Topic presentation 6/2/2012 Julian Yau

LARYNGOTRACHEAL TRAUMA

INTRODUCTION
Laryngotracheal trauma commonest occur after road traffic accidents. Laryngeal fractures may well be missed because effort will be direct towards securing the airway and other injuries (head, chest, abdomen etc). Severe effects on airflow - Poiseuilles law

Acute laryngeal injury Chronic laryngeal stenosis

CAUSES OF LARYNGEAL/ TRACHEAL INJURY

Commonest is RTA Other causes include

sharp

objects eg knife, wires Bullets Contact sports strangulation

Under age of 40,

Thyroid

cartialge is still largely cartilaginous When hit vertebrae, the laminae are spread outwards Fracture occurs down the prominence Epiglottis may be detached causing obstruction Artyenoids are pushed against the vertebrae, may become swollen or disarticulated

Over age of 40,

The

cartilage is largely ossified Compressing force against the vertebrae will shatter the thyroid cartilage Disorganize the cords, epiglottis and arytenoids Causing flattening of neck

DIAGNOSIS
Easy to miss Always suspect in patient with multiple injuries Symptoms:

dyspnea, dysphonia, pain, dysphagia, haemoptysis

Look for
surgical emphysema, stridor, Cervical bruising, Loss of thyroid prominence, Loss of normal neck outline

Mirror examination or flexible laryngoscopy may show edematous, haemorrhagic arytenoids, mucosal tears and disorganized vocal cords DL should be done in suspected cases, but may exacerbate the effect of injury

INVESTIGATIONS

Plain films (eg CXR, c spine XR)

Prevertebral
Rib

air

fractures Tracheaobronchial laceration may give a pneumothorax

CT scan

TREATMENT

Secure airway
Intubation/

tracheostomy

Supportive
Oxygen Steroids Humid

atmosphere Bed rest/ voice rest

Protection of the laryngeal function

Aim

to have no requirement of permanent tracheostomy tube, no dypsnea and normal daily activities Minimal debridement Usually involves open exploration and repair, reduction and fixation

In case of fracture thyroid cartilage

Even minor displacement will affect glottic configuration To reduce the fracture Through a horizontal collar incision Laryngofissure through the fracture line is performed with scissors Epiglottis, vocal cord fixed Mucosal laceration sutured Cartilage fragment fixed with eg stainless steel wires If anterior commissure damaged, prevent the anterior ends of vocal cords to form a web by placing a McNaught keel/silastic sheet between the cords for 5 weeks

Shattered thyroid cartilage

Refashioned

around a solid stent mould Left for 3 months

Fractures of hyoid
Remove

either side of the fractured hyoid No fuctional impairment

CHRONIC LARYNGOTRACHEAL STENOSIS

After 3-4weeks of injury Interfere with speech breathing and ability to clear secretion from the lower respiratory tract Patient found unable to speak or breathe after weaning the tracheostomy tube

CAUSES
Apart

from trauma, other causes are:

occurs if placed too high with collapsed cricoid. Sometimes at the site of inflatable cuff

Tracheostomy,

Partial

laryngectomy,

keel could be used in reconstruction for prevention of stenosis

Granulomatous

disease (TB, scleroma or Wegeners

granuloma) Tumors congenital

Management:
Should not attempt for surgery until 18 months has passed from the initial injury Aim to get rid of tracheostomy tube and preserve a good voice Should assess the length of neck and cervical trachea available for mobilization Most patients should already have a tracheostomy, they should be informed the possibility of failure to wean off Stenosis due to systemic illness usually have poor results

chronic laryngotracheal stenosis can be further classified into:

Supraglottic
Glottic Subglottic

and tracheostenosis Cricoid stenosis

Supraglottic
Excising

only the scarred area and leave the normal functioning vocal cords Mucosa is quilted down to avoid a dead space Another choice will be permanent tracheostomy

Glottic stenosis

Due to fixation of aryenoids

Arytenoid

may be removed and cords stitched in the desired position or the cords wired laterally approach, exicsing the web and closing the larynx over a McNaught Keel made of silastic excised, refashioned and fixed over a solid stent inlay of silicone for 8 weeks

anterior web of the cords

Laryngofissure

Whole glottis stenosed

Scar

Subglottic and tracheal stenosis:

Repeated

dilatation Excision of stenosed portion and re-anastomosis of the trachea

Up

to 4cm of trachea can be excised Free the tracheal stump and drop the larynx by dividing the suprahyoid muscles

Cricoid stenosis
The

only complete ring in respiratory tract Procedures trying to build out the ring have not been very sucessful Among the method available , the choice is to excise the cricoid apart from a plate on which the arytenoid lies. Free the trachea and larynx dropped down to join the cricothyroid remnant Risk of RLN injury

To operate or not?
Patient

with no tracheostomy could be advise for non operative management due to possibility of inducing scarring leading to a tracheostomy Patient with tracheostomy should be encourage since this is about 50% chance, he/she may wean off the tracheostomy tube.

CONCLUSION
High clinical suspicious of laryngeal injury in patient with multiple trauma Always look for underlying causes in patient with chronic laryngeal stenosis Aware of different operative management in laryngeal injury/ stenosis

THE END