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Traumatic laryngeal fracture
Case reports
335
Traumatic
laryngeal fracture
M. P. J. Yardley, A. J. Parker and L. H. Durham Department
of Otolaryngology,
Royal Hallamshire
Hospital, Sheffield, UK
Introduction Serious laryngeal injuries are rare. The recognition of such an injury by the accident and emergency staff and the instigation of prompt treatment can be life-saving. There are three major aetiological groups: road traffic accidents, blunt injury, and penetrating injury (Maran et al., 1981). The number of cases resulting from road traffic accidents has fallen with the introduction of whole harness rather than just the lap-type seat belts. Penetrating injuries are also uncommon in most departments in the United Kingdom, and the average casualty officer is unlikely to encounter such an injury in a &month appointment. Blunt injury, however, is the most common cause of laryngeal trauma and can vary greatly in severity. It can result from assaults, falls or sports injuries, e.g. martial arts, ice hockey, basketball. It is imperative in the management of such cases to have a high index of suspicion that the airway could become compromised, as illustrated in our report.
Figure
1. Operative
photograph
of laryngeal fracture.
Case report
be haemorrhagic but intact. The fracture was wired through the laminae of the thyroid cartilage (Figure 2 ). The patient subsequently made an uneventful recovery, being decannulated on the 5th postoperative day after resolution of the laryngeal swelling.
We present a case of fracture of the laryngeal cartilage. A man attended the accident and emergency department having tripped while at work and struck his throat against the edge of a computer. This resulted in hoarseness and mild stridor on exertion. These were subsequently confirmed when he was examined in the accident and emergency department 2 h after the injury. Ecchymoses over the laryngeal skin were noted. The laryngeal contour was observed to be normal and the patient was comfortable and not distressed. Indirect laryngoscopy revealed a normal right vocal cord but a grossly swollen left hemilarynx, and the swelling was noted to extend to the midline. On palpation of the neck crepitus was elicited from a fracture of the thyroid cartilage. There was a subsequent sudden deterioration in the patient’s upper airway which necessitated urgent surgical intervention. Emergency endotracheal intubation and a subsequent tracheostomy were performed. Direct laryngoscopy revealed grossly haemorrhagic arytenoids and false cords. The epiglottis was not displaced although there were lacerations in both valleculae. The anterior commissure was visualized and was intact. The thyroid fracture was approached via a collar incision and the haematoma was evacuated. The perichondrium was elevated on either side of the fracture which ran vertically through the left thyroid lamina 2-3 mm from the midline (Fipre 1). Close inspection showed the internal soft tissue of the larynx to
Figure 2. Postoperative repair and tracheostomy.
0 1991 Butterworth-Heinemann 0020-1383/91/040335-02
Ltd
radiograph
demonstrating
laryngeal
Injury: the British Journal of Accident Surgery (1991) Vol. 22/No. 4
336
Discussion
management
The salutary lesson the casualty officer should learn from this case is to never underestimate the severity of trauma to the throat and the need to observe any patient who has received trauma to this region, even though they initially may appear well. This is not only because of the development of oedema, but also because of the risk of haemorrhage into the soft tissues which could rapidly prove fatal.
of laryngeal injuries. 1. R. Sot. Med. 74,656.
Paper accepted 3 October
1990.
Reqtlesfs for reprints should be addressed to: Mr M. P. J. Yardley,
Reference Maran A. G. D., Murray, J. A. M., Stell P. M. et al. (1981)Early
Department of Otolaryngology, Doncaster Royal Infirmary, Doncaster, South Yorkshire DN2 5LT, UK.
Septic arthritis due to Clostridium
welchii
I. A. Harvey Alder Hey Children’s Hospital, Liverpool, UK
Case report A 7-year-old boy was admitted to hospital 24 h after sustaining a penetrating injury to the anterior aspect of his lower left thigh on a garden fork. There was inflammation around the wound together with an effusion in the adjacent knee joint. Radiographs of the lower femur and knee were normal; there was no gas within the joint or soft tissues. Aspiration of his knee revealed 20ml of ‘sanguinous pus’. Wound toilet and joint irrigation were performed. Initial antibiotic therapy was with parenteral cephradine and metronidazole. Benzyl penicillin was started when cultures of the joint aspirate revealed Closfridiwn welchii type A. Arthrotomy and washout was required for a reaccumulation of the effusion 5 days after admission. At operation a large volume of cloudy fluid was drained and the synovium was found to be inflamed. The patient was discharged 3 weeks after admission and oral antibiotic therapy with cephradine and metronidazole was continued for a further 6 weeks. The patient was last seen 20 months after admission when he had a full range of movement of the knee with no symptoms.
excellent prognosis (Everidge, 1919). Later authors report good results with drainage, excision of necrotic synovium and antibiotic therapy (Love& 1946; McNae, 1966; Torg and Lammot, 1968). In two cases found in the literature, polyvalent gas gangrene antitoxin had been administered (McNae, 1966; Torg and Lammot, 1968); however the good results in the other cases suggest that this is of little additional benefit. This report confirms the findings of other authors (Everidge, 1919; Lovell, 1946; McNae, 1966; Torg and Lammot, 1968) that with adequate treatment an excellent recovery can be expected from septic arthritis due to Clostridium welchii.
Acknowledgement I wish to thank Mr J. F. Taylor for allowing me to report his patient.
Discussion A search of the literature has revealed only seven documented cases of septic arthritis due to Clostridium welchii (Everidge, 1919; Love& 1946; McNae, 1966; Torg and Lammot, 1968). In six of these cases infection had followed a penetrating injury. Radiographs may show gas in the joint and soft tissues (Torg and Lammot, 1968) even in the absence of a penetrating injury (McNae, 1966); its absence in this case report may be due to the earlier presentation than in these other cases. In this case synovial inflammation was found at arthrotomy. Other reports (McNae, 1966; Torg and Lammot, 1968) suggest that this progresses to necrosis and sloughing of the synovium. Although Clostridiu are the only organisms which possess collagenase activity (MacLennan et al., x953), articular cartilage damage does not appear to be a feature of this infection (Lovell, 1946; Torg and Lammot, 1968). Even in 1919, thorough drainage and antiseptic washout for clostridial septic arthritis were associated with an 0 1991 Butterworth-Heinemann 002s1383/91/040336-01
Ltd
References Everidge J. (1919) A new method of treatment for suppurative arthritis of the knee-joint. Br. 1. Stlrg. 6, 566. Love11 W. W. (1946) Infection of the knee joint by Closhidium welchii. ]. Boneloint Surg. 28, 398.
MacLennan J. D., Mandl I. and Howes E. L. (1953) Bacterial digestion of collagen. $ Clin. Inuesf. 32, 1317. McNae J. (1966)An unusual case of Clostridium welchii infection. 1. BoneJoint Surg. 48B, 512. Torg J. S. and Lammot T. R. (1968) Septic arthritis of the knee due to Closfridium welchii. 1. Bone]oint Surg. SOA, 1233. Paper accepted 17 September
1990.
Requests for reprints should be a&ressed to: Mr I. A. Harvey, 29 Whitegates Crescent, Willaston, S. Wirral L64 2UX, UK.
335
Traumatic
laryngeal fracture
M. P. J. Yardley, A. J. Parker and L. H. Durham Department
of Otolaryngology,
Royal Hallamshire
Hospital, Sheffield, UK
Introduction Serious laryngeal injuries are rare. The recognition of such an injury by the accident and emergency staff and the instigation of prompt treatment can be life-saving. There are three major aetiological groups: road traffic accidents, blunt injury, and penetrating injury (Maran et al., 1981). The number of cases resulting from road traffic accidents has fallen with the introduction of whole harness rather than just the lap-type seat belts. Penetrating injuries are also uncommon in most departments in the United Kingdom, and the average casualty officer is unlikely to encounter such an injury in a &month appointment. Blunt injury, however, is the most common cause of laryngeal trauma and can vary greatly in severity. It can result from assaults, falls or sports injuries, e.g. martial arts, ice hockey, basketball. It is imperative in the management of such cases to have a high index of suspicion that the airway could become compromised, as illustrated in our report.
Figure
1. Operative
photograph
of laryngeal fracture.
Case report
be haemorrhagic but intact. The fracture was wired through the laminae of the thyroid cartilage (Figure 2 ). The patient subsequently made an uneventful recovery, being decannulated on the 5th postoperative day after resolution of the laryngeal swelling.
We present a case of fracture of the laryngeal cartilage. A man attended the accident and emergency department having tripped while at work and struck his throat against the edge of a computer. This resulted in hoarseness and mild stridor on exertion. These were subsequently confirmed when he was examined in the accident and emergency department 2 h after the injury. Ecchymoses over the laryngeal skin were noted. The laryngeal contour was observed to be normal and the patient was comfortable and not distressed. Indirect laryngoscopy revealed a normal right vocal cord but a grossly swollen left hemilarynx, and the swelling was noted to extend to the midline. On palpation of the neck crepitus was elicited from a fracture of the thyroid cartilage. There was a subsequent sudden deterioration in the patient’s upper airway which necessitated urgent surgical intervention. Emergency endotracheal intubation and a subsequent tracheostomy were performed. Direct laryngoscopy revealed grossly haemorrhagic arytenoids and false cords. The epiglottis was not displaced although there were lacerations in both valleculae. The anterior commissure was visualized and was intact. The thyroid fracture was approached via a collar incision and the haematoma was evacuated. The perichondrium was elevated on either side of the fracture which ran vertically through the left thyroid lamina 2-3 mm from the midline (Fipre 1). Close inspection showed the internal soft tissue of the larynx to
Figure 2. Postoperative repair and tracheostomy.
0 1991 Butterworth-Heinemann 0020-1383/91/040335-02
Ltd
radiograph
demonstrating
laryngeal
Injury: the British Journal of Accident Surgery (1991) Vol. 22/No. 4
336
Discussion
management
The salutary lesson the casualty officer should learn from this case is to never underestimate the severity of trauma to the throat and the need to observe any patient who has received trauma to this region, even though they initially may appear well. This is not only because of the development of oedema, but also because of the risk of haemorrhage into the soft tissues which could rapidly prove fatal.
of laryngeal injuries. 1. R. Sot. Med. 74,656.
Paper accepted 3 October
1990.
Reqtlesfs for reprints should be addressed to: Mr M. P. J. Yardley,
Reference Maran A. G. D., Murray, J. A. M., Stell P. M. et al. (1981)Early
Department of Otolaryngology, Doncaster Royal Infirmary, Doncaster, South Yorkshire DN2 5LT, UK.
Septic arthritis due to Clostridium
welchii
I. A. Harvey Alder Hey Children’s Hospital, Liverpool, UK
Case report A 7-year-old boy was admitted to hospital 24 h after sustaining a penetrating injury to the anterior aspect of his lower left thigh on a garden fork. There was inflammation around the wound together with an effusion in the adjacent knee joint. Radiographs of the lower femur and knee were normal; there was no gas within the joint or soft tissues. Aspiration of his knee revealed 20ml of ‘sanguinous pus’. Wound toilet and joint irrigation were performed. Initial antibiotic therapy was with parenteral cephradine and metronidazole. Benzyl penicillin was started when cultures of the joint aspirate revealed Closfridiwn welchii type A. Arthrotomy and washout was required for a reaccumulation of the effusion 5 days after admission. At operation a large volume of cloudy fluid was drained and the synovium was found to be inflamed. The patient was discharged 3 weeks after admission and oral antibiotic therapy with cephradine and metronidazole was continued for a further 6 weeks. The patient was last seen 20 months after admission when he had a full range of movement of the knee with no symptoms.
excellent prognosis (Everidge, 1919). Later authors report good results with drainage, excision of necrotic synovium and antibiotic therapy (Love& 1946; McNae, 1966; Torg and Lammot, 1968). In two cases found in the literature, polyvalent gas gangrene antitoxin had been administered (McNae, 1966; Torg and Lammot, 1968); however the good results in the other cases suggest that this is of little additional benefit. This report confirms the findings of other authors (Everidge, 1919; Lovell, 1946; McNae, 1966; Torg and Lammot, 1968) that with adequate treatment an excellent recovery can be expected from septic arthritis due to Clostridium welchii.
Acknowledgement I wish to thank Mr J. F. Taylor for allowing me to report his patient.
Discussion A search of the literature has revealed only seven documented cases of septic arthritis due to Clostridium welchii (Everidge, 1919; Love& 1946; McNae, 1966; Torg and Lammot, 1968). In six of these cases infection had followed a penetrating injury. Radiographs may show gas in the joint and soft tissues (Torg and Lammot, 1968) even in the absence of a penetrating injury (McNae, 1966); its absence in this case report may be due to the earlier presentation than in these other cases. In this case synovial inflammation was found at arthrotomy. Other reports (McNae, 1966; Torg and Lammot, 1968) suggest that this progresses to necrosis and sloughing of the synovium. Although Clostridiu are the only organisms which possess collagenase activity (MacLennan et al., x953), articular cartilage damage does not appear to be a feature of this infection (Lovell, 1946; Torg and Lammot, 1968). Even in 1919, thorough drainage and antiseptic washout for clostridial septic arthritis were associated with an 0 1991 Butterworth-Heinemann 002s1383/91/040336-01
Ltd
References Everidge J. (1919) A new method of treatment for suppurative arthritis of the knee-joint. Br. 1. Stlrg. 6, 566. Love11 W. W. (1946) Infection of the knee joint by Closhidium welchii. ]. Boneloint Surg. 28, 398.
MacLennan J. D., Mandl I. and Howes E. L. (1953) Bacterial digestion of collagen. $ Clin. Inuesf. 32, 1317. McNae J. (1966)An unusual case of Clostridium welchii infection. 1. BoneJoint Surg. 48B, 512. Torg J. S. and Lammot T. R. (1968) Septic arthritis of the knee due to Closfridium welchii. 1. Bone]oint Surg. SOA, 1233. Paper accepted 17 September
1990.
Requests for reprints should be a&ressed to: Mr I. A. Harvey, 29 Whitegates Crescent, Willaston, S. Wirral L64 2UX, UK.