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TITLE: Ch?n th??ng thanh qu?nSOURCE: Grand Rounds Presentation, UTMB, Dept. of OtolaryngologyDATE: September 02, 2003RESIDENT PHYSICIAN: Michael Underbrink, MDFACULTY PHYSICIAN: Anna Pou, MDSERIES EDITORS: Francis B. Quinn, Jr., MD and Matthew W. Ryan, MDD?ch: BSNT ?INH T?T TH?NG"This material was prepared by resident physicians in partial fulfillment of educational requirements established for the Postgraduate Training Program of the UTMB Department of Otolaryngology/Head and Neck Surgery and was not intended for clinical use in its present form. It was prepared for the purpose of stimulating group discussion in a conference setting. No warranties, either express or implied, are made with respect to its accuracy, completeness, or timeliness. The material does not necessarily reflect the current or past opinions of members of the UTMB faculty and should not be used for purposes of diagnosis or treatment without consulting appropriate literature sources and informed professional opinion." ?Gi?i thi?uCh?n th??ng ngoài thanh qu?n là ch?n th??ng ít g?p có t? l? x?p x? 1/30,000 trong các tr??ng h?p c?p c?u. ??y có th? là ?i?u may m?n vì ch?n th??ng thanh qu?n có th? d?n t?i nh?ng v?n ?? nghiêm tr?ng v? h? h?p và ?nh h??ng ??n gi?ng nói n?u kh?ng ???c ch?n ?oán nhanh chóng. X? trí ban ??u v?i m?t ch?n th??ng thanh qu?n c?p là ??m b?o ???ng th?. Ch?c n?ng nói, có th? ???c ?u tiên quan tr?ng th? 2. Vì th?,thúc bách bác s? Tai M?i H?ng bi?t t?i ch?n ?oán và ?i?u tr? v?i nh?ng tr??ng h?p hi?m nh?ng là lo?i ch?n th??ng nghiêm tr?ng này. Gi?i ph?u và sinh l?May m?n là thanh qu?n ???c b?o v? t?t b?i x??ng hàm d??i, x??ng ?c và s? linh ho?t c?a c?. Ch?c n?ng ??u tiên c?a thanh qu?n là t?o nên m?t ???ng khí, b?o v? ???ng h? h?p d??i, và là c? quan phát ?m. Thanh qu?n có th? ???c chia thành 3 vùng: th??ng thanh m?n, thanh m?n và h? thanh m?n. ?N?ng ?? b?i x??ng móng, s?n giáp và s?n nh?n. Th??ng thanh m?n ít ???c n?ng ?? h?n tùy thu?c vào vi?c n?ng ?? bên ngoài và g?m nhi?u t? ch?c m? m?m và niêm m?c th?a Thanh m?n t?a ch?t vào s? n?ng ?? bên ngoài và s? ph?i h?p linh ho?t c?a s?n nh?n ph?u và ho?t ??ng th?n kinh c? ?? h? tr? h? h?p và t?o ?m. ? ng??i l?n, thanh m?n là ch? h?p nh?t c?a khí ??o. Vì th?, t?n th??ng ? v? trí này có th? làm ?nh h??ng h? h?p nghiêm tr?ng. H? thanh m?n ???c h? tr? b?i ch? b?i s?n nh?n, ch? mà ? s? sinh và tr? nh? khí ??o h?p nh?t. C? ch? ch?n th??ngLo?i ch?n th??ng có th? ???c chia thành v?t th??ng ??ng gi?p ho?c xuyên th?ng. V?t th??ng ??ng gi?p th??ng g?p h?n do tai n?n giao th?ng. H?p thanh qu?n b? d?n nén gi?a nh?ng nh?ng v?t bên ngoài (ví d?,tay lái ? t? ho?c t?m g??ng ch?n tr??c xe) và m?t tr??c c?a c?t s?ng c?. Cánh s?n giáp bè ra và v?i m?t l?c ?? m?nh, có th? v? s?n th??ng theo chi?u ??ng gi?a ho?c c?nh gi?a t? nhiên. Các lo?i khác c?a v?t th??ng ch?t nh? do ch?n th??ng th? thao,hành hung c??ng hi?p, ho?c v??ng d?y treo qu?n áo hay các nguyên nh?n v? tai n?n xe c?. L?c ch?n th??ng có theery làm th??ng t?n m? m? và/ho?c m?t liên t?c s?n v?i các d?u hi?u ch?n th??ng ? bên ngoài.V?t th??ng ch?t c?ng có th? g?y nên tr?t kh?p nh?n ph?u ho?c t?n th??ng d?y th?n kinh qu?t ng??c làm h?n ch? s? di ??ng c?a d?y thanh. V?t th??ng xuyên th?ng thanh qu?n có th? x?y ra th? phát do dao ??m ho?c ??n b?n. Ph?m vi t?n th??ng thay ??i theo lo?i v? khí tác ??ng, và quan tr?ng là phát hi?n các th??ng t?n ph?i h?p, ví d? nh? th?n kinh, m?ch máu, ho?c th?c qu?n, là nh?ng tình tr?ng th??ng g?p. ? ?ánh giá ban ??uX? trí ban ??u nên theo nguyên t?c ATLS. ??m b?o m?t ???ng th? ???c ?u tiên 1. Ch?n th??ng c?t s?ng c? nên ???c ngh? t?i cho t?i khi có b?ng ch?ng chính xác. Có m?t s? bàn lu?n v? vi?c x? trí ???ng th? ? nh?ng b?nh nh?n này, nh?ng h?u h?t các tác gi? khuy?n cáo m? khí qu?n d??i g?y tê t?i ch? ??i v?i nh?ng b?nh nh?n suy h? h?p.Vi?c c? g?ng ??t n?i khí qu?n qua ???ng m?i và qua ???ng mi?ng ? nh?ng b?nh nh?n này có th? d?n t?i nh?ng t?n th??ng n?ng h?n cho khí ??o v?n d? ?? nh?/y?u. Th? thu?t m? s?n nh?n giáp nên tránh trong quy trình x? trí ch?n th??ng thanh qu?n vì ?i?u này có th? làm t?n th??ng n?ng h?n.S? c?n nh?c c?n k? l??ng ? nh?ng b?nh nh?n nhi. Do kích th??c nh? h?n c?a khí ??o tr? nh? và nguy c? s?ng n? m? m?m kèm theo trong ch?n th??ng thanh qu?n, ng??i ta khuy?n cao r?ng c?n th?c hi?n m? khí qu?n nh? n?i soi khí qu?n ? phòng m?. ? nh?ng b?nh nh?n kh?ng có nh?ng r?i lo?n ???ng th? c?p, c?n ph?i th?m khám th?c th? và h?i ti?n s? b?nh nh?n c?n th?n. ? Các tri?u ch?ng c?a ch?n th??ng thanh qu?n có th? bao g?m thay ??i gi?ng, ?au, nu?t khó, nu?t ?au, ho ra máu và/ho?c stridor (ti?ng th? rít). Khi ng?a c? kh?ng ch?u ???c do các tri?u ch?ng c?a ch?n th??ng thanh qu?n liên quan v?i nh?ng ?nh h??ng khí ??o.? Schaefer báo cáo tri?u ch?ng t??ng quan v?i h?u h?t các th??ng t?n n?ng là suy h? h?p. Fuhrman, et al., báo cáo tri?u ch?ng xác th?c nh?t là khàn gi?ng. Các d?u hi?u kinh ?i?n c?a ch?n th??ng ngo?i thanh qu?n bao g?m khàn ti?ng,tràn khí và khái huy?t.Tri?u ch?ng xác th?c nh?t theo báo cáo Fuhrman là nh?y c?m ?au và tràn khí d??i da. Các d?u ch?ng th?c th? khác, nh? là c? tr??c th?m tím và l?ch khí qu?n. Các th??ng t?n ph?i h?p bao g?m c?t s?ng c?, th?c qu?n và th??ng t?n m?ch máu ph?i ???c ngh? t?i và ?ánh giá. ? nh?ng b?nh nh?n b?t ??ng, n?i soi m?m thanh qu?n ? phòng c?p c?u nên ???c ch? ??nh. CT scan, soi thanh qu?n tr?c ti?p, soi khí qu?n và th?c qu?n ???c s? d?ng ?? l??ng giá d?a trên nh?ng d?u hi?u trên n?i soi m?m ban ??u. Trong vi?c ph?n lo?i b?nh nh?n có ch?n th??ng thanh qu?n vi?c th?m khám n?i soi m?m và nh?ng hình ?nh trên CT ngày càng quan tr?ng h?n ?? h? tr? x? trí các th??ng t?n. M?t s? s? ?? ?i?u tr? ???c ??a ra chia thành 4 nhóm b?i Schaefer và Close và Fuhrman et al ?? chia thành 5 nhóm là nhóm tách r?i nh?n khí qu?n.Ph?n lo?i các t?n th??ng thanh qu?nNhóm I các t?n th??ng g?m có t? máu nh? ? n?i thanh qu?n, phù n? ho?c rách kh?ng tìm th?y ch? v?.Nhóm II là các t?n th??ng phù n?, t? máu,rách nh? niêm m?c mà kh?ng ?nh h??ng s?n và kh?ng th?y t?n th??ng v? trên CT scan. Kh?i phù n?, rách niêm m?c, ch? v? b? th? ch?, l? s?n và/ho?c c? ??nh d?y thanh b?t ???c x?p vào nhóm th? III. Nhóm IV t?n th??ng t??ng t? nh? nhóm II kèm theo hai ???ng v? ho?c nhi?u h?n, khung thanh qu?n kh?ng v?ng ho?c có bi?u hi?n ch?n th??ng mép tr??c. Nhóm V là s? tách r?i hoàn toàn thanh khí qu?n. Hình ?nh X quang? nh?ng b?nh nh?n b?t ??ng, sau khi x? trí ???ng th?, ch?p CT scan thanh qu?n có th? ???c ch? ??nh. CT kh?ng c?n thi?t ? b?nh nh?n kh?ng có các tri?u ch?ng ??a ??n ch? ??nh ph?u thu?t, ví d? nh? ?ang ch?y máu, khái huy?t, c?n thi?t cho x? trí c?p c?u ???ng th?, l? s?n và xé rách nhi?u trên n?i soi thanh qu?n, ho?c có phì phò qua mi?ng v?t th??ng. Ng??c l?i ? nh?ng b?nh nh?n có th??ng t?n t?i thi?u và th?m khám th?ng th??ng h?u nh? kh?ng có giá tr? b?ng phim CT scan vùng c?. ? nh?ng b?nh nh?n ch?n th??ng thanh qu?n n?ng và nh?ng th?m khám c?n l?m sàng thì CTscan ?óng vai trò khách quan và là n?n t?ng nên ???c ch? ??nh. ?i?u ?áng chú ? là m?t s? tác gi? ch? ??nh CT ngay ? nh?ng b?nh nh?n ch?n th??ng n?ng tr??c khi x? trí t?i phòng m? nh? là m?t “b?n ?? ch? ???ng (road map)” ??i v?i nh?ng b?nh nh?n b? ch?n th??ng. Toàn b? c?t s?ng c? nên ???c ?ánh giá qua ?i?n quang. Ch?p m?ch và th?c qu?n có thu?c có th? ???c ch? ??nh trong m?t s? tr??ng h?p ch?n l?c, ??c bi?t ? nh?ng vùng ch?n th??ng xuyên th?ng s?u. X? trí kh?ng ph?u thu?tCh?n th??ng thanh qu?n có th? ???c ?i?u tr? n?i khoa ho?c ngo?i khoa tùy thu?c vào n?i soi thanh qu?n ban ??u và nh?ng hình ?nh trên CT scan. B?nh nh?n có th? ???c ?i?u tr? n?i khoa và theo d?i sát n?u t?n th??ng se ???c gi?i quy?t mà kh?ng can thi?p ph?u thu?t và khí ??o ?n ??nh. Nhóm I có th? x? trí m?t cách an toàn v?i th?i gian theo d?i sát t?i thi?u là 24h, n?m ??u cao, nh?n nói và th? qua kh?ng khí ???c làm ?m, ?m. Kháng sinh ???c khuy?n cáo ??i v?i t?n th??ng niêm m?c thanh qu?n. ?i?u tr? thu?c ch?ng trào ng??c c?ng ???c ch? ??nh ban ??u. M?c dù kh?ng có b?ng ch?ng, s? d?ng corticoid toàn th?n th??ng ?em l?i hi?u qu? trong vi?c làm gi?m phù n? . ?n qua x?ng d? dày qua ???ng m?i nên ???c c?n nh?c n?u có rách niêm m?c nhi?u. Vi?c th?m khám ?n?i soi m?m theo trình t? nên ???c th?c hi?n ?? ?ánh giá ???ng th? và s? lành th??ng ?? xu?t vi?n.? ?i?u tr? ph?u thu?t?i?u tr? ph?u thu?t có thu?t có th? t? th?p ??n cao t? vi?c thi?t l?p ???ng th? t?i vi?c m? r?ng gi?i quy?t ch? v? c?a khung thanh qu?n. Các v?t th??ng xuyên th?ng c?n ???c m? ra ?? th?m dò h?n là v?t th??ng ch?t.? nh?ng b?nh nh?n nhóm II t?i nhóm V ?òi h?i m?t vài hình th?c can thi?p ph?u thu?t. Các l?a ch?n ph?u thu?t ???c chia thành 1 trong 3 lo?i sau: n?i soi ??n thu?n, n?i soi kèm theo m? th?m dò, và n?i soi m? th?m dò và ??t stent thanh qu?n.N?u có b?t c? nghi ng? v? s? lan r?ng c?a t?n th??ng n?i soi nên ???c th?c hi?n. Các ch? ??nh ?? ph?u thu?t th?m dò bao g?m: xé rách r?ng niêm m?c, l? s?n, nhi?u ch? v? và th? ch? s?n v?, b?t ??ng d?y thanh, v? s?n nh?n, tr?t kh?p nh?n ph?u, và xé rách c? b? t? do d?y thanh ho?c mép tr??c.????ng v? theo h??ng ??ng gi?a ho?c c?nh gi?a cánh s?n giáp có th? ?i vào trong khung thanh qu?n và th??ng ?òi h?i ORIF. M? khí qu?n nên ???c th?c hi?n ? nh?ng b?nh nh?n có t?n th??ng lan r?ng và ?nên ???c r?ch xu?ng th?p h?n bình th??ng (s?n 4,5) theo ???ng d?c( t?t h?n ? nh?ng tr??ng h?p có tách r?i thanh khí qu?n.Khi ch? ??nh m? thanh qu?n ki?m tra, c?n ph?i th?c hi?n trong vòng 24h c?a ch?n th??ng ?? ?em l?i k?t qu? t?i ?u cho ch?c n?ng th? và phát ?m. M?t ???ng r?ch da ngang ? m?c màng nh?n giáp và bóc tách v?t c? bám da c?. B?c l? các c? b?ng và khung thanh qu?n sau ?ó theo ???ng gi?a. Thanh qu?n có th? ???c ki?m tra qua vi?c m? s?n giáp ? ???ng gi?a ho?c theo ???ng v? th?ng ??ng phía trong 2-3mm c?a ???ng gi?a.Cánh s?n giáp ???c vén ra ngoài ?? th?y ???c n?i thanh qu?n. T?t c? các s?n ???c b?c l? và các m? d??i niêm m?c ???c che ph? sau ?ó b?ng niêm m?c t? sau ra tr??c.Kh?u kín ban ??u là lu?n lu?n có th? và m? ? d?n l?u t?i thi?u. ?óng v?t th??ng b?ng ch? tiêu v?i m?i kh?u bên ngoài lòng thanh qu?n ?? tránh s? lên m? h?t. S?n ph?u b? tr?t nên ???c n?n l?i.Mép tr??c nên ???c kh?u l?i b?ng ch? 4.0 ?? treo phía tr??c c?a d?y thanh th?t vào phía ngoài màng s?n giáp. M? s?n giáp có th? sau ?ó có th? ???c c? ??nh l?i b?ng ch? kh?ng tiêu, d?y thép ho?c n?p c?ng nh?.Các s?n v? ???c n?n l?i và có th? làm cho v?ng b?ng cách s? d?ng các v?t li?u khác nhau, nh? d?y thép, ch? kh?ng tiêu, và n?p nh?. N?u v? v?n, các m?nh nh? c?a s?n kh?ng còn màng s?n nguyên v?n ???c l?y b? ?? tránh viêm s?n. S? thích nghi v?i n?p nh? v? m?t l? thuy?t có ch? thu?n l?i trong vi?c c? ??nh tr?c ti?p thanh qu?n (ít c?n thi?t ??i v?i vi?c s? d?ng ?ng nong n?i thanh qu?n), kh? n?ng t?o c?u v?i nh?ng kho?ng h?ng l?n ( g?y v?n), và ph?c hình l?i khung thanh qu?n. ? S? d?ng nong n?i thanh qu?n ?? b?o t?n ??i v?i các t?n th??ng g?m rách mép tr??c, kh?i th??ng t?n niêm m?c và v? v?n thanh qu?n. Stent giúp tái l?p l?i hình thuy?n c?a mép tr??c, làm v?ng nh?ng v? v?n nghiêm tr?ng và tránh t?o m?ng và s?o h?p. Các d?ng stent khác nhau có th? ???c s? d?ng nh? ?ng n?i khí qu?n Portex ???c thu ng?n l?i, t?o thành m?t ?ng nong ?àn h?i, ho?c t?o m?t v?ng hình ngón tay l?p ??y b?i spongel. ?ng nong nên ??t t? ch? n?p ti?n ?ình t?i s?n khí qu?n th? nh?t và làm cho v?a v?i hình d?ng c?a n?i thanh qu?n.? ?ng nong nên ???c làm cho v?ng bên trong thanh qu?n và cho phép thanh qu?n di ??ng trong khi nu?t. M?i kh?u s?u b?ng ch? kh?ng tiêu ???c ??a qua stent và thanh qu?n ? thanh th?t và m?t ch? khác ? màng nh?n giáp và t?o m?t nút ra ngoài qua da. ?ng nong kh?ng nên ?? l?u quá 2-3 tu?n. L?y ?ng nên th?c hi?n d??i g?y mê toàn th?n v?i s? h? tr? c?a n?i soi và các ph?u thu?t them ?? l?y b? các m? h?t n?u th?y c?n thi?t. ? T?n th??ng ??n ??c tách r?i thanh khí qu?n th??ng d?n t?i ch?t ngay l?p t?c. Th?nh tho?ng khí ??o có th? ???c duy trì ???c ?n ??nh v?i tình tr?ng l?p niêm m?c còn nguyên v?n. M?c dù vi?c c? g?ng ??t n?i khí qu?n thành c?ng v?i n?i soi ph? qu?n ?? ???c báo cáo, cách x? trí an toàn và th??ng làm h?n v?n là khai khí qu?n. T?n th??ng d?y qu?t ng??c hai bên và s?o h?p h? thanh m?n th??ng g?p ? b?nh c?nh ch?n th??ng này.Ph?u thu?t s?a ch?a ?òi h?i nh?ng m?i kh?u c? ??nh ch?c gi?a s?n nh?n và vòng s?n khí qu?n th? hai ?? n?ng ?? cho khí ??o. ?i?u này có th? g?p khó kh?n n?u v? s?n nh?n ?i kèm sau khi c? ??nh phía trong ? Các th??ng t?n n?ng và r?ng ? m? m?m và làm m?t liên t?c ? th??ng thanh m?n ho?c n?a thanh qu?n có th? ???c x? trí b?ng các ph?u thu?t c?t n?a thanh qu?n ?? ph?c h?i ch?c n?ng. C?t thanh qu?n toàn ph?n là ph??ng án cu?i cùng và ???c ch? ??nh ??i v?i các tình hu?ng n?i mà nh?ng y?u t? c? b?n c?a khung thanh qu?n và m? m?m kh?ng còn giá tr? s? d?ng ?? ph?c h?i l?i. K?t qu?Ch?t l??ng cu?i cùng c?a ???ng th?, gi?ng nói và ch?c n?ng nu?t là nh?ng ?i?u quan tr?ng sau khi ph?u thu?t s?a ch?a ??i v?i ch?n th??ng ngo?i thanh qu?n. T?nh tr?ng khí ??o x?u n?u b?nh nh?n v?n duy trì vi?c th? qua canuyn, v?a n?u th? vào nh? ho?c kh?ng thích ?ng khi t?p th?, t?t n?u tình tr?ng h? h?p nh? tr??c khi b? ch?n th??ng. GI?ng nói có th? coi nh? là x?u n?u còn m?t ti?ng và ch? thì th?m, v?a n?u ch?c n?ng có thay ??i ( khàn gi?ng c?i thi?n), và t?t n?u bình th??ng. Ch?c n?ng nu?t m?t là bình th??ng ho?c kh?ng bình th??ng theo nh?n ??nh ch? quan c?a b?nh nh?n.Nói chung,x? trí ch?n th??ng m?t cách dè d?t t?t h?n là ph?u thu?t l?n do các t?n th??ng n?ng n? lúc ??u. Vi?c s? d?ng stent n?i thanh qu?n là khuynh h??ng làm c?i thi?n gi?ng mà kh?ng ?nh h??ng chung ??n tình tr?ng c?a khí ??o. Th?i gian l?y stent c?ng ít h?n, và k?t qu? c?ng kh? quan h?n. Li?t d?y thanh tác ??ng ??n c? hai ch?c n?ng th? và nói. Các k?t qu? c?i thi?n c?ng cho th?y s?m h?n ??i v?i th?i gian ???c s?a ch?a ( d??i 48h t? lúc b?t ??u b? t?n th??ng.)? K?t lu?nCh?n th??ng ngo?i thanh qu?n là m?t ch?n th??ng ít g?p trong khi c?n x? trí m?t cách h? th?ng. Vi?c nh?n ??nh s?m là quan tr?ng ??i v?i vi?c c?u s?ng b?nh nh?n c?ng nh? ??m b?o ???ng th? t?t và ch?c n?ng phát ?m. Các tri?u ch?ng chính là khàn ti?ng, tràn khí d??i da, và ?au v?i m?t ti?n s? ch?n th??ng nên ngh? t?i m?t s? l??ng giá ?úng lúc v? thanh qu?n và h? tr? ???ng th?. N?i soi m?m thanh qu?n theo sau b?i CTscan và ph?u thu?t cho th?y r?ng c?n thi?t nh? là m?t tiêu chu?n trong x? trí ban ??u. Các t?n th??ng ph?i h?p nh? c?t s?ng c?, m?ch máu và các t?n th??ng th?c qu?n nên ???c ki?m tra. ?I?u tr? có th? n?i khoa ho?c ngo?i khoa (có ho?c kh?ng ??t stent) d?a vào v? trí và ?? lan r?ng c?a t?n th??ng. Tài li?u tham kh?oO’Mara, W and Hebert, F.? External laryngeal trauma.? J La State Med Soc.? Vol 152(5): 218-222. May 2000.?Jewett, B.S., Shockley, W.W., Rutledge, R.? External laryngeal trauma analysis of 392 patients.? Arch Oto HNS.? Volume 125(8): 877-880.? August 1999.?Pou, A.M., Shoemaker, D.L., Carrau, R.L., Snyderman, C.H., Eibling, D.E.? Repair of laryngeal fractures using adaptation plates.? Head & Neck.? Vol. 20:? 707-713.? December 1998.?Offiah, C.J., Endres, D.? Isolated laryngotracheal separation following blunt trauma to the neck.? J Laryng Oto.? Vol. 111: 1079-1081.? November 1997.?Beasley, D.J. and Miller, R.H.? Acute laryngeal trauma.? J La State Med Soc.? Vol 148(4):143-145. April 1996.?Carrau, R.L. and Myers, E.? Contemporary management of laryngeal trauma.? University of Pittsburgh Medical Center: Trauma Rounds.? Vol. 5(3):1-5.? June 1994.?Yen, P.T., Lee, H.Y., Tsai, M.H., Chan, S.T., and Huang T.S.? Clinical analysis of external laryngeal trauma.? J Laryng Oto.? Vol. 108:221-225.? March 1994.?Bent, J.P. and Porubsky, E.S.? The management of blunt fractures of the thyroid cartilage.? Oto HNS.? Vol. 110:195-202. 1994.?Stack, B.C. and Ridley, M.B.? Arytenoid subluxation from blunt laryngeal trauma.? Amer J Otolaryng.? Vol 15(1): 68-73. Jan-Feb 1994.?Bent, J.P., Silver, J.R., and Porubsky, E.S.? Acute laryngeal trauma: a review of 77 patients.? Oto HNS.? Vol 109:441-449. 1993.?Schaefer, S.D.? Use of CT Scanning in the management of the acutely injured larynx.? Otolaryng Clinics NA.? Vol 24(1): 31-36. February 1991.?Schaefer, S.D.? The treatment of acute external laryngeal injuries.? Arch Otolaryng HNS.? Vol 117: 35-39. January 1991.?Fuhrman, G.M., Stieg, F.H., and Buerk, C.A.? Blunt laryngeal trauma:? Classification and management protocol.? J Trauma.? Vol 30(1): 87-92. January 1990.?Gussack, G.S., Jurkovich, G.J. and Luterman, A.? Laryngotracheal trauma: A protocol approach to a rare injury.? Laryngoscope.? Vol 96: 660-665. 1986.?Schaefer, S.D.? Primary management of laryngeal trauma.? Ann Oto Rhino Laryng. Vol 91:399-402. 1982.?Leopold, D.A.? Laryngeal Trauma.? Arch Otolaryng.? Vol 109: 106-111. February 1983.Laryngeal FracturesAuthor: Samir S Pancholi, DO, Consulting Surgeon, Cosmetic Surgery of Las Vegas; Adjunct Assistant Professor of Cosmetic Surgery, Touro University; Assistant Professor of Otolaryngology-Facial Plastic Surgery, Michigan State UniversityCoauthor(s): Wayne K Robbins, DO, FAOCO, Program Director, Department of Otolaryngology-Facial Plastic Surgery, Genesys Regional Medical Center, Michigan State University; Alpesh Desai, DO, Assistant Professor, Department of Dermatology, Western University of Health Sciences; Tejas Desai, DO, Staff Physician, Department of Dermatology, Western University of Health SciencesContributor Information and DisclosuresUpdated: Jan 9, 2009Print ThisEmail ThisOverviewWorkupTreatmentFollow-upMultimediaReferencesKeywordsIntroductionA laryngeal fracture can occur following direct trauma to the neck region and may lead to life-threatening airway obstruction. For this reason, a patient suspected of having a fractured larynx should be treated in an emergent manner.ProblemA traumatically injured patient may present with many distracting injuries. Appropriate treatment of this patient requires that airway patency be the first priority. Injury to the larynx may range from simple mucosal tears to fractured and comminuted cartilage. Any combination of injuries along this continuum can result in a precipitous airway emergency.Although advancements in imaging techniques have improved their diagnosis, the rarity of laryngeal fractures and the limited experience of otolaryngologists have made this a challenging entity to manage. An organized approach to laryngeal fractures can prevent misdiagnosis and inadequate management.FrequencyA laryngeal fracture is a rare condition, occurring in approximately 1 per 137,000 inpatient visits,1 1 patient per 14,000-42,000 emergency department visits,2 and less than 1% of all blunt traumas.3 The rarity of this condition is likely due to the protected location of the larynx, with the rigid cervical spine posterior and the mandible hanging in a superior and anterior position. This protection is amplified in the pediatric population, secondary to the high position of the larynx and its elastic nature. In addition, the decrease in traumatic motor vehicle injuries because of increased seatbelt and supplemental restraint system use contributes to the rarity of laryngeal trauma. Less than 50% of all laryngeal traumas are thought to result in cricoid injury.4 Females tend to have slimmer, longer necks, predisposing them to a higher susceptibility to laryngeal injury, in particular supraglottic injury. Overall, males (77% vs 33%) tend to present with the highest percentage of traumatic laryngeal injuries,1 likely secondary to greater participation in violent sports and other activities such as fighting.5 A predisposition to comminuted fractures in older persons is attributed to calcification.The most common associated injuries with laryngeal fractures are intracranial injuries (13%), open neck injuries (9%), cervical spine fractures (8%), and esophageal injuries (3%).1 EtiologyLaryngeal fractures can be categorized as either penetrating or blunt injuries, which can be further categorized as either high or low velocity.6 Most commonly, trauma to the larynx occurs as a result of a motor vehicle accident (MVA) or clothesline injury. A small percentage of causes include direct blows sustained during assaults, sport injuries, hanging, manual strangulation, and iatrogenic causes.PathophysiologyThe mechanism of injury reflects the causative agent. Inherent in any injury resulting in a laryngeal fracture is the possibility of skeletal disruption, specifically, cricothyroid and cricoarytenoid dislocations.Laryngeal fractures from MVAs may occur in an unrestrained passenger when the extended neck impacts the steering wheel or dashboard during rapid deceleration. The anterior force compresses the larynx against the cervical vertebrae, resulting in injury.Clothesline injuries occur when an individual in motion strikes a stationary object. The result is a crush injury to the larynx against the cervical spine.Manual strangulation is a low-velocity, high-amplitude injury that commonly results in multiple fractures without significant displacement of cartilage, early presentation of hematoma, or endolaryngeal mucosal mon to all traumatic mechanisms is the direct transfer of severe forces to the larynx. These forces have the potential to produce many devastating injuries, including mucosal tears, dislocations, and fractures. Edema, hematoma, cartilage necrosis, voice alteration, cord paralysis, aspiration, and airway loss may accompany these injuries.Laryngeal injuries vary by anatomical location.Supraglottis: Traumatic forces commonly produce horizontal fractures of the thyroid alae and disruption of the hyoepiglottic ligament with subsequent superior and posterior displacement of the epiglottis. Repositioning of the epiglottis may result in the creation of a false lumen anterior to the epiglottis. This lumen may tunnel into the larynx or pass anterior to the thyroid cartilage and cause cervical emphysema.Glottis: Traumatic force results in cruciate fractures of the thyroid cartilage near the attachment of the true vocal cords.Subglottis: Crushing forces to the cricoid cartilage cause injury to the cricothyroid joint and may result in bilateral vocal cord paralysis from recurrent laryngeal nerve damage.Hyoid bone: Found more commonly in women, hyoid fractures tend to occur in the central part of the hyoid bone because of the inherent strength of the cornua.Cricoarytenoid joint: Traumatic forces that displace the thyroid alae medially or cause compression of the larynx against the cervical vertebrae often result in cricoarytenoid dislocation. This injury generally occurs unilaterally.Cricothyroid joint: Injury occurs when traumatic forces to the anterior portion of the neck cause the inferior cornu of the thyroid cartilage to be displaced posterior to the cricoid cartilage. This dislocation limits cricothyroid muscle function and therefore pitch control. Injury to the recurrent laryngeal nerve may also contribute to vocal cord paralysis.PresentationSuspect upper-airway injury in any patient who has signs of cervical trauma. Common presenting symptoms in patients with laryngeal trauma include hoarseness, neck pain, dyspnea, dysphonia, aphonia, dysphasia, odynophonia, and odynophagia; however, no single symptom correlates well with the severity of laryngeal injury.A thorough physical examination is vital to the appropriate management of laryngeal injury. Before progressing to other areas of physical examination, the cervical spine must first be cleared of injury. Common signs of laryngeal injury include stridor, subcutaneous emphysema, hemoptysis, hematoma, ecchymosis, laryngeal tenderness, vocal cord immobility, loss of anatomical landmarks, and bony crepitus. Suspect an acute fracture if tenderness is present upon palpation of the larynx. Assess for supraglottic airway obstruction if inspiratory stridor is present and lower airway injury if expiratory stridor is evident. Further examination of the glottis is necessary if a combination of inspiratory and expiratory stridor is present.IndicationsAfter completing a thorough clinical examination and review of radiologic studies, laryngeal damage can be staged as described below. This classification system can then be used to direct management of the patient and to predict morbidity and mortality.Management of Laryngeal TraumaOpen table in new window[ CLOSE WINDOW ]Table GroupSymptomsSignsManagementGroup 1Minor airway symptomsMinor hematomasSmall LacerationsNo detectable fracturesObservationHumidified airHead of bed elevationGroup 2Airway compromiseEdema/hematomaMinor mucosal disruptionNo cartilage exposureTracheostomy Direct laryngoscopyEsophagoscopyGroup 3Airway compromiseMassive edemaMucosal tearsExposed cartilageVocal cord immobilityTracheostomyDirect laryngoscopyEsophagoscopyExploration/repairNo stent necessaryGroup 4Airway compromiseMassive edemaMucosal tearsExposed cartilageVocal cord immobilityTracheostomyDirect laryngoscopyEsophagoscopyExploration/repairStent requiredGroupSymptomsSignsManagementGroup 1Minor airway symptomsMinor hematomasSmall LacerationsNo detectable fracturesObservationHumidified airHead of bed elevationGroup 2Airway compromiseEdema/hematomaMinor mucosal disruptionNo cartilage exposureTracheostomy Direct laryngoscopyEsophagoscopyGroup 3Airway compromiseMassive edemaMucosal tearsExposed cartilageVocal cord immobilityTracheostomyDirect laryngoscopyEsophagoscopyExploration/repairNo stent necessaryGroup 4Airway compromiseMassive edemaMucosal tearsExposed cartilageVocal cord immobilityTracheostomyDirect laryngoscopyEsophagoscopyExploration/repairStent requiredRelevant AnatomyCollectively, the hyoid bone, the thyroid and cricoid cartilages, and the cricothyroid and thyrohyoid membranes form the laryngeal architecture. The arytenoid, corniculate, and cuneiform cartilages also contribute to the laryngeal structure. Membranes, ligaments, and muscles connect the entire framework (see Images 4-5).Posterior view of the laryngeal cartilages and ligaments. Posterior view of the laryngeal cartilages and ligaments.Sagittal view of the laryngeal cartilages and ligaments.[ CLOSE WINDOW ]Sagittal view of the laryngeal cartilages and ligaments.The thyroid cartilage is the largest cartilage of the larynx. The shieldlike shape of this cartilage provides protection to the internal components of the larynx. Its 2 quadrilateral plates (right and left lamina) meet to form the laryngeal prominence (Adam's apple). The superior portion of this protuberance forms the superior thyroid notch. Inferiorly, the laryngeal prominence forms the inferior thyroid notch.Superior and inferior cornua project from the posterior margin of each side. The lower cornu articulates with the lateral edges of the cricoid cartilage and forms the cricothyroid joint. The thyrohyoid ligament connects the upper thyroid cornu to the greater cornu of the hyoid bone. The thyrohyoid membrane extends between the hyoid bone and the upper surface of the thyroid cartilage. The cricothyroid membrane extends between the thyroid and cricoid cartilages. The oblique line, the attachment site for the sternothyroid, thyrohyoid, and inferior pharyngeal constrictor muscles, is located on the outer surface of the thyroid cartilage.Like the thyroid cartilage, the cricoid cartilage also protects the internal laryngeal structures. The cricoid cartilage is the only true supporting structure of the laryngeal skeleton and is shaped like a signet ring. Anteriorly, this cartilage forms a relatively narrow band, while posteriorly it forms a larger lamina that is approximately 2-3 cm high. The cricothyroid articulation occurs at each junction of the lamina and arch. The inferior horn of the thyroid cartilage articulates with each side of the cricoid cartilage.The hyoid bone provides additional support to the larynx. The membrane attached to the hyoid bone elevates the larynx to prevent aspiration. The anterior body and the 2 greater cornua are directed posteriorly, and the 2 lesser cornua project superiorly.The epiglottis is a flexible, leaflike, elastic, cartilaginous structure that tapers inferiorly to become a stalklike extension called the petiole. The petiole is the attachment site for the thyroepiglottic ligament, which connects the epiglottis to the laryngeal prominence. The superior part of the epiglottis is located posterior to the tongue and anterior to the laryngeal aditus and is not protected by the thyroid cartilage. Laterally, the aryepiglottic folds attach the epiglottis to the arytenoid cartilage. The hyoepiglottic and thyroepiglottic ligaments help stabilize the epiglottic cartilage.The paired arytenoid cartilages are located on the superior-posterior border of the cricoid cartilage lamina. The triangular base of each arytenoid cartilage has 3 surfaces (posterior, anterolateral, medial) for the attachment of muscles and ligaments. The transverse arytenoid muscle attaches to the posterior surface. The vestibular ligament and the thyroarytenoid and vocalis muscles attach to the anterolateral surface. The medial surface contains laryngeal mucous glands. The base of each arytenoid also has a posterolateral muscular process (to which the posterior and lateral cricoarytenoid muscles attach) and an anterior caudal vocal process (to which the vocal ligaments attach). A cricoarytenoid joint is situated at the base of each arytenoid cartilage.The corniculate cartilages (of Santorini) are located superior to the arytenoid cartilages. The cuneiform cartilages (of Wrisberg) are located lateral and superior to the corniculate cartilages. The triticeous cartilage is located in the thyrohyoid ligament.The quadrangular membrane is elastic tissue that forms the intrinsic ligaments of the larynx—one of which is the vocal ligament. The quadrangular membrane attaches posteriorly to the upper arytenoid and corniculate cartilages. It then travels across the upper larynx to the lateral margin of the epiglottis. The lower margin of this membrane is the ventricular ligament, and the superior margin supports the aryepiglottic fold.The conus elasticus (cricothyroid membrane) bridges the space between the cricoid and thyroid cartilages. Posteriorly, the conus elasticus attaches to the arytenoid cartilage and vocal process on each side. The vocal processes project outward to form the vocal ligaments, which join anteriorly to form the anterior commissure. The ventricular ligaments attach to the superior part of the arytenoid cartilage and then across the larynx to attach to the thyroid cartilage just superior to the vocal ligaments. The ventricular ligament forms the lower free margin of the quadrangular membrane and also forms part of the plica ventricularis.The boundaries of the laryngeal aditus include the epiglottis anteriorly, the corniculate cartilages posteriorly, and the aryepiglottic folds laterally. The inferior border of the larynx is the cricoid cartilage. The larynx is divided into the supraglottis (vestibule), glottis (ventricle), and subglottis regions.The supraglottis extends from the laryngeal inlet to the vestibular folds. The vestibular folds (ie, false vocal cords, superior vocal cords) are attached anterior to the thyroid cartilage just inferior to the attachment site for the epiglottis. Posteriorly, the folds attach to the arytenoid cartilages. The ventricle of the larynx (ventricle of Morgagni) is the space between the vestibular and true vocal folds. The anterior segment of this ventricle extends into a diverticulum known as the laryngeal saccule or appendix of the laryngeal ventricle. The true vocal cords are located inferior to the ventricle.The area between the true vocal cords is known as the glottis. The glottis is considered to be the narrowest portion of the larynx. The glottic slit (rima glottidis) is the slit that separates the true vocal cords from the arytenoid cartilages. The subglottic area extends from the glottis to the cricoid cartilage. The conus elasticus forms the lateral boundary of the subglottis.The true vocal cord consists mainly of the thyroarytenoid muscle. The thyroarytenoid muscles connect the arytenoid cartilage to the inner aspect of the thyroid cartilage. The medial and lateral bellies of each muscle parallel each other. The medial belly is called the vocalis muscle, and the lateral belly extends superiorly and inserts in the thyroid cartilage.The cricoarytenoid muscles are important for proper laryngeal function. The lateral cricoarytenoid muscle stretches from the muscular process of the arytenoid to the upper lateral cricoid cartilage. The posterior cricoarytenoid muscle stretches from the muscular process of the arytenoid to the posterior portion of the cricoid. This muscle is the only muscle that can abduct the vocal cords. The interarytenoid muscles attach one arytenoid to the other. The lateral cricoarytenoid and the interarytenoid muscles mediate adduction of the vocal cords. The interarytenoid muscles are the only laryngeal muscles to have bilateral innervation from the recurrent laryngeal nerves. Recurrent laryngeal nerves innervate all of the other intrinsic muscles. The cricothyroid muscle is the only extrinsic laryngeal muscle innervated by the external branch of the superior laryngeal nerve (a branch of cranial nerve X). This muscle originates from the lower thyroid cartilage and attaches to the cricoid cartilage.Innervation and blood supplyThe vagus nerve provides the primary sensory innervation to the larynx. The internal laryngeal branch of the superior laryngeal nerve (of the vagus nerve) provides sensory innervation above the vocal cords, including the taste buds. The recurrent laryngeal nerve provides sensory innervation below the vocal cords. All of the intrinsic laryngeal muscles are innervated by the recurrent laryngeal nerve, and the extrinsic muscles (cricothyroideus) are innervated by the external branch of the superior laryngeal nerve.The blood supply to the larynx parallels the nerves and consists primarily of the superior laryngeal artery (branch of the superior thyroid artery) and the inferior laryngeal branch of the inferior thyroid artery. The cricothyroid branch of the superior thyroid artery also supplies the larynx. The inferior laryngeal artery, a branch of the inferior thyroid artery, accompanies the recurrent laryngeal nerve to the larynx. The superior and inferior laryngeal veins supply venous drainage from the larynx. These veins are branches of the superior and inferior thyroid veins, respectively.More on Laryngeal FracturesLaryngeal Fractures: WorkupAuthor: Samir S Pancholi, DO, Consulting Surgeon, Cosmetic Surgery of Las Vegas; Adjunct Assistant Professor of Cosmetic Surgery, Touro University; Assistant Professor of Otolaryngology-Facial Plastic Surgery, Michigan State UniversityCoauthor(s): Wayne K Robbins, DO, FAOCO, Program Director, Department of Otolaryngology-Facial Plastic Surgery, Genesys Regional Medical Center, Michigan State University; Alpesh Desai, DO, Assistant Professor, Department of Dermatology, Western University of Health Sciences; Tejas Desai, DO, Staff Physician, Department of Dermatology, Western University of Health SciencesContributor Information and DisclosuresUpdated: Jan 9, 2009Print ThisEmail ThisOverviewWorkupTreatmentFollow-upMultimediaReferencesKeywordsWorkupLaboratory StudiesGeneral trauma (Advanced Trauma Life Support [ATLS]) protocol is indicated for any individual who is severely injured. The airway must be secured, and other organ systems (eg, cardiac, pulmonology, vascular) must also be stabilized. Before any diagnostic study can be performed, life-threatening injuries, such as vascular injuries or internal bleeding, must be corrected.Generally, in the setting of a laryngeal fracture, chest and cervical spine radiographs are obtained to exclude associated cervical injuries. Other nonroutine studies that may be helpful are cervical arteriography and water-soluble contrast studies of the esophagus and pharynx.Laryngeal fractures are usually suspected based on symptoms and physical findings, but direct visualization of the larynx is critical to define the extent and location of injury. Endoscopy is the mainstay for direct visualization of the larynx and its surrounding structures. Abnormalities such as edema, hematomas, tears, exposed cartilage, vocal cord avulsion, vocal cord paralysis, and arytenoid dislocation can be assessed via endoscopy. Transnasal fiberoptic laryngoscopy is the procedure of choice in this setting because this procedure can assess the airway in the dynamic state and identify any abnormalities. Indirect laryngoscopy is usually avoided because of the gagging and coughing it elicits in a patient with an already compromised airway.When the cause of laryngeal injury is not readily apparent, histological studies can help to determine the cause of injury and detect other macroscopic overlooked injuries.7 Imaging StudiesCT scanning is the imaging modality of choice to assess laryngeal anatomy.8,9 A clear understanding of the Schaefer classification of laryngeal injuries is required to prevent morbidity and mortality. This classification system is based on a combination of the CT and endoscopic findings, which dictate treatment modalities.CT scanning can help detect laryngeal fractures in a patient with no clinical signs or symptoms. In patients with minor injuries and minimal symptoms (eg, edema, ecchymosis, small hematomas), a CT scan is unlikely to provide new information that would alter treatment. Similarly, a patient with airway compromise and clinically obvious fractures requires aggressive surgical treatment regardless of CT findings.Used judiciously, information gained from a CT scan will guide proper management of the patient's condition and prevent unnecessary surgical exploration; thus, the CT scan is a cost-effective means of assessing laryngeal anatomy.8 CT devices capable of spiral technique and subsecond scan times, specifically those that can reconstruct 2-dimensional axial sections, 2-dimensional coronal and sagittal images, and 3-dimensional images, can provide optimal imaging results.10 Interest in the use of 3-dimensional CT images is currently growing. This innovative and highly useful tool can provide useful information when attempting to diagnose a laryngeal fracture. Because of the complexity of laryngeal anatomy, 3-dimensional CT imaging is especially useful when conventional CT, MRI, and fibroscopy are unable to reveal laryngeal trauma.11 MRI has not gained acceptance as an evaluative tool for laryngeal fractures or trauma because of the length of time required to complete the scan and the increased physical demands placed on the patient (eg, holding breath for a long period).12 In addition, MRI is not helpful for imaging skeletal structures.Diagnostic ProceduresThe procedures below are used to evaluate patients with suspected laryngeal trauma.Fiberoptic nasopharyngoscopy: This procedure is performed in a conscious patient, with topical anesthesia. The goal of the procedure is to evaluate vocal cord function and to perform a preliminary assessment of the extent of trauma.Direct laryngoscopy: This procedure provides a detailed visual examination of the larynx. Instrumentation such as the Dedo or Pilling laryngoscope provides excellent visualization; however, complete examination of the anterior commissure may require special instrumentation.Bronchoscopy: This procedure may be performed with either a flexible or rigid bronchoscope, depending on the experience of the operator. Examination allows observation of the subglottic larynx and supporting structures.Esophagoscopy: This procedure allows visualization of the esophageal mucosa for traumatic lacerations. It may be performed with either a flexible or rigid esophagoscope, depending on the experience of the operator. Traumatic injury is common in the retrolaryngeal esophagus; therefore, close evaluation is required.Laryngeal Fractures: TreatmentAuthor: Samir S Pancholi, DO, Consulting Surgeon, Cosmetic Surgery of Las Vegas; Adjunct Assistant Professor of Cosmetic Surgery, Touro University; Assistant Professor of Otolaryngology-Facial Plastic Surgery, Michigan State UniversityCoauthor(s): Wayne K Robbins, DO, FAOCO, Program Director, Department of Otolaryngology-Facial Plastic Surgery, Genesys Regional Medical Center, Michigan State University; Alpesh Desai, DO, Assistant Professor, Department of Dermatology, Western University of Health Sciences; Tejas Desai, DO, Staff Physician, Department of Dermatology, Western University of Health SciencesContributor Information and DisclosuresUpdated: Jan 9, 2009Print ThisEmail ThisOverviewWorkupTreatmentFollow-upMultimediaReferencesKeywordsTreatmentMedical TherapyPrimarily, symptoms, direct nasopharyngoscopy, and CT scanning determine the need for treatment of laryngeal fractures. For minor injuries in which edema, hematoma, or certain small, insignificant mucosal tears are identified without evidence of other injury, medical treatment is appropriate. Mucosal tears of less than 2 cm have been treated effectively without surgical intervention.13 The goal of medical treatment is to return the patient to preinjury laryngeal function, which includes ventilation, phonation, and protection of the lower airway. Typically, in such minor injuries, tracheotomy is not required; however, close clinical observation is essential in the first 24-48 hours after injury.Bed rest is recommended for patients treated medically for laryngeal trauma, with the head of the bed elevated 30-45°. Voice rest is recommended to minimize edema, hematoma formation, and subcutaneous emphysema. Humidified air reduces crust formation and transient ciliary dysfunction. Supplemental oxygen is usually not needed and may be harmful in some patients (eg, patients with chronic obstructive pulmonary disease). Arterial blood gas (ABG) testing can be used to determine the need for supplemental oxygen.Initially, a nothing by mouth (NPO) status is recommended for patients with laryngeal fractures and mucosal tears, followed by a clear liquid diet.13 Diet regimens should mirror the severity of injury. Those patients without visible mucosal lacerations or fractures can initiate a clear liquid diet earlier than those patients with more severe injuries. Patients with severe injuries may require total parenteral nutrition supplementation during their NPO period. Avoid the use of nasogastric tubes for suctioning or feeding because of the potential for worsening laryngeal injury that results from local trauma during tube placement.The benefit of using systemic corticosteroids is controversial. Many otolaryngologists believe that corticosteroids are necessary to retard inflammation, swelling, and fibrosis and to help prevent granulation tissue formation. Systemic corticosteroids are helpful only in the first few days after the injury.The use of antibiotics is not necessary in the treatment of minor laryngeal trauma in which cartilaginous fractures and mucosal tears are not identified. However, when tears are visualized or with compound fractures of the larynx, systemic antibiotics should be used to reduce the high risk of local infection and perichondritis, which may delay healing and promote airway stenosis.The use of antireflux medications, such as H2-receptor antagonists and proton pump inhibitors, can help to reduce granulation tissue formation and tracheal stenosis. Use these medications throughout the emergent and convalescent phases of medical treatment for laryngeal fractures.Surgical TherapyThe surgical management of an unstable patient can be guided by the flow diagram depicted in Image 6.Management protocol for laryngeal trauma.[ CLOSE WINDOW ]Management protocol for laryngeal trauma.The information gained from the history, physical examination, endoscopic procedures, and imaging studies serves as an important tool when planning a neck exploration. If the airway is compromised, a tracheotomy should be performed, preferably with the patient awake under local anesthesia with mild sedation. Usually, a tracheal incision is made at a position lower than that for standard tracheotomy. An incision below the third or fourth ring is preferred when managing the airway that has laryngeal trauma. This position helps to avoid further injury to the larynx and its supporting structures.Surgical exploration begins with a horizontal skin incision in a skin crease at the level of the cricothyroid membrane. A subplatysmal apron flap is then elevated superior to the hyoid bone and inferior to expose the cricoid cartilage. Extension of the incision site facilitates examination of neural, vascular, and visceral injuries. The strap muscles are separated in the midline and are retracted laterally so that the laryngeal skeleton can be assessed adequately. At this point, identify and remove fractured pieces of the laryngeal cartilage.Depending on the injury, the larynx is entered through the thyrohyoid membrane, a midline thyrotomy, or the thyroid cartilage within 2-3 mm of the thyroid notch. If a thyrotomy is needed, a midline, vertical perichondrial incision is made in the thyroid cartilage. A subchondral dissection follows bilaterally. An oscillating saw or a number 15 blade can be used to cut through the thyroid cartilage, with care to avoid trauma to the endolaryngeal mucosa.After the thyroid cartilage is divided, the endolaryngeal mucosa is sharply divided. The endolarynx is examined in its entirety to identify the full extent of injury. The arytenoids are palpated to evaluate their mobility and position. Vocal cords are repaired using 5-0 or 6-0 absorbable sutures. Suturing the anterior surface of each damaged cord to the external perichondrium with 4-0 absorbable sutures resuspends the vocal cord. Reconstituting the anterior commissure is critical to preserving voice quality.Great care should be taken to identify and repair all mucosal lacerations with fine absorbable sutures (ie, 5-0, 6-0). Primarily close exposed cartilage with meticulous technique to minimize fibrosis and prevent formation of granulation tissue. Exposed cartilage that cannot be closed primarily may need skin or mucous membrane grafts. In the few circumstances in which a graft is required, mucous membrane, dermis, or split-thickness grafts are suitable.14 Laryngeal cartilage fractures must be reduced and immobilized. Small, isolated cartilage fractures that have no perichondrium are débrided to prevent chondritis and vocal cord dysfunction.Traditionally, wire sutures have been used to immobilize reduced laryngeal cartilage fractures (see Image 7). Recently, however, many surgeons have begun to use metal alloy plates (miniplates) for repairing laryngeal fractures. Miniplates have been shown to effectively stabilize the laryngeal architecture (see Image 9) and reshape the larynx back to its preinjury state. They also decrease the length of hospitalization, insignificantly alter operating time, and usually add no additional discomfort to the patient.15,16 More recently, the use of absorbable miniplates has been introduced. These plates have been found to be just as safe, effective, and manageable as their alloy counterparts. They also have the advantages of improved cosmesis after resorption, less bone growth restriction, less issue with plate migration, less bony resorption, and negligible image artifact.17 Most plates are composed of polylactic acid copolymer material and used for open reduction and stabilization of displaced fractures. Sasaki et al evaluated the efficacy of both MacroPore and Leibinger restorable reconstruction plates in 3 adult male patients and found both plates to be equally easy to use. In addition, adequate skeletal stabilization was achieved, which allowed for early phonation and respiratory function without long-term stenting.18 In Brazil, de Mello-Filho et al performed a retrospective study on the efficacy of adaptation plate fixation (APF) to repair the larynx. This group had no complications with the use of APF, and 19 out of 20 patients recovered their voices.19 Regardless of the method, the goal of surgical intervention is to restore the 3 primary functions of the larynx: breathing, phonating, and swallowing.Using permanent sutures or wires, the thyrotomy is then closed, and the strap muscles are reapproximated. The nasogastric tube is then placed using direct visualization.Preoperative DetailsProper patient positioning is essential when planning a neck exploration and may require hyperextension of the patient's neck after first clearing the cervical spine. The neck and tracheotomy site is prepared and draped in sterile fashion. The midcervical transverse thyrotomy incision is marked and injected with local anesthetic.Intraoperative DetailsPerhaps the most important portion of the surgery is injury assessment. Failure to adequately assess for potential injuries can result in disastrous consequences. Important structures, such as the larynx, cricoid, both recurrent laryngeal nerves, and the esophagus, must be identified and evaluated. Repair esophageal injuries before manipulating the trachea.When performing the thyrotomy, use electrocautery to make the transverse incision in the cricothyroid membrane. When using the saw or a number 15 blade, exercise extreme caution to avoid entering the lumen. Placing the patient in the Trendelenburg position can sometimes provide better visualization of the subglottic region.If required, resuspension of the vocal cords must be the last step before closure of the thyrotomy. Prior to this step, all other structures must be stabilized.Postoperative DetailsIf a tracheotomy is performed, the tube is left in place for a minimum of 5 days.Decannulation depends on several factors and should be performed on a case-by-case basis.Prophylactic antibiotics are used for at least 5 days. If a stent is used, antibiotics are continued until stent removal (usually 2-3 wk).Tube feedings are continued for at least 5-10 days.Follow-upFacial plastic and reconstructive surgery may be necessary in the future. Other procedures, such as destruction of granulation tissue, stenosis, and webs, may also be required. Patients are monitored closely for the first 6-12 months after the initial plicationsComplications include the following:AcuteAirway obstructionAphoniaDysphoniaOdynophagiaDysphagiaPostoperative complications (eg, hematoma, infection)ChronicVoice compromise (21-25%)20,21 Chronic obstruction (15-17%)20,21 Vocal cord injuries (eg, paralysis, fixation)Fistula (tracheoesophageal, esophageal, or pharyngocutaneous)Cosmetic deformityChronic aspirationInability to decannulateInjury to the recurrent laryngeal nerve is a dreaded complication of surgery and may cause vocal fold impairment. Unilateral injuries result in a weak voice, and bilateral injuries can cause respiratory compromise. Unless the recurrent laryngeal nerve is severed during surgery, no intervention is needed. However, if no improvement is noted after 6-12 months, a thyroplasty-type vocal cord medialization procedure can be performed to strengthen the voice. The vocal cord can be injected with Gelfoam if aspiration or dysphonia is present and severe.14 This procedure is only a temporary solution.Cricoarytenoid joint fixation?must be excluded before initiating any of these procedures.22 To accomplish this goal, assess vocal cord mobility using direct laryngoscopy, and assess arytenoid mobility using direct palpation. If an adequate airway and voice are present, no treatment is needed. Bilateral arytenoid fixation or recurrent laryngeal paralysis with an unstable airway is treated with arytenoidectomy, cordotomy, or vocal cord lateralization.The most common problem in the immediate postoperative period is the development of granulation tissue and ulceration from exposed cartilage. Granulation tissue may be decreased with the use of antibiotics and stents if the stents are removed in a timely fashion. The main concern with granulation tissue formation is the potential for the development of fibrosis and eventually stenosis. Many techniques have been used to slow the formation of granulation tissue, including systemic and intralesional administration of corticosteroids, long-term splinting, and low-dose radiation. These techniques have resulted in little success.14 Debulking granulation tissue through endoscopy is probably the most effective alternative treatment currently available.Subglottic stenosis is a difficult complication to treat effectively. Incomplete ring and weblike subglottic stenosis can be treated with laser excision or incision and dilation.23 More significant stenosis may require anterior or posterior cricoid splits with cartilage grafting. Direct laryngoscopy and bronchoscopy should be performed during the follow-up period to examine the extent of stenosis.Laryngeal trauma complications can manifest as inadequate voice and failure to decannulate. These can be prevented or treated in the following ways:Granulation tissueCovering all exposed cartilage to preventAvoiding stents when possibleCareful excisionLaryngeal stenosisExcision with mucosal coverageStenting selected casesLaryngotracheoplastyTracheal resection with reanastomosisVocal fold immobilityObservationVocal fold injectionThyroplasty-type vocal fold medializationArytenoidectomy and vocal fold lateralization for bilateral paralysisLaryngeal Fractures: Follow-upAuthor: Samir S Pancholi, DO, Consulting Surgeon, Cosmetic Surgery of Las Vegas; Adjunct Assistant Professor of Cosmetic Surgery, Touro University; Assistant Professor of Otolaryngology-Facial Plastic Surgery, Michigan State UniversityCoauthor(s): Wayne K Robbins, DO, FAOCO, Program Director, Department of Otolaryngology-Facial Plastic Surgery, Genesys Regional Medical Center, Michigan State University; Alpesh Desai, DO, Assistant Professor, Department of Dermatology, Western University of Health Sciences; Tejas Desai, DO, Staff Physician, Department of Dermatology, Western University of Health SciencesContributor Information and DisclosuresUpdated: Jan 9, 2009Print ThisEmail ThisOverviewWorkupTreatmentFollow-upMultimediaReferencesKeywordsOutcome and PrognosisThe overall outcome and prognosis of a patient with a laryngeal fracture depends on several factors, such as extent of injury, timing of repair, and the ability of the otolaryngologist to properly evaluate and treat the patient who has been traumatized. Generally, success is measured in terms of voice and airway function. Minor injuries usually result in return to preinjury airway and voice status. More significant trauma results in voice changes and requires more intensive procedures for airway stabilization.Certain factors have been identified that correlate with a good outcome. Although controlling some of these factors is virtually impossible, a basic understanding and knowledge of these indicators can help predict the ultimate morbidity or mortality of a patient.Early repair of injury is essential in obtaining the best outcome. Evidence suggests that ideal timing for the repair of laryngeal fractures is within the first 24-48 hours after injury.24,25 If repair occurs later, the rate of complications (dysphonia, aspiration, and tracheotomy dependence) increases considerably. Early repair decreases the complications of chronic airway obstruction, poor voice quality, persistent granulation tissue, wound contractures, and stenosis.After studying 392 patients with laryngeal trauma, Jewett (1999) found an increased mortality rate (0.78% vs 0.5%) in patients in whom tracheostomy was performed versus those in whom it was not performed.1 The reason for tracheostomy was unclear and possibly associated with other common associated injuries (eg, head or chest injury).Penetrating trauma is prognostically more favorable than blunt trauma. Leopold (1983) found that penetrating trauma resulted in good airway function 93% of the time, and 70% of patients recovered with excellent voice quality. In contrast, 68% of patients who had sustained blunt trauma had good airway function, while 39% of patients recovered with excellent voice quality.Vocal cord mobility is another documented favorable prognostic sign. Vocal cord dysfunction usually results from recurrent laryngeal nerve injury or arytenoid subluxation. Leopold's study revealed that good airway function was found in 81% of patients with good vocal cord mobility, while good airway function was found in only 72% of patients with vocal cord dysfunction. The data are even more impressive when voice change was compared. Excellent voice quality was found in 56% of patients with normal vocal cords, while excellent voice quality was found in only 17% of patients with vocal cord immobility (1983).26 Much controversy exists regarding the use of laryngeal stents and whether their use improves patient outcome in laryngeal trauma. Inherent difficulties arise when measuring their influence because most injuries that require stent placement are severe and probably will have some complications regardless of stent use. The basic tenet for the use of laryngeal stents requires that they serve as internal fixation devices and as a means of preventing endolaryngeal scarring; however, the use of stents is associated with risks. Stents may increase the prevalence of infection and granulation tissue formation. Specific indications are needed for their use, including multiple cartilaginous fractures, anterior commissure lacerations, and significant distortion of laryngeal architecture.Stent placement does not serve as a substitute for primary closure of mucosal lacerations and reduction and internal fixation of laryngeal fractures.14,27 Patients treated without stents had better resultant airway function (88% of patients without stents vs 71% of patients with stents).26 Similarly, patients treated without stents had better voice results (61% of patients without stents had excellent voice results vs 33% of patients with stents).26 Choices of stents range from finger clots with foam rubber to commercially prepared polymeric silicone stents. Place the material in the larynx so that the material moves freely with the larynx during swallowing. Also, contour the stents to the shape of the larynx to avoid mucosal damage. If internal sutures break, use a 4-point fixation device to allow an easier recovery from the stent. Most authors agree that stents should be removed in 10-14 days.Future and ControversiesBecause of the rarity of serious laryngeal trauma, limited clinical research is available to guide treatment decisions. The poor results associated with the use of internal stents remains an obstacle in treatment. Research that describes specific injuries necessitating the use of stents will help to improve outcomes. Recently, investigation and clinical use of adaptation plates to stabilize laryngeal fractures has shown promising results and may reduce future need for internal laryngeal stents. Further investigation into the use of absorbable polyvicryl miniplates or mesh could reduce long-term complications.Several promising techniques that may be beneficial in the future of laryngotracheal reconstruction have been recently described. Several authors have described the use of autogenous laryngeal cartilage in laryngotracheal reconstruction.28 Others have described the use of tracheal homografts from cadavers.29 In 1998, at the Cleveland Clinic, the first laryngeal transplant was performed in a patient who lost phonation after a motorcycle accident. Reports of patients with laryngeal transplants suggest good-to-excellent results in phonation and airway.30 Perfecting laryngeal transplantation in the future could provide an alternative for patients with poor outcomes resulting from laryngeal fractures.?Acknowledgments I would like to thank Drs. Alpesh Desai and Tejas Desai for their hard work, long hours,?initiative, dedication, and assistance?in getting this article off the ground and into publication. ................
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