Emergent Management (for Unstable Patients)
The initial resuscitation begins with following three steps: (1) securing the airway, (2) obtaining hemodynamic stability while controlling the bleeding, and (3) immobilizing the cervical spine. The optimal choice of airway control is often debated. Intubation may be performed safely if the vocal folds are easily seen, there are no visible injuries, and the smallest tube possible is used. However, endotracheal intubation can cause further injury to an already tenuous airway, resulting in an emergent need for airway control. In addition, the extent of injury may not be known prior to attempted direct laryngoscopy. Surgical airway control such as an awake tracheotomy (performed under local anesthetic) or a cricothyroidotomy may often be more prudent in these situations. If a cricothyroidotomy is performed, it should be converted to a formal tracheotomy as soon as possible to prevent long-term sequelae (eg, subglottic stenosis).
In contrast to adults, pediatric patients are unlikely to cooperate with a tracheotomy while awake. In addition, their neck anatomy is often more challenging owing to a high laryngeal position and soft cartilage. Therefore, a pediatric airway is preferably secured with a rigid bronchoscope while maintaining spontaneous respiration before a tracheotomy is performed.
After stabilization of the airway, the patient should be examined and the injury stratified to help guide further management.
External Laryngeal Trauma
Laryngeal injuries are grouped according to increasing severity (Table 34–1; Figure 34–3). Patients with Group I injuries have minor endolaryngeal hematomas or lacerations. These patients are treated successfully with medical management alone, typically. Group II injuries demonstrate airway compromise, more severe soft tissue injury, or single nondisplaced laryngeal fractures. These patients are usually managed with a tracheotomy followed by direct laryngoscopy and esophagoscopy. If an arytenoid dislocation is discovered, then closed reduction should be attempted. Group III injuries include patients with massive edema, mucosal tears with exposed cartilage, displaced fractures, or vocal cord immobility. Group IV describes the unstable larynx with comminuted fractures. A Group V classification is the most severe type of injury; these patients present with complete laryngotracheal separation. Injuries within Groups III–V require immediate operative repair and may involve the use of stent. The ability to restore the integrity of the larynx impacts a patient's long-term outcome with regard to voice, airway, and the quality of life. It must be noted that this classification system does not account for patients with significant injuries (displaced fractures with altered vocal quality) who have mild or no airway compromise. These patients will often present later with complaints of hoarseness alone. If the injury was relatively recent, repair may be attempted to improve long-term functional outcome.
Table 34–1. Classification of Laryngeal Injury. ||Download (.pdf)
Table 34–1. Classification of Laryngeal Injury.
|I||Minor endolaryngeal hematoma; minimal airway compromise, if any; no detectable fractures|
|II||Endolaryngeal hematoma or edema associated with compromised airway; minor mucosal lacerations without exposed cartilage; nondisplaced fracture shown on a CT scan|
|III||Massive endolaryngeal edema with airway obstruction; mucosal tears with exposed cartilage; immobile vocal cord(s)|
|IV||Same as group III with more than two fracture lines on imaging studies; massive derangement of endolarynx|
Treatment algorithm for the acute management of external laryngeal trauma. (Data from Schaefer SD: The acute management of external laryngeal trauma: a 27-year experience. Adapted, with permission, from Schaefer SD. Arch Otolaryngol Head Neck Surg. 1992;118:598.)
Group I and II injuries often heal spontaneously and have excellent outcomes. These injuries are usually managed nonsurgically with humidified air, head of bed elevation, and voice rest. To prevent complications from an undetected or progressive injury, the patient should be closely observed with serial fiberoptic examinations and continuous pulse oximetry for 24–48 h. Antibiotics are often prescribed when there is observable mucosal injury. The use of steroids is controversial. Steroids probably decrease edema if given within the first few hours after injury. The prophylactic treatment of laryngopharyngeal reflux is also recommended to prevent exposure of an injured larynx to acidic gastric contents.
In more severe injuries, the careful approximation of mucosal tears and the reduction of fracture segments are required to prevent long-term voice disturbance or airway compromise. Findings that tend to lead to a recommendation for surgery include: (1) lacerations involving the anterior commissure, injury to the free edge of the true vocal fold, or the finding of exposed cartilage; (2) displaced or comminuted fractures; (3) vocal fold immobility; or (4) arytenoid dislocation.
Some data indicate that patients with treatment delays of 48 hours have inferior outcomes when compared with patients whose injuries are repaired soon after the initial trauma. Early intervention is generally preferable since it allows an accurate identification of the injury, less scarring, and superior long-term results.
Fractures can affect the voice by changing the geometry of the larynx and glottal configuration. Therefore, the precise reduction and fixation of even minimally displaced or angulated fractures is often advocated. Fractures traditionally have been repaired with stainless-steel wires or absorbable sutures. Miniplates (titanium or absorbable) provide immediate stability and good results (Figure 34–4) although they are often difficult to place in the cartilaginous framework.
Intraoperative photo graphs of the patient from Figure 34–2. The first photograph (A) was taken before rigid fixation using a plating system; the second photograph (B) was taken after the plate was inserted. Note that the plate is carefully bent to restore the proper anterior commissure angle and location.
When there is significant disruption of the endolaryngeal soft tissue, a midline thyrotomy to the level of the cricothyroid membrane is performed through a horizontal anterior neck incision. The arytenoids are palpated and reduced if dislocated or avulsed. Only obvious devitalized tissue is débrided. Mucosal lacerations are repaired with primary closure or local flaps to cover any exposed cartilage with the goal of preventing perichondritis, the formation of granulation tissue, and scarring. Grafts are rarely needed.
The use of stents is controversial because of the increased risk of infection and granulation formation. Stents provide structural stability and are indicated in patients with laryngeal instability following inadequate fracture fixation. In the presence of severe soft tissue disruption or lacerations involving the anterior commissure, stents may help prevent synechiae. After 1 or 2 weeks, they are typically removed endoscopically.
Penetrating neck trauma is classified by the level of injury based on the clinical features and the ease of surgical access: (1) Zone I extends from the sternal notch to the cricoid; (2) Zone II extends from the cricoid to the angle of the mandible; and (3) Zone III extends cranially from the mandible to the skull base. This classification system directs the diagnostic evaluation and treatment.
With sophisticated ancillary tests and the accurate identification of localizing signs and symptoms, the surgical exploration of penetrating neck trauma is being used increasingly on a selective basis. Immediate operative exploration including triple endoscopy (direct laryngoscopy, bronchoscopy, and esophagoscopy) is used for all patients with hemodynamic instability or airway compromise. The hypopharynx should be closely inspected for injury. Injuries above the level of the arytenoids often heal spontaneously and may be expectantly managed. Lower hypopharyngeal and cervical esophageal injuries require open exploration, primary closure, and drainage due to the higher incidence of salivary leak, infection, and subsequent fistula.
The stable patient is stratified depending on the presence of other signs or symptoms such as expanding hematoma, dysphonia, hemoptysis, hematemesis, or dysphagia. This group of symptoms is explored more selectively.
Injuries crossing into Zones I and III of the neck are more difficult to examine clinically and approach surgically; therefore, imaging—including angiography—is often performed. Zone I injuries are studied with preoperative arteriography and often gastrograffin swallow studies because of the risk of occult injuries reported by some clinicians. Because of difficult surgical access to the vasculature at the base of the skull, patients with Zone III injuries are also studied with arteriography, with the therapeutic option of embolization should an injury be found. Patients with isolated Zone II injuries, however, are usually explored surgically, often without imaging.
The management of asymptomatic patients is controversial. With these patients, some evidence supports observation alone because the physical examination is extremely sensitive in detecting injuries that require operative intervention. In these patients, imaging and adjunctive testing are very helpful in guiding further management.
Intubation injuries may cause a wide variety of acute and chronic conditions. High endotracheal tube cuff pressures may cause progressive hoarseness or airway obstruction from glottic or subglottic edema. Compressive neuropathies caused by direct pressure of the cuff may lead to vocal fold paralysis. Mucosal injury is commonly seen, particularly in the posterior larynx and subglottis and usually results from pressure necrosis due to the presence of the tube and/or cuff or from traumatic intubation. These injuries may progress and lead to granuloma formation, fixation of the cricoarytenoid joint, web formation, or stenosis. The incidence of posterior glottic stenosis increases with the length of intubation and may occur in up to 14% of patients intubated for more than 10 days. Differentiating glottic stenosis from vocal fold paralysis can often be difficult, since both result in partial or complete vocal fold immobility. Typically, the cause of the immobility can be elucidated either by manual assessment of arytenoid mobility or by the use of laryngeal electromyography.
Most cases of granulation tissue formation seen after intubation trauma resolve spontaneously after some time. However, further treatment may be necessary in certain cases. This treatment typically involves a combination of voice therapy and antireflux medication. This combination reduces the impact of behavioral and local inflammatory factors that are presumed to cause ongoing laryngeal irritation. In certain refractory cases, botulinum toxin injections can be used to forcibly reduce the impact of ongoing phonotrauma. Pulsed-dye or pulsed potassium titanyl phosphate laser treatment has also been successful. Operative removal of the granuloma is rarely necessary except in cases of partial airway obstruction. It should be noted that surgical removal does not obviate the need for voice therapy and antireflux medications. Without controlling these factors, granulomas may recur after surgical excision alone.
The management of stenosis depends on its location and severity. It may be detected weeks or months after extubation, when a patient presents for the evaluation of recent exercise intolerance or stridor. Thin webs that tether the anterior glottis can be surgically divided. A keel may then be placed to prevent the web from reforming between apposed denuded mucosa. Posterior laryngeal stenosis and cricoarytenoid joint fixation are typically treated with repeated dilation through an endoscopic approach. However, occasionally, an open approach through a laryngofissure or the use of a stent is required. Other techniques utilized to treat failures or more severe cases include arytenoidectomy or partial posterior cordotomy.
Subglottic or tracheal stenoses may be initially approached with endoscopic laser incision and dilation. More severe stenoses may require laryngotracheal reconstruction or segmental resection with primary anastomosis. Tracheal segments 4–5 cm in length may be removed if performed with release maneuvers.
In unilateral vocal fold paralysis, patients with persistent dysphonia or significant aspiration—despite therapy—may benefit from vocal fold augmentation with a temporary injection material while awaiting the spontaneous return of function. A medialization laryngoplasty with or without arytenoid adduction or injection augmentation with a more permanent substance is typically recommended if the paralysis is likely to be permanent.
Patients with bilateral vocal fold immobility often present with stridor. Relieving the airway obstruction may require a partial posterior cordectomy, arytenoidectomy, or arytenoid lateralization procedure. In more pressing cases, airway relief is often provided via a tracheostomy.
The finding of arytenoid dislocation is suggested by an uneven vocal cord level seen on laryngoscopy. However, this appearance can also be seen with vocal fold paralysis, which occurs much more commonly. Laryngeal EMG and CT scanning can be used to clarify the diagnosis.
Benninger MS, Gillen JB, Altman JS. Changing etiology of vocal fold immobility. Laryngoscope.
. (Vocal fold immobility is most commonly a result of a malignant disorder and surgical trauma, while intubation injuries still account for a significant number of cases.)
Butler AP, Wood BP, O'Rourke AK, Porubsky ES. Acute external laryngeal trauma: experience with 112 patients. Ann Otol Rhinol Laryngol. 2005;114:5. (Outcome may be predicted by the initial severity of injury and is improved with earlier intervention.)
Clyne SB, Halum SL, Koufman JA, Postma GN. Pulsed dye laser treatment of laryngeal granulomas. Ann Otol Rhinol Laryngol. 2005;114(3):198. (In-office use of the pulsed dye laser is a relatively safe and effective method for treating laryngeal granulomas that do not respond to antireflux therapy and speech therapy.)
De Mello-Filho FV, Carrau RL. Management of laryngeal fractures using internal fixation. Laryngoscope
. (Adaptation plating systems are well tolerated and effective, and provide immediate stabilization of laryngeal fractures.)
Gold SM, Gerber ME, Shott SR, Myer CM. Blunt laryngotracheal trauma in children. Arch OtolaryngolHead Neck Surg 1997;123(1):83 (Review of pediatric laryngotracheal injuries, which combines the classification systems proposed by Fuhrman et al and Schaefer and Brown for laryngotracheal injuries.)
Schweinfurth JM. Endoscopic treatment of severe tracheal stenosis. Ann Otol Rhinol Laryngol. 2006;115(1):30 (Severe and complete tracheal stenoses may be successfully treated endoscopically, which is associated with few complications, low morbidity, a short operative time, and a short length of hospitalization when compared with tracheal resection.)
Sekharan J, Dennis JS, Veldenz HC, Miranda F, Frykberg ER. Continued experience with physical examination alone for evaluation and management of penetrating Zone II neck injuries: Results of 145 cases. J Vasc Surg
. (Penetrating neck trauma of Zone II may be safely and accurately managed based on the findings of the physical examination of vascular injury.)
Stanley RB Jr, Armstrong WB, Fetterman BL, Shindo ML. Management of external penetrating injuries into the hypopharyngeal-cervical esophageal funnel. J Trauma.
. (The severity of injuries increases as they descend from the upper hypopharynx to the cervical esophagus, with the former being amenable to expectant treatment.)
, Porter JM, Fernandez LG. Penetrating neck trauma: An overview of management. J Oral Maxillofac Surg.
2002;60(8):918. (Review of management of penetrating trauma to the neck.)
Yin SS, Qiu WW, Stucker FJ. Value of electromyography in differential diagnosis of laryngeal joint injuries after intubation. Ann Otol Rhinol Laryngol. 1996;105(6):446. (Laryngeal electromyography can help in the diagnosis of cricoarytenoid joint fixation.)