trauma symp 2011

4TH TRAUMA SYMPOSIUM

MANAGEMENT OF LARYNGEAL INJURIES

IN

NECK TRAUMA

Dr. M. Naim Manhas

E.N.T. Specialist

King Abdul Aziz Hospital-Makkah

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trauma symposium—WHY?

Since the increase in incidence of trauma patients

For last two decades, because of increase in number of cars on roads

Natural disasters, local warfare activity

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Increased the number of trauma patients after the world war-2

Since the increase in number of trauma patients and revolution in medical technology

Providing sophisticated intensive care units leading to manage severe trauma patients

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This set up has given birth to a new speciality

“ TRAUMATOLOGY”

Many countries have come up with independent “trauma centres”

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“purpose of symposium”

Short comings of last symposium

Introduction of new protocol to

minimize the post traumatic complication

Recommedation laid in last

symposium

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BLUNT

•Neck injuries

PENETRATING

IATROGENIC

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Blunt injuries of neck

Bruises over the neck

Hematoma

Surgical emphysema

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Blunt injuries of neck

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Laryngeal injuries

dysphonia

Subcutaneous

emphysemahemoptysis hematoma

Airway

obstruction

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diagnosis of airway injury

Physical

examination

Imaging

studies

Endoscopic

examination

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management

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problematic

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Emergency airway management

Awake fiberopticintubation

Awake orotrachealintubation

Surgical airway

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pediatric consideration

Larynx more superior (c4)

Mandibular protection

Generally more soft tissue and less cartilage damage

Circumferential area is less

Vulnerable to submucosal changes

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Pediatric airway

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caution

• Not to be used as effectivness is decresed

• When the anatomy is distorted

Laryngeal mask airway

• Should be avoided until the airway is secured

• If necessary surgical airway

Neuromuscular blockade

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laryngeal trauma(neck-injury)

Airway stable

• Flexable fiberoptic laryngoscopy

• Normal endolarynx observation

Mild abnormality

• C.T. scan normal / Abnormal

• Non displaced,non angulated thyroid cartilage fracture

Mucosa and cartilage displaced

• Tracheotomy or intubation

• Direct laryngoscopy and esophagoscopy

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laryngeal trauma(neck-injury)

Impending airway

• tracheotomy

• Direct laryngoscopy and esophagoscopy

obstruction

• Hematoma, small laceration but endolarynx intact

• observation

• Isolated fracture displaced or angulated thyroid

• Cartilage but endolarynx intact

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surgical exploration

Significant voice alteration

Expanding hematoma / shock

Massive subcutaneous emphysema

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surgical exploration

Open exploration of neck with open reduction and internal fixation of fracture without thyrotomy

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laryngeal thyrotomy

Laryngeal cartilage stable,anteriorcommissureintact

ORIF- fractures

Repair mucosal laceration

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laryngeal thyrotomy

Laryngeal cartilage unstable,anterior commissuredisrupted,massive mucosal injuries

ORIF fractures, repair mucosal laceration and endolaryngealstent

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penetrating neck injuries

Neck zones

Zone -1 thoracic outlet

Cricoid cartilage to sternal notch

Zone-2 central

Cricoid to angle of mandible

Zone-3 skull base

Angle of mandible to base of skull

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Neck zone concept outdated

Location of skin wound not a reliable indicator of underlying injuries

Length of neck makes it impractical to divide into three short zones

Wounds often occur at border between zones and difficult to classify

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Epidemiology of penetrating neck injuries

40% of penetrating neck injuries do not involve important structures

Structures involved:-

-major vein: 15-25%

-major artery: 10-15%

-pharynx or esophagus: 5-15%

Larynx or trachea: 4-12%

Major nerves: 3-8%

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Debatable issue

Some surgeons have advocated mandatory exploration of all penetrating neck wounds on the basis that serious injury can exist in the absence of clinical findings.

Others have advocated a selective approach operating only upon patients whose findings suggest a major vascular or visceral injury

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penetrating neck injuries

since zone 2nd has all the vital structures and any injury in this area needs immediate neck exploration in case patient is symptomatic.

As per the studies it is difficult to make decisions regarding the exact zone for the injuries which are on border line, as the area of neck is small so the indications for immediate surgical exploration----

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Indication of immediate surgical exploration

Exsanguinatinghemorrhage

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Guidelines

Pentrating neck wounds

Symptomatic/ asymptomatic

Angiography/ neck exploration

Endoscopy examination/angiog-

raphy/

Refractory shock or evolving stroke

Immediate neck exploration

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Esophageal injury--diagnosis

If missed leads to high morbidity and mortality

Contrast swallow study:-

Extravasation is diagnostic

Negative study is not reliable

50% of leak—missed with gastrograffin

25% of leaks missed with barium

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Recommendations

If gastrograffin study is negative then repeat with Barium

Avoid gastrograffin in patients without gag / cough reflex or unprotected airway.( causes pneumonitis if aspirated)

Endoscopy 50% of injuries can be missed , esp. if the patient is on ventilator.

Combination of contrast study with esophagoscopy reduces missed injuries to 5%

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latrogenic laryngeal injuries

The iatrogenic trauma(intubation related laryngeal injuries)

Has been neglected so far or has not been the topic for discussion,

As we all know that since the introduction of modern Intensive Care Units and introduction of

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latrogenic laryngeal injuries

Pvc biocompatable high volume and low pressure trans- laryngeal

Tubes has decreased the incidence of laryngeal complications after long term intubation.

Still the incidence of laryngeal injuries in our ICU is 15to 20 %

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Acute complication of intubation

Difficult anatomy

Excessive force

Inexperienced

doctor

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Endotrachealtubes

Upper limit size in

females :-7mm

Upper limit size in

males:-8mm

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Acute complication of intubation

Hematoma formation

Laceration

Avulsion

Scarring and granulomaformation

Dislocation of arytenoidcartilage

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Sequelae of prolonged intubation

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pathogensis

Non-specific hyperemia and edmadue to mucosal irritation

Edma often marked in the mucosa of the laryngeal ventricle

Prolapse or protrusion of the mucosa

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pathogensis

Edma within the submucosa in the subglottis

Delayed airway obstruction after extubation

Edma of true vocal cords persists, long after extubation as Reinkei’sedma---vocal cord dysfunction

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pathogenesis

Ulceration :- with varying degrees of granulation tissue formation

Common site susceptable site for irritation is mucosa overlying the vocal process

Prolapse of granulation in glottis after extubation airway obstruction REINTUBATION

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Posterior glottic stenosis both common adults and children

Deep ulceration occurs with chondritis of the arytenoid and cricoid cartilage

Heal by fibrosis formation of fibrous bands between arytenoidcartilages

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Abduction of the vocal cords are limited

Misdiagnosed as bilateral abductor paralysis

Peudolaryngealparalysis

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Sub-glottis stenosis in both adults and children

Children are more prone to mechanical trauma of subglottic region during intubation because of presence

Of loose tissue covering the cricoidcartilage and leads to edma formation.

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A mild edma in children in subglotticarea can lead to critical airwayobstruction

Sub glottic dimension in infants:- fullterminfant having less than 4 mm and premature infant having less than 3 mm

Cause symptomatic airway obstruction

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Prevention of postintubation injuries

Early detection of laryngeal injury and early anticipation of complication

Will reduce the incidence of complications.

Lot of controversies regarding the time for evaluation of larynx and tracheotomy

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Time of intubation

More than 10 days and less than 10 days

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1

2

0

0.5

1

1.5

2

2.5

3

3.5

2

37% 71%


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On the basis of these complications it is recommended that patients

Intubated for 7 days should under go tracheotomy if extubation is not imminent

And length of intubation greater than 10 days should be avoided.

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except

Infants Patients with burn injuries

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Result of recent studies done at university hospital Vall”Hebron-spain

• On 4th day of intubation1st laryngeal examination

• On 7th day of intubation

• Extubation was done –if unsuccessful then tracheotomy done

2nd laryngeal examination

• One month after extubation

• Or after tracheotomy

3rd laryngeal examination

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Result of serial laryngeal examinations

findings 1st laryngeal examination

2nd laryngeal examination

3rd laryngeal examination

normal 7.8% 10% 26.6%

edma 84% 43.3% 13.3%

preflap 42% 16% 26.6%

flap 13% 30% 26.6%

granuloma 5.2% 13.3% 0

ulceration 0 46.6% 33.3%

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conclusion

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conclusion

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trauma symp 2011

Health & Medicine