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 Trauma to the Larynx The larynx is a well-protected structure that is both anatomically and functionally complex. Blunt injuries to this region can lead to problems involving aspiration, phonation or respiration. They can even cause rapid asphyxiation. Four of every ten blunt laryngeal trauma victims are estimated to die at the scene of the accident. Blunt laryngeal trauma is a rare event, but one that the otolaryngologist must be prepared to evaluate and treat. The most common cause of these injuries is motor vehicle accidents. The mechanism of injury is usually via the steering wheel or dashboard. Classically, the presentation is one of hoarseness and subcutaneous emphysema over the anterior neck in combination with a history of anterior neck trauma. Many studies, however, have noted that the presenting signs and symptoms can be quite varied. They can include dysphagia, dysphonia, stridor, shortness of breath, anterior neck pain and tenderness, loss of thyroid cartilage prominence, or hemoptysis. Any combination of these findings may be present initially so it is imperative to maintain a high index of suspicion concerning any patient presenting with a plausible mechanism for anterior neck trauma. The cornerstones of diagnostic evaluation in suspected laryngeal trauma are flexible laryngoscopy and computerized tomography (CT scan). Based on the physical, endoscopic and radiographic findings, these injuries can be classified into one of four groups using Schaefer's classification system: Group 1: minor endolaryngeal edema, lacerations, Group 2: moderate edema, lacerations Group 3: massive edema, mucosal disruption Group 4: group 3 and The management of blunt traumatic laryngeal injuries begins, as with any trauma patient, with following the Advanced Trauma Life Support protocol (AILS). Associated injuries are common, and special attention should be directed towards cervical spine, thoracic and central nervous system injuries. Although rare, esophageal injuries must be considered and ruled out with either radiographic contrast studies or direct esophagoscopy. If the airway is compromised, absolute priority must be given to establish an airway by the least traumatic means. The method of choice is tracheotomy. Further treatment depends on the extent of laryngeal damage. Those victims with Group 1 traumatic injuries can be treated medically with close observation, head-of-bed elevation, and humidified inspired air. Group 2 injuries usually require tracheotomy for airway stabilization and control. Direct laryngoscopy and esophagoscopy should also be performed as soon as possible. Group 2 patients can often be decannulated in three to four days. Group 3 and 4 trauma require airway stabilization followed by open exploration via a midline thyrotomy. When open exploration is required it should be performed within the first 24 hours after the injury. Careful attention must be directed towards limited debridement of mucosa and cartilagineous fragments, meticulous closure of all mucosal defects with fine absorbable suture, and reduction and fixation of laryngeal fractures. Endolaryngeal stents may be necessary when massive mucosal disruption or comminuted laryngeal skeletal fractures are present. Stents are also required when the anterior commissure or true vocal fold margins are involved. The keys to successful outcome in blunt laryngeal trauma are prompt, early intervention; limited debridement; and meticulous wound closure. If these principles are followed an excellent prognosis can be expected in both respiratory and phonatory ability. Case Presentation A 23-year-old African American female with no pertinent past medical or surgical history, was involved in a motor vehicle accident. She was a restrained, front seat passenger wearing a lap-type seat belt. Her car was traveling approximately 20-25 miles per hour when it collided with the rear-end of another vehicle. On impact, her head and anterior neck region struck the dashboard. She was then taken to Ben Taub General Hospital where she complained of hoarseness, anterior neck pain, and left facial pain. She denied loss of consciousness, dysphagia, or difficulty breathing. Physical exam revealed that she was hemodynamically stable and in no respiratory distress. Ecchymosis and edema were noted involving the left periorbital region without palpable stepoff. Abrasions, tenderness, and crepitance were present over the anterior neck but there were no palpable fractures. Lateral neck x-rays confirmed the presence of subcutaneous air without evidence of bony irregularities. Fiberoptic laryngoscopy revealed a hematoma involving the right aryepiglottic fold. There were no mucosal defects, the vocal folds were mobile, and the airway was uncompromised. An axial CT scan of the neck was performed which indicated no laryngeal fractures. The patient was managed conservatively with frequent fiberoptic re-evaluations. She showed steady improvement in quality of voice and resolution of supraglottic edema. Bibliography Angood PB, Attia EL, Brown RA, Mulder DS. Extrinsic civilian trauma to the larynx and cervical trachea - important predictors of long-term morbidity. J Trauma 1986;26:869-873. Austin JR, Stanley RB, Cooper DS. Stable internal fixation of fractures of the partially mineralized thyroid cartilage. Ann Otol Rhinol Laryngol 1992;101:76-80. Casiano RR, Goodwin WJ Jr: Restoring function to the injured larynx. Otolaryngol Clin North Am 1991;24:1215-1226. Cassisi NJ, Issacs JH Jr. Trauma. In: Cummings CW, Fredrickson J. Otolaryngology Head and Neck Surgery, Volume 3. St. Louis: Mosby, 1986: 1943-1964. Clemente CD. Anatomy - a regional atlas of the human body, 2nd ed. Baltimore: Urban and Schwarzenberg, 1981. Fuhrman GM, Steig FH 3d, Buerk CA. Blunt laryngeal trauma: classification and management protocol. J Trauma 1990;30:87-92. Ganzel TM, Mumford LA. Diagnosis and management of acute laryngeal trauma. Am Surg 1989;55:303-306. Gluckman JL, Mangas AK. Laryngeal trauma. In: Paparella MM, Shumrick DA, Gluckman JL, Meyerhoff WL, editors. Otolaryngology. Volume 3: head and neck, 3rd ed. Philadelphia: WB Saunders, 1991: 2231-2244. Gussack GS, Jurkovich GJ. Treatment dilemmas in laryngotracheal trauma. J Trauma 1988;28:1439-1444. Gussack GS, Jurkovich GJ, Luterman A. Laryngotracheal trauma: a protocol approach to a rare injury. Laryngoscope 1986;96:660-665. Harris HH. Management of injuries to the larynx and trachea. Laryngoscope 1972;82:1924-1929. Harris HH, Ainsworth JZ. Immediate management of laryngeal and tracheal injuries. Laryngoscope 1965;75:1103-1115. Herano M, Kurita S, Terasawa R. Difficulty in high-pitched phonation by laryngeal trauma. Arch Otolaryngol 1985;111:59-61. Kennedy KS, Harley EH. Diagnosis and treatment of acute laryngeal trauma. Ear Nose Throat J 1988;67:584,587,590-2 passim. Leopold MA. Laryngeal trauma - a historical comparison of treatment methods. Arch Otolaryngol 1983;109:106-12. Mathog RH. Atlas of craniofacial trauma. Philadelphia: WB Saunders, 1992. Meglin AJ, Biedlingmaier JF, Mirvis SE. Three-dimensional computerized tomography in the evaluation of laryngeal injury. Laryngoscope 1991;101:202-7. Minard G, Kudsk KA, Croce MA, Butts JA, Cicala RS, Faian TC. Laryngotracheal trauma. Am Surg 1992;58:181-187. Myer CM 3d, Orobello P, Cotton RT. Bratcher GO. Blunt laryngeal trauma in children. Laryngoscope 1987;97:1043-1048. Olson NR. Laryngeal trauma. Washington DC: American Academy of Otolaryngology - Head and Neck Surgery Foundation Inc., 1982. Olson NR. Surgical treatment of acute blunt laryngeal injuries. Ann Otol 1978;87:716-721. Olson NR, Sullivan MJ. Epiglottis in reconstruction of the larynx and tracha. Ann Otol Rhinol Laryngol 1985;94:437-441. Schaefer SD. The treatment of acute external laryngeal injuries. Arch Otolaryngol Head Neck Surg 1991;117:35-39. Schaefer SD, Close LG. Acute management of laryngeal trauma. Update. Ann Otol Rhinol Laryngol 1989;98:98-104. Schild JA, Denneny EC. Evaluation and treatment of acute laryngeal fractures. Head Neck Surg 1989;11:491-496. Snow JB. Diagnosis and therapy for acute laryngeal and tracheal trauma. Otolaryngol Clin North Am 1984;17:101-113. Stanely RB Jr, Cooper DS, Florman SH. Phonatory effects of thyroid cartilage fractures. Ann Otol Rhinol Laryngol 1987;96:493-496. Wenig BL, Schild JA, Mafee MF. Epiglottic laryngoplasty for repair of blunt laryngopharyngeal trauma. Ann Otol Rhinol Laryngol 1990;99:709-713. Grand Rounds Archive | Department Home page BCM Public | BCM Intranet | Privacy Notices | Contact BCM | BCM Site Map | ©2001-2006 Baylor College of Medicine
|