Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature Blunt Laryngeal Trauma I will concentrate on blunt laryngeal trauma. Anterior blunt injuries are most commonly the result of motor vehicle accidents. The incidence of this type of injury is declining, presumably because of mandatory seat belt laws, lower speed limits and the use of front seat airbags. If no seat belt is worn or if only a lap belt is used, the driver is thrust forward during rapid deceleration with the neck in a hyperextended fashion. This position removes the bony protection afforded by the mandible and exposes the larynx to anterior crushing forces. If the larynx then strikes the steering wheel or the dashboard, it may be compressed between these objects and the cervical spine. With a moderate blow to the larynx, the momentum of the vocal folds causes a shearing effect between the vocalis muscle and the internal perichondrium, resulting in injuries such as endolaryngeal mucosal tears, edema or hematoma. More severe trauma produces fractures of the laryngeal cartilages and disruption of the laryngeal ligament. Arytenoid cartilage subluxation or dislocation may result in a fixed vocal fold. Unilateral recurrent laryngeal nerve injury is often associated with cricoarytenoid joint injury. Cricoid cartilage fractures may occur alone or with other injuries, especially secondary to lower cervical trauma. The so-called clothesline injuries occur when the rider of a vehicle such as a motorcycle or a snowmobile encounters a fixed horizontal object such as a clothesline at neck level. This type of injury impacts a large amount of energy over a relatively small area, resulting in massive trauma. Many of these injuries lead to immediate death resulting from a crushed larynx or separation of the cricoid from the larynx or trachea. Strangulation injuries occur from manual compression or in attempted suicides by hanging. Typically, the initial finding may be hoarseness or abrasions of the skin on the neck. However, these injuries may appear later, within 12 to 24 hours, to be associated with marked edema and loss of the airway. Associated injuries may also occur in the setting of blunt cervical trauma. Hyoid bone fractures and epiglottic injuries can cause airway obstruction. Also, the greater or lesser corner of the thyroid cartilage may lacerate the pharyngeal mucosa as it is pressed against the cervical vertebrae. Blunt trauma tends to effect the larynx of a child differently from that of an adult. The pediatric larynx is situated higher in the neck and is better protected by the mandible. Laryngeal fractures are less common because of the elasticity of the pediatric cartilaginous skeleton; however, the lack of extensive fibrous tissue support in the child and the relatively loose attachments of the mucous membranes increase the likelihood of soft tissue damage. Finally, the cricothyroid membrane is narrow in children and this reduces the likelihood of laryngotracheal separation. The evaluation of laryngeal trauma begins with a history and physical. Any patient with anterior neck trauma should be considered to have an upper airway injury. The classic symptoms associated with laryngeal trauma include hoarseness, pain, dyspnea and dysphagia. Surprisingly, no single symptom seems to correlate well with the severity of the injury. When the laryngeal lumen is severely compromised, aphonia and even apnea occur signifying the immediate need for the establishment of an alternative airway. In the setting of trauma, a thorough physical examination of the neck is required to identify associated neurovascular injury. Cervical spine injuries must be ruled out in all patients with neck trauma. Active bleeding, expanding hematoma, bruits and the loss of pulses are signs associated with vascular injury. The usual signs of laryngeal trauma include stridor, change in voice, hemoptysis, subcutaneous emphysema and tenderness or deformity of the laryngeal skeleton. The type of stridor may suggest the location of the lesion. Inspiratory stridor typically results from partial supraglottic airway obstruction that may result from edema, hematoma, foreign body, soft tissue injury or cartilaginous fractures. Expiratory stridor may portend lower airway pathology from a tracheal injury. Combined inspiratory and expiratory stridor suggests partial obstruction at the level of the glottis. Change in voice is commonly seen because of the change in the architecture of the larynx. Hematomas of the true vocal folds add mass to the vibratory unit and lower the fundamental frequency of vibration. Paresis of the vocal fold from damage to either the recurrent laryngeal nerve or from mechanical dislocation of a cricoarytenoid joint may cause a weak breathy voice. Ultimately, any alteration in the larynx that changes the airflow pattern has the potential to alter the voice. In severe trauma, the patient may be completely aphonic. Cervical subcutaneous emphysema is associated with the loss of integrity of the upper aerodigestive tract. The amount of air may range from slight soft tissue emphysema to a massive pneumomediastinum. Associated soft tissue derangements of the larynx may result in a ball-valve effect, forcing massive amounts of air into the neck as well as the chest. After the initial examination and securing the airway, direct fiberoptic laryngoscopy is attempted. Care should be taken during this exam because the minor trauma associated with the insertion of the scope may sometimes be able to precipitate an airway emergency. The larynx should be examined for vocal fold mobility, hematomas, lacerations, exposed cartilage and airway patency. Partial limitation of vocal fold motion indicates a structural deformity or dislocation of the arytenoid, whereas complete immobility is more suggestive of recurrent laryngeal nerve injury. Failure of the true vocal folds to meet in the same horizontal plane may also be present indicating a structural change in the laryngeal framework or again, superior laryngeal nerve injury. Computed tomography has replaced soft tissue radiographs and laryngograms as the examination of choice when evaluating patients involved with laryngeal trauma. CT allows the evaluation of the laryngeal skeleton in a noninvasive manner and is useful when the results directly effect the treatment plan. Specifically, there are two groups of patients, who do not require a CT scan for diagnostic evaluation and this would include first of all, patients with obvious fractures or large endolaryngeal lacerations, who would require open exploration, and secondly, patient with minimal anterior neck trauma and a normal physical exam. All intermediate patients should be scanned to assess the extent of laryngeal injury. When used CT may be expected to confirm indirect or flexible fiberoptic laryngoscopic findings, to detect cartilage fractures that are not clinically apparent, and hopefully to assess poorly visualized areas such as the subglottic and anterior commissure regions. The initial evaluation and treatment of the trauma patient consists of airway preservation, cardiac resuscitation, control of hemorrhage, stabilization of neural and spinal injuries and a systematic investigation for other injuries. Controversy exists regarding the best way to establish an alternative airway in the presence of laryngeal trauma. Dr. Gussack's protocol for emergency room airway management and blunt laryngeal trauma recommends orotracheal intubation over emergent tracheotomy unless laryngotracheal disruption is clinically obvious. However, Dr. Schafer's protocol recommends tracheotomy in all cases where airway control is required. His concern stems from experience with several iatrogenic complications associated with orotracheal intubation. He does note that if orotracheal intubation is to be attempted in the emergency room setting, it must be done under direct visualization by experienced personnel using a smaller than normal endotracheal tube. Surgical teams should be prepared to perform an awake tracheotomy in those patients, who can not be successfully intubated in an orotracheal fashion. A child with a traumatized larynx is a special case because it is generally difficult to perform a tracheotomy under local anesthesia in this situation. Inhaled anesthesia with spontaneous respiration is used to achieve bronchoscopic intubation, which allows direct visualization of laryngeal injuries. After a successful bronchoscopy, tracheotomy may be performed as required. Management of injuries to the larynx is based on the mechanisms and extent of the injury found during the initial assessment. The first priority is always to establish the airway. If the patient is breathing well and the injury does not require surgical care, the patient may be observed in the hospital for 24 hours. Since all injuries to this area carry a propensity for airway embarrassment, it is best to be cautious when determining the need for airway intervention. In 1989, Dr. Schafer presented an algorithm to be followed in the evaluation of laryngeal trauma patients that derived from a review of the treatment of 120 laryngeal trauma patients over a 23 year period. The initial step in this protocol is to determine the stability of the airway based on the patient's symptoms and signs of injury. A patient with evidence of impending airway obstruction should have the airway secured either by orotracheal intubation or tracheotomy. A patient with a stable airway on the other hand should next be evaluated with flexible fiberoptic laryngoscopy. For the patient with a stable airway, findings on fiberoptic laryngoscopy help determine the next treatment step. A patient with a normal endolarynx on fiberoptic exam may be observed and no further therapy warranted. However, a patient with a mild abnormality on endolaryngeal exam such as edema, small hematomas with intact mucosal coverage, or small glottic or supraglottic lacerations without exposed cartilage should next be evaluated with a CT scan. If this is normal, the patient may be observed for a 24-hour period. Bedrest with elevation of the head for several days may help to resolve any laryngeal edema. A period of voice rest may help minimize further edema or hematoma. The use of cool humidified air helps prevent crust formation in the presence of mucosal damage. Systemic corticosteroids have been used sporadically in the treatment of these laryngeal trauma patients in an effort to reduce edema and subsequent fibrosis but no clinical or experimental evidence supports their use. If they are used, they are most likely to be of benefit in the first few hours after injury. If there is evidence of a mucosal tear or laceration, antibiotics may be useful as a prophylaxis against infection. Likewise, if the CT scan shows a nondisplaced non-angulated thyroid cartilage fracture, the patient follows this algorithm and is usually observed. However, if the CT shows disruption of the mucosa or cartilage, the patient's airway should be secured either by intubation or tracheotomy and subsequent direct laryngoscopy and esophagoscopy should be performed. Endoscopy is used to determine the full extent of laryngeal and adjacent aerodigestive tract injuries. When the injuries are observed, surgical management should be performed as soon as possible. For patients with impending airway obstruction, Dr. Schafer, as previously discussed, proceeds with awake tracheotomy followed by direct laryngoscopy and esophagoscopy. If laryngoscopy reveals a hematoma or small ulceration but an intact endolarynx, the patient may be observed and no further surgical therapy warranted. If, however, the patient has a displaced or angulated thyroid cartilage fracture but an intact endolarynx, then one should proceed with open exploration of the neck with open reduction and internal fixation of the fracture without the need for thyrotomy. If the mucosa and cartilage are disrupted, then one should proceed with laryngeal thyrotomy. Overall, injuries likely to require laryngeal exploration and repair include lacerations involving the free margin of the vocal fold, large mucosal lacerations, exposed cartilage, multiple and displaced cartilage fractures, avulsed or displaced arytenoids and vocal fold immobility. The optimal timing for endoscopic evaluation and surgical management of the trauma patient remains controversial. Some authors assure that waiting several days after trauma allows the edema to resolve so that endolaryngeal lacerations may be better identified and approximated. However, on the basis of several large series of laryngeal trauma cases, it appears that early surgical intervention is more effective in allowing accurate identification of mucous membrane, muscle and cartilaginous injuries that can be repaired primarily, rather than relying on healing by secondary intention or grafting. Exploration is done through a horizontal skin incision and a skin crease at the level of the cricothyroid membrane. Sub-platysmal flaps are elevated superiorly to the level of the hyoid bone and inferiorly to just below the cricoid. The incision may be extended to explore and repair any associated neural, vascular or visceral injury. The infrahyoid strap muscles are separated in the midline and retracted laterally to expose the laryngeal skeleton and any fractures. An isolated fracture of the thyroid cartilage with an intact endolarynx, meaning no mucosal lesions or exposed cartilage, can be reduced and internally fixated with wire closure or nonabsorbable suture closure. A thyrotomy is indicated for more severe injuries involving mucosal or cartilage disruption. In this procedure, the thyroid cartilage is incised in the midline using either an oscillating saw or a side-cutting dental burr and the endolarynx is entered through the cricothyroid membrane. If there is a paramedian vertical fracture of the thyroid cartilage within three millimeters of the midline, this fracture may be used as access to the larynx. Under direct visualization, the incision is extended superiorly through the anterior commissure to the thyroid membrane. The entire endolarynx is examined to determine the full extent of the injury and the arytenoids are palpated to assess their position and their mobility. All mucous membrane, muscle and cartilage with a viable blood supply should be preserved and restored to its original position. Exposed cartilage is the primary factor responsible for the formation of granulation tissue and subsequent fibrosis and must be primarily covered. Failure to do so, results in the need for grafting and healing by secondary intention. Lacerations are meticulously approximated with 5-0 or 6-0 absorbable suture such as Chromic gut or Vicryl. Wounds with minimal tension can be closed with simple interrupted sutures whereas those under more tension require undermining and the use of horizontal mattress sutures. At this time, if a dislocated arytenoid is found, it is reduced. After repairing the endolaryngeal injuries, with or without stenting, the larynx is closed by suturing the most anterior aspect of the mucosa and the folds to the outer perichondrium of the thyroid cartilage with interrupted 4-0 or 5-0 absorbable suture. This step reconstitutes the normal scaphoid shape of the anterior commissure that is critical for normal phonation. Cartilaginous fractures are fixated with braided 5-0 wire or with nonabsorbable suture passed through holes drilled on either side of the fracture or with mini-plates. In 1992, Dr. John Austin reported the use of a wire tube technique to perform stable internal fixation of fractures of the partially mineralized thyroid cartilage, such as that which exists in most patients under the age of 40. In the wire tube technique, to repair a displaced lateral laminal fracture, wire is passed through a blunted #18 gauge needle and then through the cartilage in a horizontal fashion. Wire and tube will remain in place permanently; therefore, the endolaryngeal aspect of the wire must be passed submucosally. The forces are then distributed over a broad enough area to prevent complete pull-through of the wire. For midline fractures with flattened lamina, the wire is passed in a trans-laryngeal mattress fashion. The wire is then secured with approximation and fixation of the fracture with normal alignment of the lamina. Recent studies in the literature have supported the use of adaptation mini-plates to stabilize laryngeal fractures. The use of adaptation plates and cartilage that is not completely calcified is technically demanding but the results are promising. The plates conform to the laryngeal framework after precise bending to restore the pre-injury geometry of the larynx. This preserves the airway and the anterior-posterior diameter at the glottic level. Stability of the laryngeal skeleton is immediate. Mini-plates have been shown in experimental animal studies to produce cartilaginous unions between fragments as opposed to the fibrous unions seen with wire fixation. The measure of distraction at the fracture site was significantly greater in the wired repairs compared to the plate repairs. The rate of infection and the rate of extrusion are low with the use of plates. The disadvantages of the use of plates include the cost and the additional skill needed to use them. Cricoid fractures can also be elevated and wired to a mini-plate or an arch bar. Anterior defects in the cricoid ring can also be repaired by immobilizing the sternohyoid muscle over the cricoid defect and then suturing the muscle to the remnants of the cricoid cartilage and the cricothyroid membrane. Multiple cartilaginous fractures that can not be stabilized adequately using open reduction and internal fixation, and extensive lacerations involving the anterior commissure are specific indications for the use of stents. Massive mucosal injuries may also require stenting to prevent mucosal adhesions. Laryngeal stents may serve initially as an internal fixation device and thereafter should prevent endolaryngeal scarring and maintain the internal configuration of the larynx. Certain studies have shown that stents may increase the incidence of infection and granulation tissue, but clinical findings sometimes dictate their use. The choice of stents ranges from finger cots filled with foam rubber to commercially manufactured polymeric silicone stents. They should all be made of soft material to prevent any further mucosal damage. A stent can be created using 3.5 cm length of Gore-Tex endotracheal tubing. The superior end of the tube is oversewn to help prevent aspiration and smooth clamps are then placed to approximate the levels of the true and false vocal folds. The stent is then autoclaved to reform the tube to the desired shape. Commercially manufactured stents include the Montgomery and the Hood endolaryngeal stents and are made of silicone of precise firmness so as to offer support but not injure the surrounding tissue. The stent should extend from the false vocal fold to the first tracheal ring to add stability and prevent endolaryngeal adhesions. It should be secured in a manner that would allow its removal endoscopically. The stent is secured by two monofilament sutures run through the laryngeal ventricle and brought out through the cricothyroid membrane and tied to a skin button. Regardless of the type of stent, most authors recommend that stents should be removed in 10-14 days to help minimize mucosal damage. But a severely damaged larynx may need stenting for up to several months. The patients with epithelial injuries at the anterior commissure benefit from the use of a silicone keel in contrast to a stent. These are used to keep the opposing surfaces of the two vocal folds from contacting to help prevent side-to-side web formation. The intralaryngeal portion of the silicone keel is inserted between the vocal cords and the keel is then sutured to the thyroid lamina with two figure-of-eight 4-0 polyethylene sutures. These sutures tightly approximate the thyroid lamina and fix the keel firmly in place. The presence of the keel inserted through a laryngofissure may lengthen the anterior-posterior dimension of the larynx. Insertion of the keel allows for the migration of mucosa in an anterior fashion and prevents adhesions and synechiae. The keels are usually left in place for approximately two to three weeks. Other injuries that may be encountered in blunt laryngeal trauma include cricotracheal separation and recurrent laryngeal nerve injury. Cricotracheal separation is fortunately very rare and associated with many factors including a precarious airway, loss of cricoid support and a high incidence of recurrent laryngeal nerve injury. When a patient sustains lower cervical trauma, this injury must be considered and recognized so that the tenuous airway can be preserved. Unfortunately, this injury is often associated with asphyxiation at the time of trauma. These patients should undergo awake tracheotomy to secure the airway. If the cricoid cartilage is intact, direct mucous membrane repair is done with absorbable suture. To distribute the tension on the wound away from the cricotracheal anastomosis, nonabsorbable sutures are placed from the superior aspect of the cricoid cartilage to the inferior aspect of the second tracheal ring. In the presence of a cricoid fracture, the effectiveness of the repair is limited by the stability of the cricoid cartilage after internal fixation. Reconstruction of the severely injured cricoid cartilage with the assistance of internal fixation and stenting is preferable to significant resection of the cricoid with thyrotracheal anastomosis. The management of a severed recurrent laryngeal nerve continues to be a surgical dilemma. Even with microscopic repair of the transected nerve, vocal fold mobility is not regained as a result of the mixture of abductor and adductor fibers in the nerve. Nerve regeneration may help prevent muscle atrophy, however, and in this fashion maintain some strength of voice. All postoperative laryngeal trauma patients should receive antibiotics for 5 to 7 days in an effort to reduce infection and granulation tissue. The head of the bed should be elevated to minimize edema and the patient should be encouraged to ambulate as soon as tolerated. They should be started on antacids as well as H2 blockers to help prevent reflux that may cause increased scarring in a healing larynx. Nasogastric tubes should be avoided when possible, to help prevent reflux as well as erosion of the posterior cricoid mucosa that is associated with their use. Early recognition of laryngeal injuries and the application of consistent management principles have led to decreased morbidity and mortality from laryngeal trauma. Success is measured in terms of restoration of the voice and airway. In patients with edema, hematomas or minor lacerations, an excellent recovery of both voice and airway can be achieved without surgery or with minimal surgical intervention such as a tracheotomy or endoscopy. With severe lacerations or cartilaginous fractures, good results may still be obtained with early primary repair of lacerations and internal fixation of fractures. The University of Texas Southwestern Medical Center in Dallas described the outcome of a series of 139 patients with laryngeal trauma, Group 1 patients had minor injuries managed without operative intervention. Group 2 patients were managed with tracheotomy and endoscopy, but their injuries did not warrant open exploration or repair. Group 3 patients had displaced or multiple fractures of the laryngeal skeleton or endolaryngeal laceration. Group 4 patients were similar to Group 3 patients; however, they also required stenting given the massive extent of their laryngeal fractures. In this report, a good voice was reported to be normal or comparable to that before injury. Moderate to marked hoarseness was described as a fair voice and a voice just above a whisper was classified as poor. Airway quality was judged as good if the patient denied restriction, fair if some restriction persisted and poor if permanent tracheotomy was required. Only two patients were left with a poor airway as defined by the inability to de-cannulate. Time to decannulation in those patients undergoing tracheotomy, along with exploration ranged from 14 to 35 days. Those with stents needed 35 to 100 days for decannulation. All but 16 of the 115 of evaluated patients achieved a good voice and those 16 were classified as having a fair voice. The most common problem in the immediate postoperative period is the development of granulation tissue. Granulation tissue most often develops in the presence of bare cartilage. This problem is often a precursor to fibrosis and subsequent stenosis. Multiple techniques have been used in attempts to arrest the formation of granulation tissue including the use of systemic as well as intralesional corticosteroids, long-term splinting and low dose irradiation. But, these methods have had little success. Probably the most effective technique is to minimize the initial formation of granulation tissue by attempting to cover all exposed cartilage meticulously with a primary closure of laryngeal laceration. In addition, using intraluminal stents only in highly selective cases, as described previously, and keeping the stents in place for the minimal amount of time, may help to decrease the amount of granulation tissue that forms. Despite the strict adherence to principles of management in laryngeal trauma that have been discussed, fibrosis and stenosis may occur. Therapeutic measures depend, to some extent, on the level of the stenosis. Supraglottic stenosis may often be corrected simply by excising the scar tissue and then using local flap advancement for wound coverage. A keel or stent may be used, as needed, to maintain the repair. The rehabilitation of glottic stenosis depends on the extent of the lesion. Thin anterior glottic webs may simply be lysed and a keel placed to prevent recurrence. Posterior glottic webs may be excised and resurfaced with local advancement flaps. Subglottic stenosis continues to be difficult to treat no matter what the cause. Less extensive lesions may be treated with repeated dilatation or conservative non-circumferential laser excision of scar tissue. More significant stenosis may require anterior posterior cricoid split with cartilage grafting or even tracheal resection. After a blunt trauma, a persistently immobile vocal fold may be due to either recurrent laryngeal nerve injury or to cricoarytenoid joint fixation. Differentiating these causes is essential in selecting the proper form of therapy, and is best accomplished by observing the vocal fold for any sign of movement with fiberoptic laryngoscopy or with direct laryngoscopy under light anesthesia followed by palpation of the arytenoid to assess its mobility. If the arytenoid is mobile, the vocal fold should be observed for as long as one year, to await the possible spontaneous return of recurrent laryngeal nerve function. If aspiration or dysphonia is severe, injecting the vocal fold with Gelfoam may serve as a temporizing measure. Persistent paralysis resulting in an inadequate voice may be rehabilitated with either Teflon injection of the vocal fold or with thyroplasty type medialization procedures. In the case of a fixed arytenoid unilaterally with an adequate voice and airway, no treatment is needed. Bilateral arytenoid fixation or recurrent laryngeal nerve paralysis with a compromised airway often is treated with arytenoidectomy and vocal fold lateralization but this usually results in a weaker voice. In summary, although each instance of blunt laryngeal trauma produces a unique therapeutic dilemma, using basic primary treatment principles greatly simplifies the management plan. Using CT in some cases of laryngeal trauma obviates the need for direct laryngoscopy and open exploration. In some cases, tracheotomy rather than endotracheal intubation may be the method of choice for establishing an airway when required. Immediate or early open exploration for significant injuries allows the primary closure of all mucosal lacerations thus helping to prevent some long-term complications of laryngeal trauma. Stenting is not required when the cartilaginous skeleton is stable after internal fixation and when mucosal coverage of the anterior commissure can be reconstituted. Using a primary management protocol to treat laryngeal trauma will help to successfully maintain laryngeal function in a predictable fashion.
Case Presentation ZC is a 30-year-old man brought to Ben Taub General Hospital after being involved in a high-speed motor vehicle accident. He was an unrestrained driver of the vehicle hit at its front end. He was transported via ambulance to the BTGH Emergency Room where he was disoriented and complained of abdominal pain. He had a cervical collar in place. He was tachypneic, but maintained his blood pressure, heart rate and oxygen saturation. On physical exam he had subcutaneous emphysema of the neck and upper chest. He had blood in his oral cavity and a small posterior pharyngeal mucosal wall tear. On flexible laryngoscopy, limited by the pooling of blood, he had bilaterally symmetric vocal cord movement and no visible areas of exposed cartilage. The laryngeal structures appear slightly rotated. The patient was then carefully orally intubated by the anesthesia service. A lateral cervical spine X-ray showed subcutaneous air in the neck. A CT scan of the neck revealed extensive air collections within the retropharyngeal, carotid, posterior cervical and upper mediastinal spaces. The thyroid and cricoid cartilages were only partially ossified making the interpretation of the CT difficult, but it was suggestive of acute fractures involving the right superior and inferior horns of the thyroid cartilage. On the second hospital day he was taken to the operating room for a tracheotomy and neck exploration. He was found to have a large disruption in the left thyroid ala with a diagonal fracture extending from the right superior aspect of the thyroid cartilage to the left lower aspect of the cartilage. A thyrotomy revealed mucosal injury over the left false vocal fold and the left arytenoid joint was exposed. The mucosal lesions were reapproximated and a Hood endolaryngeal stent was inserted and secured to the skin. The thyroid cartilage fractures were repaired using the wire-tube technique. 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