laryngotracheal trauma by dr syafiqah kamel

Laryngotracheal trauma slide can serve as a quick reference for ENT colleagues.

1. LARYNGOTRACHEAL TRAUMA

2. OUTLINE

3. Anatomy of larynx

4. Subsites of larynx

5. Blood supply: laryngeal branches of the superior and inferior thyroid arteries and crico -thyroid branch of the superior thyroid artery Nerve supply: branches of vagus nerve (superior laryngeal nerve and recurrent laryngeal nerve)

6. CLASSIFICATION

7. AETIOLOGY

8. PATHOPHYSIOLOGY

9. Two phases of blunt trauma to the larynx in younger patient Initially, the larynx is compressed against the vertebral column and is fractured along the prominence The larynx then springs back into position. However, the vocal cords are detached at their anterior ends.

10. Blunt trauma to the larynx in older patients where the thyroid cartilage has ossified. The initial impact shatters the larynx, which cannot recoil. The neck is flattened and the airway is reduced.

11. HISTORY

12. Physical examination Stridor- inspiratory, expiratory or both Subcutaneous emphysema Hemoptysis Laryngeal tenderness, ecchymosis, edema Loss of thyroid cartilage prominence Associated injuries: vascular, cervical spine, esophagus If airway is stable, the airway should be examined using flexible scope.

13. GENERAL AIRWAY MANGEMENT The priority is to ensure the airway is safe and secure. ORL and anaesthetist should together manage the airway. In cases of minimal oedema, a course of IV steroid (dexamethasone) with observation in HDU is reasonable. (Schaefer’s I) Endotracheal intubation can be done under direct supervision. Blind intubation may lead to more damage of the laryngeal structure. Use of cricoid pressure is contraindicated. This should be done in OT. Tracheostomy under LA may be needed to secure the airway (gold standard)

14. PRINCIPLES OF MANAGEMENT OF LARYNGEAL FRACTURES Injuries need to be corrected ASAP, ideally within 48 hours. Hyoid bone fracture (strangulating injury,karate ) warrants no treatment Thyroid cartilage fracture (high velocity blunt injury) should be treated with ORIF using mini plate or wire. Any associated soft tissue injury to the larynx should be repaired if possible including mucosal tear. Vocal cords that have lost attachment anteriorly to the thyroid cartilage should be re-suspended.

15. Any exposed cartilage should be covered with mucosa or perichondrium to minimize granulation tissue formation and long term scarring. Non displaced laryngeal fracture may be treated expectantly. Any degree of displacement should be reduced and fixed. Endolaryngeal stenting is necessary when there are multiple displaced fractures and/or multiple and severe mucosal lacerations where adhesions likely to occur The stent should be removed in OT after 10-14 days, and patient can often be decannulated at the same time.

16. LONG TERM COMPLICATIONS Hematoma leading to fibrosis, scarring and webbing. Possible dysphonia and dyspnea needing tracheostomy Inability to protect the airway ( eg:trauma to RLN) may need long term tracheostomy Subglottic stenosis may form as result from initial trauma or as consequences from surgical intervention eg : high tracheostomy.

17. Montgomery laryngeal stent

18. referrence 1. Logan Turner’s Diseases of the nose, throat and ear, head and neck surgery, 11 th edition. 2. Funzi Shi, Jennifer W. Uyeda. Multidetector CT of laryngeal injuries: principle of injury recognition. Radiographics 2019 (online)