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Repair of a laryngeal fracture using miniplates
Int. J. Oral Maxillofac. Surg. 2007; 36: 748–750 doi:10.1016/j.ijom.2007.01.026, available online at http://www.sciencedirect.com
Technical Note Trauma
Repair of a laryngeal fracture using miniplates
A. Thor1, A. Linder2 1 Department of Oral and Maxillofacial Surgery, Uppsala University Hospital, SE-751 85 Uppsala, Sweden; 2Department of Otolaryngology Head and Neck Surgery, Uppsala University Hospital, SE-751 85 Uppsala, Sweden
A. Thor, A. Linder: Repair of a laryngeal fracture using miniplates. Int. J. Oral Maxillofac. Surg. 2007; 36: 748–750. # 2007 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. Injuries to the larynx (voice box) can lead to loss of vital functions; the airway may be obstructed, the voice distorted or lost, and the protection of the airway during swallowing may fail. In order to preserve these functions, a stable repair that restores the anatomy as closely as possible is needed. The repair should interfere minimally with the neuromuscular functions of the larynx. The case is described of a 59-year-old male who suffered a severe laryngeal fracture in a workplace accident. Utilizing miniplates, the fracture was reduced and fixed in the correct position. After healing, the patient could be decannulated and has regained his voice, swallows without difficulty and has a patent airway. The results have been sustained over a 2-year follow-up.
Accepted for publication 10 January 2007 Available online 5 April 2007
The larynx, or voice box, is mostly noted for its role in phonation, but it is also an important safeguard of the lower airway while swallowing, and serves as a variable valve that regulates airflow and air pressure during respiration. If the larynx is injured, these functions are threatened. In the short term, preservation of the airway takes precedence, but for a good longterm result all three functions must be restored. The outcome is dependent on good anatomical alignment, stable fixation, and surgical techniques that do not cause injury to the neuromuscular functions of the larynx. The laryngeal framework is principally made up of the thyroid and cricoid cartilages. These structures are composed of hyaline cartilage but gradually become ossified with advancing age. The muscular insertions and directions of pull increase the stress in certain areas so that typical fracture patterns occur when excessive
was put on intravenous antibiotics (cefuroxim, changed before surgery to imipenem). The injuries were investigated by a computed tomography (CT) scan (Fig. 1), that showed a fracture with escape of air into the soft tissues of the neck and pronounced posterior displacement of the upper medial segment of the thyroid cartilage. A 3D reformatting was attempted, but proved technically unsatisfactory due to the uneven calcification of the cartilages. No cervical spine injuries were found. The patient was transferred to Uppsala University Hospital which is a tertiary referral centre. The attending ENT surgeon reviewed the case with the maxillofacial surgeon, and it was agreed that the fracture should be exposed and repaired using miniplates. Surgery was performed on the 4th day after the injury. The larynx was exposed by an anterior neck incision and the
0901-5027/080748 + 03 $30.00/0
force is applied. The muscular pull can also contribute to misalignment of the fractures. The fractures in an adult larynx resemble those of the thinner bones in the facial skeleton. Here is presented a case where a maxillofacial surgeon’s experience of miniplate fixation of facial fractures was combined with an ENT surgeon’s knowledge of the functional anatomy of the larynx to achieve optimal repair of a severe laryngeal fracture. Case
A 59-year-old lumberjack was working in a forest when one of his tools suddenly became dislodged and hit him across the anterior neck. He was transported to the county hospital and intubated with difficulty. A tracheostomy was performed to secure the airway without further trauma to the fractured larynx, and the patient
# 2007 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Laryngeal fracture repaired with miniplates
749
Discussion
Fig. 1. Sagittal CT scan of the fracture showing dorsal displacement of the superior fragment and air escaping into the soft tissues of the neck.
fracture line dissected. The displaced fracture was mainly horizontal though U-shaped (Fig. 2). There was also a midline vertical fracture with minimal displacement but with instability. The vocal folds were found to be entirely within the lower segment but changed by marked swelling. A preliminary alignment was achieved with sutures. Miniplates of 1.5 mm and 1.3 mm together with selfdrilling screws of 4 mm were used to unite the segments into larger blocks and join the blocks to form a stable unit (Fig. 3). The anterior angulation of the laryngeal framework could be restored by bending the appropriate plates (1.5 mm) to an almost 908 angle in the horizontal dimension. The anterior ossified parts of the thyroid cartilage gave excellent anchorage to the plates and screws, especially in the midline reduction of the fracture. A total of six miniplates were needed. The patient did not require intensive care postoperatively. The intravenous imipenem was continued for 1 week postoperatively and then changed to phenoxymethyl penicillin for another 2 weeks. A postoperative CT after 1 week showed excellent alignment (Fig. 4). The patient was returned to the county hospital where the tracheostomy was closed on the 11th postoperative day. He spoke with a somewhat hoarse voice and could resume a normal diet on the 13th day after the naso-gastric tube was removed. He underwent a check-up including micro-laryngoscopy 2 months later, showing slight scarring at a level above the vocal folds. Two years after the repair, the patient continues his heavy work without any restraint from his airway, and swallows without difficulty. His voice is somewhat strained but easily intelligible and he is moderately disturbed by mucus in the larynx.
The incidence of laryngeal trauma in the USA was estimated to be 1/137000 over a 5-year period in the late 1990s4. In this study 248 of 392 patients required surgery. Another often quoted estimate is that of SHAEFER9 who stated that laryngeal trauma was diagnosed in 1/30000 emergency room visits. The accepted explanation for the low incidence of this type of injury is that the chin and upper thorax help to protect the anterior neck from direct trauma. There is consensus that minor trauma with no airway compromise can be treated conservatively. Significant laryngeal
Fig. 2. Schematic drawing of the fracture system, seen from anterior end. The upper, dorsally displaced, segment is marked in darker colour. The fracture lines are shown in red.
Fig. 3. The contour of the larynx restored (oblique anterior view). Three miniplates are visible. Note how the upper thyroid cartilage, which was flattened by the trauma, has regained its shape by use of a bent upper plate.
750
Thor and Linder References
Fig. 4. Postoperative sagittal CT scan showing the repaired fracture. Three screws are visible as dense objects. The plane of the scan is slightly more lateral than in Fig. 1.
trauma requires that the airway is secured in the acute phase and that the anatomy is restored so that the larynx retains its functions after healing. Possible sequelae after inadequately treated injuries include scar stenosis restricting the airway, decreased tone of the vocal folds with a weak or hoarse voice, and vocal fold immobility causing either airway narrowing or loss of voice together with aspiration during swallowing. The cartilaginous framework defines the cross-sectional area of the laryngeal airway, the tone of the vocal folds, as well as the direction of pull of the intra-laryngeal muscles. In order to achieve an overall good result, it is critical to bring about precise reduction and stable fixation of displaced fractures of the framework. Studies from the early 1990s, reflecting techniques preceding miniplates, report that a good laryngeal airway was achieved in over 90% but a good voice in only 70%, as discussed by JEWETT et al.4. The alternative to miniplates is wire fixation10, but as noted by de MELLO-FILHO and CARRAU1 miniplates allow for a more exact and enduring fixation. An interesting rabbit study by DRAY et al.2 compared the healing of fractured cartilage fixed by plates or wire. They found cartilaginous healing of fractures fixed with plates, but fibrous healing in those fixed with wire. Since experimental wound healing in rabbits may differ from the healing of human
injuries, the data should be interpreted cautiously. Ideally, the operation should be carried out early to avoid infection of mucosal lacerations, granuloma formation and misaligned healing. The delay in operation in the present case fortunately did not compromise the result. Systemic corticosteroids may reduce the post-traumatic edema, but their use has not been shown to be advantageous to the healing of the fracture3, and therefore it was thought better to avoid corticosteroids. Although infrequent, neck injuries can occur in conjunction with facial injuries and need consideration when planning surgery5. The use of miniplates to stabilize laryngeal fractures has been discussed in the medical literature3,6–8, but the topic of laryngeal fractures is rarely dealt with in publications on maxillofacial surgery. There are similarities between the texture of the laryngeal framework and some of the areas encountered in facial fractures, and the strategy for anchoring a system of unstable fragments to a stable unit is similar. Metal or resorbable plates may be used according to the preference of the surgeon8. The exposure of the fracture requires familiarity with the functional anatomy of the larynx, so that the innervation (especially the superior laryngeal nerve) and the muscles are spared. The present case points to a field of collaboration between maxillofacial and ENT surgeons.
1. de Mello-Filho FV, Carrau RL. The management of laryngeal fractures using internal fixation. Laryngoscope 2000: 110: 2143–2146. 2. Dray TG, Coltrera MD, Pinczower EF. Thyroid cartilage fracture repair in rabbits: comparing healing with wire and miniplate fixation. Laryngoscope 1999: 109: 118–122. 3. Hwang SY, Yeak SC. Management dilemmas in laryngeal trauma. J Laryngol Otol 2004: 118: 325–328. 4. Jewett BS, Shockley WW, Rutledge R. External laryngeal trauma analysis of 392 patients. Arch Otolaryngol Head Neck Surg 1999: 125: 877–880. 5. Kuttenberger JJ, Hardt N, Schlegel C. Diagnosis and initial management of laryngotracheal injuries associated with facial fractures. J Craniomaxillofac Surg 2004: 32: 80–84. 6. Lykins CL, Pinczower EF. The comparative strength of laryngeal fracture fixation. Am J Otolaryngol 1998: 19: 158–162. 7. Pou AM, Shoemaker DL, Carrau RL, Snyderman CH, Eibling DE. Repair of laryngeal fractures using adaptation plates. Head Neck 1998: 20: 707– 713. 8. Sasaki CT, Marotta JC, Lowlicht RA, Ross DA, Johnson M. Efficacy of resorbable plates for reduction and stabilization of laryngeal fractures. Ann Otol Rhinol Laryngol 2003: 112: 745– 750. 9. Shaefer S. The acute management of external laryngeal trauma. Arch Otolaryngol Head Neck Surg 1992: 118: 598– 604. 10. Woo P. Laryngeal framework reconstruction with miniplates. Ann Otol Rhinol Laryngol 1990: 99: 772–777. Address: Andreas Thor Institution of Surgical Sciences Department of Oral and Maxillofacial Surgery Uppsala University Hospital SE-751 85 Uppsala Sweden Tel: +46 18 611 6450 Fax: +46 18 55 92 29 E-mail: [email protected]
Technical Note Trauma
Repair of a laryngeal fracture using miniplates
A. Thor1, A. Linder2 1 Department of Oral and Maxillofacial Surgery, Uppsala University Hospital, SE-751 85 Uppsala, Sweden; 2Department of Otolaryngology Head and Neck Surgery, Uppsala University Hospital, SE-751 85 Uppsala, Sweden
A. Thor, A. Linder: Repair of a laryngeal fracture using miniplates. Int. J. Oral Maxillofac. Surg. 2007; 36: 748–750. # 2007 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. Injuries to the larynx (voice box) can lead to loss of vital functions; the airway may be obstructed, the voice distorted or lost, and the protection of the airway during swallowing may fail. In order to preserve these functions, a stable repair that restores the anatomy as closely as possible is needed. The repair should interfere minimally with the neuromuscular functions of the larynx. The case is described of a 59-year-old male who suffered a severe laryngeal fracture in a workplace accident. Utilizing miniplates, the fracture was reduced and fixed in the correct position. After healing, the patient could be decannulated and has regained his voice, swallows without difficulty and has a patent airway. The results have been sustained over a 2-year follow-up.
Accepted for publication 10 January 2007 Available online 5 April 2007
The larynx, or voice box, is mostly noted for its role in phonation, but it is also an important safeguard of the lower airway while swallowing, and serves as a variable valve that regulates airflow and air pressure during respiration. If the larynx is injured, these functions are threatened. In the short term, preservation of the airway takes precedence, but for a good longterm result all three functions must be restored. The outcome is dependent on good anatomical alignment, stable fixation, and surgical techniques that do not cause injury to the neuromuscular functions of the larynx. The laryngeal framework is principally made up of the thyroid and cricoid cartilages. These structures are composed of hyaline cartilage but gradually become ossified with advancing age. The muscular insertions and directions of pull increase the stress in certain areas so that typical fracture patterns occur when excessive
was put on intravenous antibiotics (cefuroxim, changed before surgery to imipenem). The injuries were investigated by a computed tomography (CT) scan (Fig. 1), that showed a fracture with escape of air into the soft tissues of the neck and pronounced posterior displacement of the upper medial segment of the thyroid cartilage. A 3D reformatting was attempted, but proved technically unsatisfactory due to the uneven calcification of the cartilages. No cervical spine injuries were found. The patient was transferred to Uppsala University Hospital which is a tertiary referral centre. The attending ENT surgeon reviewed the case with the maxillofacial surgeon, and it was agreed that the fracture should be exposed and repaired using miniplates. Surgery was performed on the 4th day after the injury. The larynx was exposed by an anterior neck incision and the
0901-5027/080748 + 03 $30.00/0
force is applied. The muscular pull can also contribute to misalignment of the fractures. The fractures in an adult larynx resemble those of the thinner bones in the facial skeleton. Here is presented a case where a maxillofacial surgeon’s experience of miniplate fixation of facial fractures was combined with an ENT surgeon’s knowledge of the functional anatomy of the larynx to achieve optimal repair of a severe laryngeal fracture. Case
A 59-year-old lumberjack was working in a forest when one of his tools suddenly became dislodged and hit him across the anterior neck. He was transported to the county hospital and intubated with difficulty. A tracheostomy was performed to secure the airway without further trauma to the fractured larynx, and the patient
# 2007 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Laryngeal fracture repaired with miniplates
749
Discussion
Fig. 1. Sagittal CT scan of the fracture showing dorsal displacement of the superior fragment and air escaping into the soft tissues of the neck.
fracture line dissected. The displaced fracture was mainly horizontal though U-shaped (Fig. 2). There was also a midline vertical fracture with minimal displacement but with instability. The vocal folds were found to be entirely within the lower segment but changed by marked swelling. A preliminary alignment was achieved with sutures. Miniplates of 1.5 mm and 1.3 mm together with selfdrilling screws of 4 mm were used to unite the segments into larger blocks and join the blocks to form a stable unit (Fig. 3). The anterior angulation of the laryngeal framework could be restored by bending the appropriate plates (1.5 mm) to an almost 908 angle in the horizontal dimension. The anterior ossified parts of the thyroid cartilage gave excellent anchorage to the plates and screws, especially in the midline reduction of the fracture. A total of six miniplates were needed. The patient did not require intensive care postoperatively. The intravenous imipenem was continued for 1 week postoperatively and then changed to phenoxymethyl penicillin for another 2 weeks. A postoperative CT after 1 week showed excellent alignment (Fig. 4). The patient was returned to the county hospital where the tracheostomy was closed on the 11th postoperative day. He spoke with a somewhat hoarse voice and could resume a normal diet on the 13th day after the naso-gastric tube was removed. He underwent a check-up including micro-laryngoscopy 2 months later, showing slight scarring at a level above the vocal folds. Two years after the repair, the patient continues his heavy work without any restraint from his airway, and swallows without difficulty. His voice is somewhat strained but easily intelligible and he is moderately disturbed by mucus in the larynx.
The incidence of laryngeal trauma in the USA was estimated to be 1/137000 over a 5-year period in the late 1990s4. In this study 248 of 392 patients required surgery. Another often quoted estimate is that of SHAEFER9 who stated that laryngeal trauma was diagnosed in 1/30000 emergency room visits. The accepted explanation for the low incidence of this type of injury is that the chin and upper thorax help to protect the anterior neck from direct trauma. There is consensus that minor trauma with no airway compromise can be treated conservatively. Significant laryngeal
Fig. 2. Schematic drawing of the fracture system, seen from anterior end. The upper, dorsally displaced, segment is marked in darker colour. The fracture lines are shown in red.
Fig. 3. The contour of the larynx restored (oblique anterior view). Three miniplates are visible. Note how the upper thyroid cartilage, which was flattened by the trauma, has regained its shape by use of a bent upper plate.
750
Thor and Linder References
Fig. 4. Postoperative sagittal CT scan showing the repaired fracture. Three screws are visible as dense objects. The plane of the scan is slightly more lateral than in Fig. 1.
trauma requires that the airway is secured in the acute phase and that the anatomy is restored so that the larynx retains its functions after healing. Possible sequelae after inadequately treated injuries include scar stenosis restricting the airway, decreased tone of the vocal folds with a weak or hoarse voice, and vocal fold immobility causing either airway narrowing or loss of voice together with aspiration during swallowing. The cartilaginous framework defines the cross-sectional area of the laryngeal airway, the tone of the vocal folds, as well as the direction of pull of the intra-laryngeal muscles. In order to achieve an overall good result, it is critical to bring about precise reduction and stable fixation of displaced fractures of the framework. Studies from the early 1990s, reflecting techniques preceding miniplates, report that a good laryngeal airway was achieved in over 90% but a good voice in only 70%, as discussed by JEWETT et al.4. The alternative to miniplates is wire fixation10, but as noted by de MELLO-FILHO and CARRAU1 miniplates allow for a more exact and enduring fixation. An interesting rabbit study by DRAY et al.2 compared the healing of fractured cartilage fixed by plates or wire. They found cartilaginous healing of fractures fixed with plates, but fibrous healing in those fixed with wire. Since experimental wound healing in rabbits may differ from the healing of human
injuries, the data should be interpreted cautiously. Ideally, the operation should be carried out early to avoid infection of mucosal lacerations, granuloma formation and misaligned healing. The delay in operation in the present case fortunately did not compromise the result. Systemic corticosteroids may reduce the post-traumatic edema, but their use has not been shown to be advantageous to the healing of the fracture3, and therefore it was thought better to avoid corticosteroids. Although infrequent, neck injuries can occur in conjunction with facial injuries and need consideration when planning surgery5. The use of miniplates to stabilize laryngeal fractures has been discussed in the medical literature3,6–8, but the topic of laryngeal fractures is rarely dealt with in publications on maxillofacial surgery. There are similarities between the texture of the laryngeal framework and some of the areas encountered in facial fractures, and the strategy for anchoring a system of unstable fragments to a stable unit is similar. Metal or resorbable plates may be used according to the preference of the surgeon8. The exposure of the fracture requires familiarity with the functional anatomy of the larynx, so that the innervation (especially the superior laryngeal nerve) and the muscles are spared. The present case points to a field of collaboration between maxillofacial and ENT surgeons.
1. de Mello-Filho FV, Carrau RL. The management of laryngeal fractures using internal fixation. Laryngoscope 2000: 110: 2143–2146. 2. Dray TG, Coltrera MD, Pinczower EF. Thyroid cartilage fracture repair in rabbits: comparing healing with wire and miniplate fixation. Laryngoscope 1999: 109: 118–122. 3. Hwang SY, Yeak SC. Management dilemmas in laryngeal trauma. J Laryngol Otol 2004: 118: 325–328. 4. Jewett BS, Shockley WW, Rutledge R. External laryngeal trauma analysis of 392 patients. Arch Otolaryngol Head Neck Surg 1999: 125: 877–880. 5. Kuttenberger JJ, Hardt N, Schlegel C. Diagnosis and initial management of laryngotracheal injuries associated with facial fractures. J Craniomaxillofac Surg 2004: 32: 80–84. 6. Lykins CL, Pinczower EF. The comparative strength of laryngeal fracture fixation. Am J Otolaryngol 1998: 19: 158–162. 7. Pou AM, Shoemaker DL, Carrau RL, Snyderman CH, Eibling DE. Repair of laryngeal fractures using adaptation plates. Head Neck 1998: 20: 707– 713. 8. Sasaki CT, Marotta JC, Lowlicht RA, Ross DA, Johnson M. Efficacy of resorbable plates for reduction and stabilization of laryngeal fractures. Ann Otol Rhinol Laryngol 2003: 112: 745– 750. 9. Shaefer S. The acute management of external laryngeal trauma. Arch Otolaryngol Head Neck Surg 1992: 118: 598– 604. 10. Woo P. Laryngeal framework reconstruction with miniplates. Ann Otol Rhinol Laryngol 1990: 99: 772–777. Address: Andreas Thor Institution of Surgical Sciences Department of Oral and Maxillofacial Surgery Uppsala University Hospital SE-751 85 Uppsala Sweden Tel: +46 18 611 6450 Fax: +46 18 55 92 29 E-mail: [email protected]