|Year : 2007 | Volume
| Issue : 1 | Page : 57-59
An Unusual Laryngeal Injury
A Kohli1, P Bhadoria2, A Bhalotra3, R Anand4, P Goyal1
1 M.B.B.S., PG Student, Department of Anaesthesiology and Intensive Care, Maulana Azad Medical College & LNH, NewDelhi-110002, India
2 M.D., Prof, Department of Anaesthesiology and Intensive Care, Maulana Azad Medical College & LNH, NewDelhi-110002, India
3 M.D., Asst. prof, Department of Anaesthesiology and Intensive Care, Maulana Azad Medical College & LNH, NewDelhi-110002, India
4 M.D., Director, Prof and Head, Department of Anaesthesiology and Intensive Care, Maulana Azad Medical College & LNH, NewDelhi-110002, India
|Date of Acceptance||15-Jan-2007|
|Date of Web Publication||20-Mar-2010|
4-LFTodarmalsquare,Todarmallane, Barakhamba Road, New Delhi - 110002
Source of Support: None, Conflict of Interest: None
Blunt injuries to the anterior neck are most commonly due to road traffic accidents but the incidence of such types of injuries are decreasing probably due to stricter laws pertaining to seat belts and drunken driving. Experience in managing such injuries is limited due to their rarity. The mainstay of management revolves around establishing and maintaining a patent airway and integrity of the spine. Here we document a case of a 25 year old male who met with a Road traffic accident while driving a motorbike and sustained a clear cut linear wound on the right side of the neck with minimal airleak due to the helmet clip. On exploration, he was found to have massive epiglottic edema, mucosal abrasions, lacerations and a thyroid cartilage fracture. The mechanism of injury was probably a combination of penetrating and blunt trauma neck. This case highlights the mechanism of laryngeal injury, its presentation and management
Keywords: Road traffic accident, Airway, Laryngeal injury, Thyroid cartilage fracture
|How to cite this article:|
Kohli A, Bhadoria P, Bhalotra A, Anand R, Goyal P. An Unusual Laryngeal Injury. Indian J Anaesth 2007;51:57-9
| Introduction|| |
Laryngeal injuries are quite rare due to the protection offered to the laryngeal apparatus by the mandible and cervical spine. However acute blunt laryngeal trauma can be a life threatening event and often poses a difficult airway problem.  The initial management of these injuries has a tremendous impact on the probability of survival of patient and his long term quality of life. The first priority in such cases is establishing an appropriate airway. The most conservative and reliable method of securing an airway in such patients remain tracheostomy when the patient is awake. In this case report injury to the laryngeal apparatus is caused by a helmet clip which makes it unusual. It is very interestingly seen that a small linear cut visible externally on anterior aspect of neck, has resulted in a severe laryngeal damage internally. The key to a successful outcome in blunt laryngeal trauma is prompt and early intervention with limited debridement and meticulous wound closure. If these principles are followed an excellent prognosis can be expected in both respiratory and phonatory abilities.
| Case report|| |
A 25 years man of average height and weight with no pertinent medical or surgical history, met with a road traffic accident. He was driving a motor bike wearing a helmet when he suddenly collided with a car, his motorbike overturned and while falling his helmet clip struck the right side of his neck resulting in a linear cut. He presented to the casualty at about 12 midnight with the chief complaints of difficulty in speaking and mild hoarseness of voice. There was no history of difficulty in breathing, loss of consciousness, ENT bleed, dysphagia, or history suggestive of head injury. The patient was conscious, well oriented and haemodynamically stable. On examination a linear wound, approximately 4cm in length was seen on the right side of his neck, one finger breadth above the thyroid cartilage. Margins of the wound were well demarcated and there was crustation around it with minimal air leak. There was no active bleeding. Both laryngeal crepitus and tenderness were present.
Indirect laryngoscopic examination done by otorhinolaryngologist revealed an overhanging epiglottis and endolarynx could not be visualized. X-ray soft tissue neck and cervical spine both AP and lateral view and chest X-ray were normal. CT scan of the neck was done which revealed depressed fracture of the right thyroid cartilage, edema of aryepiglottic fold, arytenoids and right true vocal cords.
However, by 4.00 AM the patient developed mild respiratory distress and a tracheostomy was done by the ENT surgeons under local anaesthesia. The following day the patient was brought in the theatre for panendoscopy on an emergency basis. All preoperative investigations were within normal limits and he was taken up as ASA grade 1E. In the operation theatre he was induced with Fentanyl 100 mcg and Propofol 100mg intravenously and O 2 , N 2 O, Isoflurane administered through the Bain circuit which was connected to the tracheostomy tube. After ensuring adequacy of ventilation and absence of any air leak, the patient was given Vecuronium bromide 4mg. Direct Laryngoscopy was done by the ENT surgeons and revealed oedema of the epiglottis and both valleculae, slough over the left arytenoid and interarytenoid region with a tear. Bilateral pyriform sinuses were normal. The 4cm linear laceration on the right side of the neck at the level of the upper border of thyroid cartilage was extended on both sides. On exploration, thyroid cartilage was found to have a midline fracture with breaching of inner and outer perichondrium [Figure 1]. The cricothyroid membrane was also found to be disrupted. The left true vocal cord appeared normal whereas right true vocal cord was breached at the junction of anterior and posterior halves. Repair of the cricothyroid membrane was done and perichondrium of the thyroid cartilage was approximated. Endolaryngeal stenting was planned but due to its nonavailablity, thyroid cartilage fragments were approximated with 3 - 0 nylon sutures and the wound closed. [Figure 2]. Surgery lasted for 3 hours. At the end muscle relaxation was reversed with atropine and neostigmine and the patient was able to breath spontaneously through the tracheostomy tube.
On the 6th postoperative day, the patient was again taken up for direct laryngoscopic assessment under general anaesthesia. Fair recovery was seen. An organised haematoma seen in the posterior commisure was drained. Lacerations were present in the right arytenoid and interarytenoid region with mild odema in right aryepiglottic fold. A Ryles tube (16) was passed through the left pyriform sinus into the oesophagus.
Decannulation of the tracheostomy was successfully done on the 15th postoperative day followed by strapping. 10 days later suturing of the tracheostomy stoma was done under local infiltration. Patient was allowed oral feeds. He was able to phonate beyond everyone's expectations and was discharged and followed in the clinic with good recovery.
| Discussion|| |
Experience in managing laryngeal trauma is limited even in many major trauma centres due to the rarity of injury.  Laryngeal injury is uncommon as anteriorly the inferior projection of the mandible affords significant protection and posteriorly the larynx is protected by the rigid cervical spine.
The mechanism of laryngeal injury can be blunt trauma, penetrating trauma, inhalational injury and injury caused by caustic ingestion.  In this case it was probably a combination of both blunt and penetrating injury caused by an impact on the leather strap and metallic clip of the helmet. In penetrating trauma the cervical wound itself is a major indicator of injury to underlying structures. On the other hand, blunt trauma of the neck is often associated with few physical findings even though serious injuries may be present.  Both thyroid and cricoid cartilages are composed of hyaline cartilage and are therefore prone to fracture. The distensiblity of the subglottic and supraglottic submucosa allows rapid accumulation of oedema fluid. Air may also cause epiglottic emphysema further contributing to airway compromise. These changes usually occur within 1 hour of the trauma. Airway obstruction caused by endolaryngeal swelling is unlikely to occur later than 6 hours after the injury unless the patient coughs, strains or speaks. 
Early recognition of these injuries is based on a high index of suspicion, careful attention to signs and symptoms, thorough physical examination and judicious use of anciliary procedures and radiological examination. Dysphonia ranging from mild hoarseness to aphonia, dyspnea and stridor are the common presenting symptoms of laryngeal injury. Other symptoms include haemoptysis, dysphagia, odynophagia, subcutaneous emphysema, loss of laryngeal protuberance and cervical pain and tenderness. Superficial signs usually do not reflect the severity of laryngeal injury; severe laryngeal damage being present despite minimal soft tissue injury to the anterior aspect of the neck. ,
Definitive diagnosis of suspected laryngeotracheal injury is made by radiological and endoscopic studies. Soft tissue anterioposterior and lateral neck X-rays are usually done to identify oedema, subcutaneous emphysema and bony injuries. CT scan neck may detect an unsuspected injury, confirm diagnosis of a laryngotracheal fracture and assess the severity of a fracture preoperatively. Whereas indirect laryngoscopy gives information of the endolarynx, it may not be feasible in an injured and agitated patient. Direct laryngoscopy using flexible fiberoptic bronchoscope may be considered in a stable patient. However care should be taken in a non intubated patient as the insignificant trauma associated with the insertion of the fiberoscope may precipitate an airway emergency.
In any patient with neck injury the first priority is to establish an airway.  Manipulation of the spine must be avoided until a cervical spine injury has been ruled out. Immediate tracheostomy rather than endotracheal intubation, should be performed in acutely asphyxiating patients. In addition to removing respiratory obstruction rapidly, tracheostomy reduces intrabronchial pressures and prevent the spread of emphysema into the subcutaneous tissue, mediastinum and pericardium. Any opioids or sedatives are contraindicated in patients with an obstructed airway as not only do they eliminate the hypoxic and hypercarbic respiratory drive, but they also depress the cough reflex and set the stage for aspiration.
Initial airway management in the presence of less severe respiratory compromise is somewhat controversial. Many authors advocate immediate tracheostomy without prior tracheal intubation. , They prefer this approach as it avoids acute complications induced by attempts at intubation, such as entry into false passage and damage to already injured laryngeal structures. Tracheostomy, if elected, should be performed at the lower cervical tracheal rings to prevent tension on and bacterial contamination of the injured region after repair. It should be performed without extending the neck and with spine protection measures if cervical spine injury has not been ruled out. Cricothyroidotomy can provide an adequate airway if injury is limited to larynx. However, it aggravates the mucosal, ligamentous and cartilagineous damage already caused by the original trauma. It may also be technically difficult. The most important disadvantage of cricothroidotomy, however, is the possibility of acute airway obstruction in cricotracheal separation injuries with entry of the cannula into a false passage. Even when the cricothyroidotomy tube remains within the airway, air may escape through a lacerated tracheal wall, preventing adequate ventilation. Thus this procedure is contraindicated when blunt laryngotracheal trauma is suspected. 
If the patient is breathing well and there is no respiratory compromise, observation may be all that is indicated - remembering that all injuries in this region carry a propensity for airway compromise. Injudicious maneuvers such as forceful neck examination, hypopharyngeal suctioning, changing the patient's position from sitting to supine, and nasogastric tube insertion should be avoided during the initial stages of trauma as they may precipitate airway obstruction.
In these patients intubation and anaesthesia are usually required for panendoscopy, which is perfomed under elective conditions within 24 hours after trauma. During this period these patients are treated conservatively using voice rest, bed rest with head end elevation, humidified oxygen, nebulized racemic epinephrine, corticosteroids and antibiotics.
If anaesthesia is required soon after the trauma in a patient without evidence of airway obstruction, either primary tracheostomy or endotracheal intubation may be chosen. Endotracheal intubation can further damage the larynx, may be exceedingly difficult, can interfere with subsequent examination and repair of the larynx and may convert an urgent procedure to an emergent one. If intubation is attempted, intraveneous anaesthetics and muscle relaxants should not be administered before the airway is secured. These agents may result in severe and uncontrollable airway obstruction. Induction of general anaesthesia with inhalational agents and maintenance of spontaneous respiration has been recommended but may be fraught with difficulties secondary to laryngeal spasm. Thus the most conservative and reliable method of securing an airway in a patient of laryngeal injury is local tracheostomy when the patient is awake. However, adequate topical anaesthesia of the upper airway is essential before any airway manipulation is attempted in an awake patient. Agitation, straining and coughing may result in increased intratracheal pressure, spread of subcutaneous emphysema and complete airway obstruction.
The type, extent and timing of definitive surgical treatment are based on panendoscopic findings and the patient's general condition. Definitive repair may be undertaken immediately after panendoscopy or later. However it is generally recommended that surgery should be performed on haemodynamically stable patients within 24 hours after injury.
An estimated early mortality rate is as high as 30% due to airway obstruction and associated injuries.  In patients who survive, residua include laryngotracheal fibrosis and contusions, breathing difficulties, dysphonia and recurrent pulmonary aspiration. Delay of immediate treatment beyond 24 hours appears to contribute to development of late complications.
The outcome depends on extent of laryngeal injury and quality of subsequent repairs, Co- ordination between departments of Anaesthesia and ENT and early quality care can contribute to a good outcome in patient's respiratory and phonatory ability.
| References|| |
|1.||Goldenberg D, Golz A, Flex Goldenberg R, Jaochism HZ. Severe laryngeal injury caused by blunt trauma of the neck. J Laryngol Otol 1997; 111(12): 1174-76. |
|2.||Ikram M, Naviwala S. Acute management of external laryngeal trauma: case report. Ear Nose Throat J 2000; 79(10): 802-04. |
|3.||Steven D.Shaeffer. Laryngeal and oesophageal trauma; Cummins text book of head and neck surgeries, vol 3, 5th ed: 2004; 2090-2107. |
|4.||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. |
|5.||Miles WK, Olson NR, Rodergue ZA. Acute treatment of experimental laryngeal fractures. Ann Otol 2001; 80: 710. |
|6.||Camnitz PS, Shepherd SM, Handerson RA. Acute blunt laryngeal and tracheal trauma. Am J Emerg Med 1987; 5: 157. |
|7.||Hermon A, Segal K, Har El G et al. Complete cricotracheal separation following blunt trauma of the neck. J Trauma 1987; 27: 1365-68. |
|8.||Mara W, Hebert AF. External laryngeal trauma. J La Stat Med Soc 2000; 152(5): 218-22. |
|9.||Mathisen DJ, Grillo H. Laryngotracheal truma. Am Thorac Surg 1987; 43: 254. |
|10.||Shaeffer SD, Close LG. Acute management of laryngeal trauma.Ann Otol Rhinol Laryngol 1989; 98: 98-101. |
|11.||Mace SE. Blunt laryngotracheal trauma. Ann Emerg Med 1986;15: 836. |
|12.||Bhojani RA, Rosen baun DH, Dikmen E. Contemporary assessment of laryngotracheal trauma. J Thorac Cardiovasc Surg 2005; 130(2): 426-32. |
[Figure 1], [Figure 2]