Michelle Mekky, MA, CCC-SLP, BRS-S

Speech-Language Pathologist

Memorial Hermann Hospital & Children’s Memorial Hermann

Hospital

PurposeEducate the SLP on the medical

diagnosis, medical treatment, and ultimate rehabilitation of voice and swallowing following airway/laryngeal trauma.  

Nelson Review Article• Why this article

• Lack of clinical research on this patient population in the SLP literature

Laryngeal Anatomy

Anatomy continued

Mechanism of Injury• Blunt Trauma-fractures/dislocation• Penetrating Trauma• Intubation Trauma• Thermal and Chemical Trauma

Blunt Trauma• Larynx is relatively well-protected• Lateral shielding by

sternocleidomastoid muscle• Posterior protection from cervical

vertebrae• Anterior protection by mandible

Examples of Blunt Trauma

Ex. of Blunt Trauma (cont)

Internal Trauma

Fractures and Dislocations• Midline or paramedian are most

common• Comminution & complex fractures

do occur• Surgical Management: ORIF &/or

tracheostomy• Use of stents

Laryngeotracheal Separation

• Severe airway compromise• Many die at the scene of the accident, unless

mucosal attachment remains• Tracheostomy performed ASAP • Intubation in the field may do more harm

than good• Bilateral recurrent nerve injury and subglottic

stenosis are common complications• Ultimate surgical intervention is sometimes a

total laryngectomy

Penetrating Trauma• Car accidents• Knifes• Bullets (handgun versus shotgun)• Other accidents: falling on sticks

or glass• Blast injuries

Vascular Injuries• Occur in 25-56% of penetrating

neck wounds• Most commonly to the carotid and

subclavian arteries-most common cause of death

• 20-30% of penetrating neck wounds result in laryngeal, tracheal, or esophageal injuries

Intubation Trauma• Prolonged intubation leads to

trauma in 4-13% of cases• Larger endotracheal tubes cause

more trauma• History of smoking or ETOH

consumption can be very drying to the mucosa

• GERD/LPRD

Intubation trauma caused by:

• Abnormal anatomy (~10% of the population)

• Difficult laryngescopy• Multiple intubations/extubations• Skill of person placing (resident vs.

attending)• Emergent versus Elective

When trachs are placed• In most hospitals tracheostomies

are performed after 10-14 days of endotracheal intubation

• If multiple trips to the OR are required

• Policies vary greatly between the different ICUs

Reaction to Intubation• Within 48 hours of intubation

granulation tissue begins to form• Mucosal ulceration is usually

present

Immediate Laryngeal Complications

• Glottic or subglottic edema• Mucosal laceration• Dislocation of the arytenoids• Avulsion of the epiglottis• Vocal cord paralysis

When to refer to ENT post intubation/extubation

• Hoarse voice greater than 48 hours

• Sore throat greater than 48 hours• Dysphagia• Odynophagia• Stridor

Management of Arytenoid Dislocation

• Needs to occur by ENT with 24-48 hours of identification

• Can sometimes be treated by direct endoscopy

Treatment of Avulsion of the Epiglottis

• Open repair• Laser excision

True VC Paralysis• May occur as result of intubation &/or

extubation• Brandwein et al. discovered that the anterior

branch of the recurrent laryngeal nerve is vulnerable to compression between the inflated cuff of the ETT, the lateral projection of the abducted arytenoids, and the thyroid cartilage.

• Cord is usually lying in the paramedian position

Late injuries of Intubation• Intubation granuloma• Cricoarytenoid ankylosis (fibrosis)• Glottic webs• Subglottic stenosis

Avoiding Late Injuries of Intubation

• Limiting amount of time the pt is intubated• Using the smallest ETT which will permit

adequate respiratory support• Using low-pressure cuffs• Careful fixation of the tube to limit

movement during assisted ventilation• Use of steroids and antibiotics• Early recognition/tx of such laryngeal

injuries

Intubation Granuloma• Forms when blood supply is poor• Area is exposed to potential contamination• Steroids is a medical tx• Antibiotics to promote healing of the

mucosa• Late presentations: voice changes,

globus, repetitive medical course of tx• Sometimes permanent

Glottic Web• Can result from simultaneous

denudation of both VFs near the anterior commissure

• When they heal together they produce a web

• Probably occurs more often as a complication or surgery rather than from intubation

Picture of Glottic Web

Medical tx of Glottic Webs• Surgical placement of anterior

tantalum keel• Endoscopic management with a

laser or mechanical lysis-followed by placement of an internal Teflon keel

Subglottic Stenosis• Definition: narrowing of the

subglottic space above the inferior margin of the cricoid cartilage and below the level of the glottis

• Can be anterior, posterior, or complete

Subglottic Stenosis (cont)• Grade I - Obstruction of 0-50% of

the lumen obstruction• Grade II - Obstruction of 51-70% of

the lumen• Grade III - Obstruction of 71-99% of

the lumen• Grade IV - Obstruction of 100% of

the lumen (ie, no detectable lumen)

Picture of Subglottic Stenosis

Tx of Subglottic Stenosis• Tracheostomy• Open reduction• Cricotracheal resection• Medical management of GERD/LPRD

if in the patient’s known history• Steroids/Antibiotics• Grafting

Consequences of Self-Extubation

• Edema• Possible vocal cord damage• Cartilage dislocation

Thermal and Chemical Trauma

• Inhalation of hot gases (caustic or not) cause trauma

• Stabilize the airway• Sudden edema is of primary

concern

Long term Injuries • Loss of mucosal integrity• Infection• Chondritis (inflammation of

cartilage)• Fibrosis

What the MD looks for:• Cough• Carbon particles• Blood in the sputum• Voice change• Stridor• Dyspnea (shortness of breath)

Course of Treatment• At least admitted for observation• Difficult to determine if

tracheostomy is indicated

Medical Management of the Airway

• Oral intubation after spine is clear• Rarely a cricothyroidotomy is

performed for an emergent airway when a trach cannot be completed

• Must be revised to a tracheostomy ASAP (within a few hours)

Role of the SLP• Aphonia/Hoarseness• Aspiration/Penetration• Avulsed/Amputated Epiglottis• Edema• Unilateral VC paresis/paralysis• Bilateral VC paralysis• Hearing Loss

Aphonia/Hoarseness• Get dx from ENT• Medical management is the best

course of tx for bringing back voicing

• Facilitate communication with a communication board and/or written communication systems

Aspiration/Penetration• Determine if postural changes are

helpful during MBS/FEES• MUST take into account fatigue on ability

to perform maneuvers (respiration and structural)

• May try: supraglottic swallow, super-supraglottic swallow, head down, or head rotation.

• Diet Modification is usually necessary with or without enteral access

Avulsed/Amputated Epiglottis

• May lead to initial odynophagia with all oral intake

• Chin down or super-supraglottic swallow may be a helpful to try during MBS/FEES

Edema• Vocal rest• Medical Management

– Steroids– Anti-inflammatories

Unilateral VC Paresis/Paralysis

• Many patients with unilateral paresis recover in the first 7-10 days post trauma

• Those with paralysis usually overcompensate with the good cord in 1-3 weeks

• Temporary tx’s by ENT: fat injection• Permanent tx’s by ENT: medialization

laryngoplasty or thyroplasty

Bilateral Vocal Cord Paralysis

• Causes– Paralysis (neurological)– Fixation of the cricoarytenoid joints– Both

Tx of Bilateral VC Paralysis• Usually trached and NOT a candidate

for a speaking valve• Written

communication/Communication board/electrolarynx during acute hospital stay

• If permanent with no recovery to either cord then: Speech generating device with or without electrolarynx

Hearing Loss• Reported cases of acoustic trauma SN HL

following blunt neck trauma• Segal et. al suggests it could be due to

sheer forces acting on the cervical spine that transition to the inner cranium

• Other theories suggest a neuromuscular mechanism, a neuro-vascular mechanism, or a mechanical vascular obstruction

• Tinnitus/Balance difficulties

Hearing Loss (cont)• Audiological/ENT referral is

appropriate• Referral to physical therapy may

be indicated• Speech tx for aural rehabilitation

Thoughts for the Future• Research in voice recovery s/p

airway trauma• Research in swallowing function

s/p airway trauma