngoscopy, bronchoscopy and repair of laryngeal mucosal lacerations were performed. The Lindholm laryngoscope was placed in the valecula, and the larynx was visualized. The anterior three-quarters of both true
vocal cords were found to be avulsed off the thyroid cartilage at the anterior commissure and retracted back toward the arytenoid cartilages (Fig. 1). Examination of the subglottis demonstrated subglottic edema, but the remainder of the trachea and main stem bronchi were normal. An ethibond suture was passed from the skin of the anterior neck through the thyroid cartilage into
Fig. 1. (A) Intraoperative photograph and (B) schema of laryngotracheal injury demonstrating bilateral avulsion of the leading edge of the true vocal cords from the anterior commissure of the larynx.
D.C. Bloom et al. / Int. J. Pediatr. Otorhinolaryngol. 60 (2001) 243–247
245
Fig. 2. (A) Intraoperative photograph and (B) schema demonstrating use of suture to reapproximate true vocal cords and to reconstruct the anterior commissure.
the larynx at the level of the anterior commissure. It was passed though the anterior-most portion of the left true vocal cord and then delivered into the mouth. This was repeated on the right side and again delivered into the mouth. The two sutures were tied within the mouth and then pulled from the anterior neck until the laceration was closed and the vocal cords reapproximated to the
anterior commissure (Fig. 2). The external suture was tied over a sterile button at the skin. Gelfoam packing was placed over the mucosa, and a small endotracheal tube was placed. Postoperatively, the patient was placed on steroids, antibiotics, anti-reflux precautions and medication. Repeat endoscopic examination was performed 4 days later, at which point he was extubated without
246
D.C. Bloom et al. / Int. J. Pediatr. Otorhinolaryngol. 60 (2001) 243–247
complications. He was seen in follow-up at 2 years after surgery, at which time he had a normal appearing larynx with a good voice.
3. Discussion Laryngotracheal injury in the pediatric population is rare and potentially life-threatening. The reported adult incidence is 1 in 30,000 or less than 1% of all blunt trauma injuries [1]. The incidence is lower in children. Children are involved in fewer assaults and motor vehicle accidents, with the majority of laryngeal trauma occurring because of falls, bicycle injuries, fixed-wire injury or motor vehicle accidents. The pediatric larynx is favorably located at the C-4 vertebral level, which is higher than the adult, and allows the mandible to partially shield the larynx from blunt trauma. The pediatric larynx is also relatively protected by the pliability of the cartilage and relative lack of ossification that makes it less likely to fracture. This increased pliability of the pediatric larynx can result in splaying outward of the thyroid cartilage without fracture during an anterior blow that causes avulsion of the vocal cords anteriorly [2]. This is the presumed pathophysiologic mechanism underlying the injury in this case. Any child with a neck injury may have a laryngeal injury. The presenting symptoms of acute laryngeal trauma consist of voice change, stridor, respiratory distress, dysphagia, odynophagia and hemoptysis. The typical signs include edema, crepitation, subcutaneous emphysema, loss of thyroid cartilage prominence, open neck wound and palpable cartilage fracture. Any patient with compromised ventilation and a history of neck trauma should have the airway secured endoscopically or surgically. If the patient is hemodynamically stable, the laryngotracheal complex can be evaluated with fiberoptic nasopharyngoscopy and computed tomography. Laryngeal injuries are classified into five groups [2] (Table 1). Nonsurgical management including observation, delivery of humidified air, and voice rest is reserved for group 1. The surgical options for laryngeal injuries in groups 2– 5 include endoscopy alone, endoscopy with exploration, and
endoscopy with exploration and stenting. Endoscopy alone is performed whenever any doubt exists to the degree of injury following physical examination, fiberoptic examination and computed tomography. Minor edema, hematomas and mucosal lacerations are treated with a secure airway and conservative therapy. Endoscopy with open exploration is considered for any of the following indications: (1) large mucosal laceration, (2) exposed cartilage, (3) multiple or displaced cartilaginous fractures, (4) vocal cord immobility, (5) fractured cricoid cartilage, (6) lacerations of the anterior commissure or free margin of a vocal cord, and (7) disruption of the cricoarytenoid joint [1]. Stenting is indicated for: (1) comminuted laryngeal fractures, (2) massive mucosal injuries, and (3) injuries that involved disruption of the anterior commissure [1]. Kurien and Zachariah recently reported a protocol for the management of pediatric laryngeal injury. While effective, their case series demonstrated several complications of open exploration of laryngeal injury, including subglottic and glottic stenosis [3]. We report a case of endoscopic repair of a traumatic anterior commissure injury. A low threshold for taking patients to the operating room for endoscopic evaluation will enable accurate evaluation of the extent of laryngeal injury and may enable repair of select laryngeal injuries. Endoscopic evaluation and repair of injuries inTable 1 Classification of laryngotracheal injury [2] Group
Characteristics
1
No detectable fracture; no mucosal lacerations; minor endolaryngeal hematoma; minimal airway compromise Endolaryngeal hematoma or edema with compromised airway; minor mucosal lacerations without exposed cartilage; nondisplaced fracture Massive edema with airway obstruction; mucosal lacerations with exposed cartilage; immobile vocal cord Same as group 3 with massive derangement of the endolarynx; more than two fracture lines on CT Laryngotracheal separation
2
3
4
5
D.C. Bloom et al. / Int. J. Pediatr. Otorhinolaryngol. 60 (2001) 243–247
cluding mucosal lacerations, and lacerations of the true vocal cord should be performed when technically feasible. This will allow early decannulation, provide for functional speech and normal deglutition, and decrease the number of required explorations and stents.
247
edge of the true vocal cords from the anterior commissure of the larynx provides an alternative to tracheotomy, stenting and exploration of the neck in the treatment of this severe laryngeal injury.
References 4. Conclusion Pediatric laryngotracheal complex injury is rare, requiring a high index of suspicion for diagnosis. Early endoscopic evaluation is essential for determining the extent of injury, assessing the need to secure the airway, and establishing plans for surgical interventions. Our method of endoscopic repair of bilateral avulsion of the leading
[1] J.P. Bent, J.R. Silver, E.S. Porubsky, Acute layrngeal trauma: a review of 77 patients, Otolaryngol. Head Neck Surg. 109 (3-1) (1993) 441 – 449. [2] D.T. Link, R.T. Cotton, The laryngotracheal complex in pediatric head and neck trauma: securing the airway and management of external laryngeal injury, Pediatr. Head Neck Trauma 7 (2) (1999) 133 – 143. [3] M. Kurien, N. Zachariah, External laryngotracheal trauma in children, Int. J. Pediatr Otorhinolarygol. 49 (2) (1999) 115 – 119.