Laryngeal Trauma

Dr Chris Acott

Dr Russell M Davies 1914 - 1991

BMJ July 24 1880 pp 123

“He sat in bed supporting himself with stiffened arms: his head was thrown forwards, and he had the distressed anxiety so characteristic of impending suffocation …. His inspirations were crowing and laboured, and there was a very frequent forced attempt to swallow, attended by extreme pain, … He spoke in a muffled whisper, and confined his answers, when possible, to monosyllables, or substituted signs by head or hand. …”

Sir William MacEwen 1848-1924

Laryngeal trauma

Blunt Penetrating

Laryngeal Trauma: incidence

• Rare – 1/5000 – 1/137,000

» Current Opinion Otolaryngology 2000; 8(6):497-502

– 1/14,000 – 1/42,000» American Association Oral Maxillofacial

Surgeons 2006: 203-214

Laryngeal Trauma: incidence

• Rare – Why? – under reported - paucity of peer reviewed

data - » American Association Oral Maxillofacial

Surgeons 2006: 203-214» Current Opinion Otolaryngology 2000

8(6):497-502

– patients die before reaching hospital – not reported in data

– larynx well protected & flexible• mandible - superiorly; sternocleidomastoids –

laterally; clavicles – inferiorly. » American Association Oral Maxillofacial

Surgeons 2006: 203-214» Current Opinion Otolaryngology 2000

8(6):497-502

Laryngeal Trauma: Diagnosis

• DIAGNOSIS OF SUSPICION – laryngeal trauma NEEDS to be excluded– diagnosis may not be obvious in a patient with

an uncompromised airway– symptoms & signs unrelated to degree of trauma

• this may also be reason for under reporting

• Once diagnosed the extent of injury must be defined before any attempt at intubation– ETT across injured larynx can convert mucosal

laceration to a more complex problem• ETT can cause complete laryngo-tracheal separation

Laryngeal Trauma: Morbidity/mortality

• Mortality– 0-18%

» J Trauma 1990 30(1):87-93

• Delay in diagnosis increases morbidity & mortality– pharyngeal, oesophageal & vessel injury must

be excluded

• Concurrent occult oesophageal injury significantly contributes to morbidity & mortality– evaluation of oesophagus mandatory - NB

before placement N/G tube

Laryngeal trauma:Diagnosis of Suspicion

• HISTORY• Hoarseness - 90%• Tenderness - 90%• Subcutaneous

emphysema - 60%• Anterior neck

contusion - 40%• SOB - 40%

Current Opinion Otolaryngology 2000 8(6):497-502

Laryngeal trauma:Diagnosis of Suspicion

• Inability supine - 30%• Pain - 30%• Tracheal deviation -

20%• Haemoptypsis - 20%• Dysphagia - 10%• Aphonia - 10%

Current Opinion Otolaryngology 2000 8(6):497-502

Associated injuries

• Chest trauma - 40%• Facial #s - 30%• Facial laceration - 30%• Long Bone #s - 30%• Oesophageal laceration - 10%• Head injury - 10%• Pharyngeal trauma/perforation - rare• None - 30%

Current Opinion Otolaryngology 2000 8(6):497-502

Laryngeal trauma:History may give some idea of

injury• Complete L-T separation associated with:

– hyperextension injuries: avulsion of larynx – tearing of fibrous ring between CC & 1st tracheal ring

– strangulation– rarely associated with blunt trauma– ASSOCIATED WITH # CRICOID CARTILAGE

• # Thyroid Cartilage:– neck hyperflexion

• Knife or Gunshot wounds – evaluate the oesophagus

Multiple threats to airway:

• Direct penetration• Distorted tissue

planes• Haematoma• Oedema• Excessive blood &

secretions

Multiple threats to airway: ..2

• IPPV & coughing:– worsen air leaks– s/c emphysema

• Cricoid pressure: – lead to laryngo-

tracheal separation

Multiple threats to airway: ..3

• Cricothyroidotomy: – may compound

injury

• ETT: – mucosal disruption– false passage– laryngo-tracheal

separation

Laryngeal trauma:Airway

Stable Unstable

Airway can become unstable

at anytime

Laryngeal trauma:Airway

Stable Unstable

Inability to tolerate supine position –

URGENT TRACHEOSTOMY

Laryngeal Injuries: ..1

• Vocal cord injury• Arytenoid swelling &

dislocation• Crico-tracheal

separation– usually associated with

death

• Soft tissue contusion• Superficial mucosal

laceration

Laryngeal Injuries: …2

• Thyroid cartilage fracture– most common site

of fracture

• Epiglottic fracture• Mixed injuries• Shattered calcified

thyroid cartilage in elderly

Investigations:

• Plain Xray (may not be helpful due to extensive s/c emphysema)– pneumomediastinum &

pneumothorax– air in tissues– # Cx spine

• CT– cartilage & soft tissue

injury– airway patency

Investigations: .2

• Laryngoscopy– vocal cord paralysis– mucosal & cartilage

separation– haematoma– Laceration– Arytenoid displacement

Fractured Larynx:Management

• Tracheostomy under LA vs GA• Management is NOT A LEARNING

EXPERIENCE• HELIOX • FOB & Cricothyroidotomy may not

be appropriate• Intubation may not be appropriate

– may cause complete separation

WHY HELIOX?

1. Less dense – work of breathing less.

2. Decrease amount of subcutaneous emphysema

Helium - Upper airway obstruction

“When it is available an even better effect can be expected from inhalation of 79% Helium with 21% Oxygen”– Wylie Churchill Davidson 1960 pp 382

Reynold’s Number

• < 2000 laminar flow• 2000 -10000 transitional flow• >10000 turbulent flow

Turbulent flow

• Turbulent flow– F ~ P1/2/Lρ1/2

F = flow; P = pressure; ρ = density; L = length.

(Radius important but not expressible as a power of the diameter - as radius decreases

flow decreases also)

Turbulent flow: flow greater with Heliox than air or O2

Density important

Relationship between pressure and flow during turbulent flow

• Even if flow is turbulent there is less work of breathing and greater flow with given pressure change Comparison between Heliox (black)

& air or O2 (yellow)

Heliox

O2

Why Helium?Hylegaard et al

• O2 breathing initial bubble growth– O2 > He solubility in fat

– build up O2 around bubble in tissue

• Helium breathing bubble constantly shrunk

Helium mixtures: Physics /Gas flux

• GAS FLUX = diffusion x solubility coefficient– He>N2 diffusibility (smaller atomic wt)

– He<N2 solubility in fatty tissue, water & blood

– He<O2 solubility in fatty tissue

• therefore:- – N2 or O2 flux into fatty tissue > He flux

HENSE ANY AIR POCKETS WILL SHRINK.

WHY HELIOX?

• HELIOX WILL GAIN PATIENT’S CONFIDENCE AND MAKE BREATHING EASIER

• AND MAY DECREASE THE AMOUNT OF S/C EMPHYSEMA.

Heliox on Anaesthetic Machine

5 Case Histories

Maybe others – but not recognised.• trauma patients on ICU ventilator – laryngeal

oedema when extubated a couple of days later – ‘floppy epiglottis’ on intubation

1. Walker in mountains– hoarse voice in GP’s surgery– GA - laryngoscopy – unable to identify any

structures, unable to intubate (fortunately!!)– obstructed during tracheostomy with retractors

2. Motorcyclist on farmer’s property– intubated at scene

5 Case Histories

3. MVA – car rolled.– hanged by seat belt upside down– complete tracheal/laryngeal separation– partial obstruction with palpation of neck - GA

4. Motorcyclist – MVA – Modbury Hospital– gaseous induction– complete obstruction during tracheostomy –

retractors again

5. And ….

…. patient number 5.

• Able to speak and say “EEEE”

• Air bubbling freely from thyroid holes– covered with wet drape

• CT scan –no # Cricoid!!– found to have one

• No s/c emphysema• No respiratory distress• Able to lie flat

TRACHEOSTOMY

Head extended exposing the neck.

Neck palpated. LA injected.

Horizontal 6 cm incision to anterior borders sternocleidomastoid muscles.

Skin, subcut tissue, platysma to deep fascia.

May not be able to extend the head.Palpation of structures may

press on trachea & cause anxiety.

LA stings – may increase anxiety.

Veins may be enlarged due to inspiratory/expiratory pressures

SURGICAL TRACHEOSTOMY

Self retaining retractor placed,dissection to strap muscles

Strap muscles divided & retracted. Langerbech retractors placed.

Retractor placement important – to much pressure

can obstruct airway.

Thyroid isthmus exposed, clamped , divided and ligated, rotated externally & sutured.

Trachea is exposed

Retractor placement again important – to much pressure

can obstruct airway.

Tracheal incision sited over

2nd & 3rd or 3rd & 4th tracheal rings.

Tracheostomy tube inserted

Placement of tube may cause some distress

Summary:

• Rare – diagnosis of suspicion• Mortality ~20%

– increases if unrecognised

• Concurrent oesophageal injury increases morbidity & mortality– needs to be excluded

• Inability to lie supine – indication immediate tracheostomy

Summary: ..2

• Consider Heliox if available• Avoid coughing – may make s/c

emphysema worse and airway impossible

• Awake tracheostomy vs SV GA?– careful palpation– care with retractors

3rd SIG Airway MeetingLorne March 9-11 2012

“Everything airways including problems outside the OT”

Thank You

Laryngeal Trauma

Dr Chris Acott

Head extended exposing the neck.**

Neck palpated. LA injected.*

Horizontal 6 cm incision.Anterior borders sternocleidomastoid muscles.

Skin, subcut tissue, platysma to deep fascia.

Self retaining retractor placed, dissection to strap muscles.*

Strap muscles divided & retracted.

Langerbech retractors placed.**

Thyroid Isthmus divided.

Trachea is exposed

Sited over 2nd & 3rd or 3rd & 4th tracheal rings