NECK INJURIES ITS TREATMENT

1. NECK TRAUMA
DR SATINDER PAL SINGH

2. Background
 Few emergencies pose as great a challenge
as neck trauma. Because a multitude of organ
systems (eg, airway, vascular, neurological,
gastrointestinal) are compressed into a
compact conduit, a single penetrating wound
is capable of considerable harm.
 Airway occlusion and exsanguinating
hemorrhage pose the most immediate risks to
life. From the time when Ambroise Pare
successfully treated a neck injury in 1552,
debate has continued about the best
approach for particular neck wounds

3.  Neck trauma accounts for 5-10% of all serious
traumatic injuries. Approximately 3500 people die
every year from neck trauma secondary to hanging,
suicide, and accidents.
 Initially missed cervical injuries secondary to neck
trauma result in a mortality rate of greater than 15%.
 10% of neck wounds lead to respiratory compromise.
Loss of the airway patency may occur precipitously,
resulting in mortality rates as high as 33%.
 Zone I injuries are associated with the highest
morbidity and mortality rates.
 Sex-Trauma is more common among males than
among females.
 Age-Most people who experience neck trauma are
adolescents and young adults.

4. PATHOPHYSIOLOGY
A clear understanding of the
anatomic relationships within
the neck and the mechanisms
of injury is critical to devising a
rational diagnostic and
therapeutic strategy.

5. ANATOMY
 Think: vessels, airway, esophagus, spine, spinal cord, nerves,
ducts
 Superficial fascia: covers the platysma just below the skin
 Platysma: b/w the superficial and the deep fascia; violation
increases risk of damage
 Deep Fascia
 Investing layer: surrounds neck and splits to encase the SCM
and trapeziuz
 Pretracheal layer: adheres to cricoid and thyroid cartilage and
travels behind the sternum to attach to the pericardium:
PRETRACHEAL LAYER IS THE REASON THE NECK
CONNECTS TO THE MEDIASTINUM
 Prevertebral: envelops the cervical and prevertebral muscles
and extends to form the axillary sheath Carotid sheath
 Formed by components of all three layers

6. STRUCTURES AT RISK
 With the neck protected by the spine
posteriorly, the head superiorly, and the
chest inferiorly, the anterior and lateral
regions are most exposed to injury.
 The larynx and trachea are situated
anteriorly and are therefore readily exposed
to harm.
 The spinal cord lies posteriorly, cushioned
by the vertebral bodies, muscles, and
ligaments.
 The esophagus and the major blood

8. •Musculoskeletal structures at risk include
the vertebral bodies; cervical muscles,
tendons, and ligaments; clavicles; first and
second ribs; and hyoid bone.
•Neural structures at risk include the spinal
cord, phrenic nerve, brachial plexus,
recurrent laryngeal nerve, cranial nerves
(specifically IX-XII), and stellate ganglion.
•Vascular structures at risk include the
carotid (common, internal, external) and
vertebral arteries and the vertebral,
brachiocephalic, and jugular (internal and

9. •Visceral structures at risk include the
thoracic duct, esophagus and pharynx,
and larynx and trachea.
•Glandular structures at risk include
the thyroid, parathyroid, submandibular,
and parotid glands.
•Associated structures at risk of
intrathoracic injuries include the
esophagus, tracheobronchial tree, lung,
heart, and great vessels.

10. Zone Classification
Anatomy classification is excellent for
describing the static location of
structures
Injury is not static, and an injury to the
neck may enter the anterior triangle
and then pass through the posterior
triangle.
A more useful classification of neck
anatomy for trauma is the Zone
classification developed by Roon and

11. This classification system can guide
the clinician in the diagnostic and
therapeutic management
Based on level of injury to the neck in
a caudal to cranial orientation
Zone 1:
Lower Border = Clavicles
Upper Border = Cricoid Cartilage

12. ANATOMIC ZONES

13. Zones of the Neck
.
Zone I: Thoracic inlet to
Cricoid cartilage
Zone II: Cricoid
cartilage to the Angle
of mandible
Zone III: Angle of the
mandible to skull base

14. CLASSIFICATION

16.  Zone I the base of the neck, is
demarcated by the thoracic inlet
inferiorly and the cricoid cartilage
superiorly.
 Zone II encompasses the midportion
of the neck and the region from the
cricoid cartilage to the angle of the
mandible.
 Zone III characterizes the superior
aspect of the neck and is bounded by
the angle of the mandible and the

17. Zone I
 Zone I Structures
◦ Vertebral arteries
◦ Proximal carotid arteries
◦ Major thoracic vessels
◦ Superior Mediastinum
◦ Lungs, trachea
◦ Esophagus
◦ Spinal cord
◦ Cervical nerve roots
◦ Signs of a significant injury in the zone I
region may be hidden from inspection of the
chest or the mediastinum

18. Zone I
From the clavicles to
the cricoid
 Trachea
 Lungs
 Proximal carotid and
vertebral arteries
 Jugular veins
 Thoracic Vessels
 Esophagus
 Superior
Mediastinum
 Thoracic Duct
 Spinal Cord
 Brachial Plexus

19. Zone I
Ghana Emergency Medicine
Collaborative
Advanced Emergency Trauma Course
Mysteriouskyn (Wikipedia)
Zone 1
Trauma.org
Ghana Emergency Medicine Collaborative
Advanced Emergency Trauma Course

20. Neck trauma. Zone I injury.

21. Zone II
From cricoid to angle of mandible
 Trachea
 Larynx
 Carotid and vertebral aa.
 Jugular Vein
 Esophagus
 Spinal Cord

22. Important structures in this region
include the carotid and vertebral
arteries,
jugular veins, pharynx, larynx, trachea,
esophagus, and cervical spine and
spinal cord.
Zone II injuries are likely to be the
most apparent on inspection and tend
not to be occult.
Additionally, most carotid artery injuries
are associated with zone II injuries

23. Zone II
Medicine Collaborative
Advanced Emergency Trauma Course
Zone 2

24. Zone III
Angle of mandible to base of skull
 Distal carotid and vertebral arteries
 Pharynx
 Spinal cord

25. Diverse structures, such as the
salivary and parotid glands,
esophagus,
trachea, vertebral bodies, carotid
arteries,
jugular veins, and major nerves
(including cranial nerves IX-XII),
traverse this zone.
Injuries in zone III can prove difficult
to access surgically.

26. Zone III
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Collaborative
Advanced Emergency Trauma Course
Zone 3
Ghana Emergency Medicine Collaborative
Advanced Emergency Trauma Course

27. ZONE CONTENTS COMMENTS
ZONE I Common carotid
Vertebral artery
Subclavian artery
Mediastinal major vessels
Apices of lungs
Esophagus
Tracheal
Thyroid
Thoracic duct
Spinal cord
Thoracic outlet thus neck AND
mediastinal structures
Difficult to apply pressure to
vascular
injuries thus more difficult to
examine
Difficult to examine for subtle
injuries
Difficult access to explore in OR
thus more likely to image before
OR
ZONE II Carotid and vertebral arteries
Larynx and tracheal
Esophagus and pharynx ,Jugular
vein
Vagus and recurrent
laryngeal n. ,spinal cord
Easier to apply pressure to
bleeders
Easier to locally explore in ED
Easier to examine in ED
Easier to explore in OR
MORE likely to investigate/operate
only if signs of significant injury
ZONE II Carotid and vertebrals
Distal jugular vein
Salivary and parotid glands
CN 9,10,11,12 Spinal cord
More difficult to examine
More likely to explore in OR

28. Signs of laryngeal or tracheal
injury
 Voice alteration
 Hemoptysis
 Stridor
 Drooling
 Sucking, hissing, or air frothing or bubbling through the
neck wound
 Subcutaneous emphysema and/or crepitus
 Hoarseness
 Dyspnea
 Distortion of the normal anatomic appearance
 Pain on palpation or with coughing or swallowing
 Pain with tongue movement
 Crepitus: Noteworthy in only one third of cases

29. Signs of esophageal and
pharyngeal injury
 Dysphagia
 Bloody saliva
 Sucking neck wound
 Bloody nasogastric aspirate
 Pain and tenderness in the neck
 Resistance of neck with passive motion
testing
 Crepitus
 Bleeding from the mouth or nasogastric
tube

30. Signs of carotid artery injury
 Decreased level of consciousness
 Contralateral hemiparesis
 Hemorrhage
 Hematoma
 Dyspnea secondary to compression of the
trachea
 Thrill
 Bruit
 Pulse deficit

31. Signs of jugular vein injury
 These include hematoma,
 external hemorrhage,
 hypotension

32. Signs of spinal cord or brachial
plexus injury
 Diminished upper arm capacity
 Quadriplegia
 Pathologic reflexes
 Brown-Séquard syndrome
 Priapism and loss of the bulbocavernous reflex
 Poor rectal tone
 Urinary retention, fecal incontinence, and
paralytic ileus
 Horner syndrome
 Neurogenic shock
 Hypoxia and hypoventilation

33. Signs of cranial nerve injury
 Facial nerve (cranial nerve VII): Drooping of the
corner of the mouth
 Glossopharyngeal nerve (cranial nerve IX):
Dysphagia (altered gag reflex)
 Vagus nerve (cranial nerve X, recurrent
laryngeal): Hoarseness (weak voice)
 Spinal accessory nerve (cranial nerve XI):
Inability to shrug a shoulder and to laterally
rotate the chin to the opposite shoulder
 Hypoglossal nerve (cranial nerve XII): Deviation
of the tongue with protrusion

34. DIAGNOSTIC STRATEGIES
 TRIPLE SCOPE + Angiography
 Bronchoscopy
 Esophagoscopy
 Laryngoscopy
 Other: doppler, CTA, MRA

35. Diagnosis
 Imaging studies
 In addition to cervical and chest radiography, the
following supplementary tests may be useful:
 Computed tomography (CT) scanning
 Magnetic resonance imaging (MRI)
 Color flow Doppler ultrasonography
 Contrast studies of the esophagus
 Interventional angiography
 Endoscopy--Laryngoscopy, bronchoscopy,
pharyngoscopy, and esophagoscopy may be useful in
the assessment of the aerodigestive tract. Rigid
endoscopes are superior to flexible scopes.

36. General Indications for Angiography
(assuming patient not unstable)
•Hematoma
• Vascular bruit/thrill
• Decreased pulse in upper extremity
• Signs of CVA
General Indications for TRIPLE SCOPE
• Hematemesis
• Hemoptysis
• Chest tube air leak
• Subcutanoues or mediastinal air
• Oropharyngeal blood

37. Rosen’s signs of injury
SOFT signs HARD signs
 Hemoptysis/hematemesi
s
 Oropharyngeal bleeding
 Dyspnea
 Dyphonia/dysphagia
 SubQ or mediastinal air
 Chest tube air leak
 Nonexpanding
hematoma
 Expanding hematoma
 Severe active bleeding
 Shock unresponsive to
fluids
 Decreased/absent radial
pulses
 Vascular bruits/thrills
 Cerebral ischemia
 Airway obstruction

38. Goals of the Guideline
 Management of penetrating injuries to zone II of the
neck that penetrate the platysma.
1. Is mandatory operative management or selective
operative
management appropriate?
2. Can duplex ultrasonography (US) or CT angiography
rule
out an arterial injury in patients with no hard signs of
vascular injury on physical examination, thereby making
arteriography unnecessary?
3. Are both contrast studies (barium or gastrograffin
swallow)
and esophagoscopy needed to safely rule out esophageal

39. Mandatory versus Elective
Exploration
 Immediately life threatening: massive
bleeding, expanding hematoma,
hemodynamic instability,
hemomediastinum, hemothorax, and
hypovolemic shock.Immediate surgical
exploration
 Hemodynamically stable ,non–life-
threatening features can undergo thorough
imaging investigations to determine the
extent of injury.

40. Initial Management
Initial Management is the same as all trauma
cases
 A : airway with C-spine control
 B : breathing and ventilation
 C : circulation
 D : disability and neurologic status
 E : exposure and evaluation other injury

41. Airway
◦ Securing the airway should be
considered if the patient is going to be
leaving your supervised area
◦ Endotracheal intubation using rapid
sequence technique is the first choice
◦ Cricothyrodotomy is second line
treatment when intubation is not
successful
◦ Care should be taken to when intubating
to avoid an injured trachea

42. • Patients with acute respiratory distress need a
definitive and secure airway
• In neck trauma there is sometimes a debate as to
when to intervene
 Multiple blind intubation attempts will
risk enlarging a lacerated piriform sinus
wound and extending it iatrogenically
into the mediastinum.
• Blood and air from facial and neck injuries can
distort the normal anatomic appearance and
increase the difficulty of intubation
• Tracheal tear may be exacerbated by extending the
neck.

43. Breathing
◦ All patients should receive high-flow oxygen
◦ Based on the zone and the proximity to the
thoracic inlet, there could be simultaneous
injury to the thorax
◦ If you notice any difficulty ventilating then
suspect either upper airway injury or thorax
◦ Evaluate for asymmetric breath sounds
◦ Consider tension pneumothorax if there is
evidence of tracheal deviation

44. Circulation
◦ Active bleeding should be addressed
immediately by direct point pressure
◦ Do not clamp bleeding vessels
because you could cause further
ischemia
◦ Avoid placing IV access where the
flow would head towards the injured
area.
 Extravasation could create more
distortion and compression

45. Disability
◦ Examine and inspect for evidence of
focal neurological deficit
◦ This could suggest direct nerve
injury, or spinal cord injury or
vascular injury leading to ischemia

46. Zone 1 injury
 Below cricoid, dangerous
area
 Protect zone  bony thorax
and clavicle
 Motality rate 12 %
◦ Potential for injury to great
vessel and mediastinum
 Mandatory exploration : not
recommend
 Angiography and esophageal
evaluation: usually suggest
◦ > 1/3 no symptom at
presentation

47. Zone 1 injury
 Esophageal evaluation
endoscopy , contrast
esophagogram
◦ Contrast medium
 Barium- based
 Gastrografin ( meglumine diatrizoate)
◦ Combination tests should not miss an
njury
 CT scan
◦ Determine the path of projectile

48. Zone 2 injury
 Largest zone,most common site of
trauma 60-75%
 Between angle of mandible & inf
border of cricoid cartilage
 Isolate venous injury &
pharyngoesophageal injury most
common structure missed clinically
 All pt. are admitted for observation
and 24 hr re-evaluation
 50% of death  hemorrhage from
vascular structure

49. Indications for Immediate
Surgery after Penetrating Neck
Trauma Shock
 Pulsatile bleeding
 Expanding hematoma
 Unilateral extremity pulse deficit
 Audible bruit or palpable thrill
 Airway compromise
 Wound bubbling
 Extensive subcutaneous emphysema
 Stridor
 Hoarseness
 Signs of stroke/cerebral ischemia

50. Penetrating Injury
Airway Control
Immediate Exploration
Unstable Zone II (Hard Signs)

51. Zone II Injury
 Operative management of GSW to carotid artery
Trauma.org

52. Zone 2 injury
 Symptomatic  neck exploration
 Asymptomatic
◦ Directed evaluation and serial exam
 Arteriography,
 Laryngotraheoscopy
 flexible esophagoscopy
 barium swallow
 Requires adequate physician ,24 hr facility
prepared for emergency testing and Surgery

55. Angiography
: Zone1 & 3
 Routine preoperative arteriography in
stable case
 Surgical approach is more difficult than
zone 2
 If wound involve both side of neck (
stable but symptomatic) four vessel
angiography

56. Angiography
: Zone1 & 3

57. Angiography
: Zone2
 Easy accessible,low risk for exploration
 Certain indication for an angiogram in zone 2
◦ Stable pt. who has persistent hemorrhage
◦ Neurodeficit compatible with adjacent vascular structure
damage eg. Horner’s syndrome , hoarseness
 Need exploration
◦ Positive arteriography
◦ Negative arteriography but positive clinical sign
 Asymptomatic in zone 2
◦ Controversy,
 No sig difference btw. Clinical exam & angiography
◦ CTA fast ,minimal invasive in hemostatic stable

58. CT ANGIOGRAPHY
Advantages
 •Superior image
quality
 •Readily available,
quick
 •Limited
interuservariability
 •Safe
 •Shows surrounding
structures
 laryngeal injuries and
a stable patent airway
Limitations
 Poor timing of contrast
load
 Patient movement
 Metallic artifact
 Body habitus
 Not therapeutic

59. Technique of vascular repair
 End to end or autogenous graft
reccomended when stenosis is
evident by arteriography
 Ligation of common or internal
carotid a.reserved for
irreparable injury and in pt, who
are in a profound coma state
 Delayed complication from
unrepaired vascular injury
◦ Aneurysm formation
◦ Dissecting aneurysm
◦ AV fistulas

60. Pharynx and esophageal
injury
 Clinical sign and symptom  neck exploration
◦ subcutaneous emphysema
◦ Hematemesis
◦ Hypopharyngeal blood
 >50%of Pt.  asymptomatic at presentation
 Combination of esophagoscopy and contrast
esophagography
◦ Most sensitive for detected injury
 Delayed explore & repair beyond 24 hrs after
injury poorer outcome

61. Digestive tract evaluation
 Possible esophageal
perforation  gastrografin
swallow
 Barium : extravasation & distort soft
tissue plane and toxic

62. Digestive tract evaluation
 Flexible esophagoscopy
◦ Missed perforation :
cricopharyngeus, hypopharynx
◦ Negative endoscopy but air
leak in soft tissue 
mandatory neck explore
 Infiltrate methylene blue : localize
injury size
 Combination of flexible and
rigid endoscopy
◦ Exam entire cervial and upper
esophagus
◦ No perforation missed

63. Digestive tract evaluation
 Suspicious pharyngeal perforation
◦ NPO for several days
◦ S&S : fever , tachycardia,widening of
mediastinum
 Repeat endoscopy or neck exploration
◦ Esophageal injury in the early phase
 Two layer closure with wound irrigation
 Debridement
 Adequate drainage
◦ Extensive esophageal injury  lateral
cervical esophagostomy

64. Penetrating of hypopharynx
 Superior to the level of arytenoid
cartilage
◦ IV ABO
◦ NPO ทางปาก 5-7 days
◦ Primary closure not always necessary
 Inferior to the level of arytenoid
cartilage
◦ Dependent portion
◦ Exploration with primary watertight
closure
◦ Use absorbable suture with drainage of
adjacent neck space
◦ NPO 5-7 days
◦ Treat liked esophageal injury

65. Treatment
 Conservative
◦ Medical therapy
 Adequate ventilation & oxygenation
 Fluid resuscitation
 Monitor neurolodic status
 Pain control
 ABO
 Tetanus prophylaxis

66. Treatment
 Surgical approach
◦ Zone 1
 Median sternotomy
 Thoracotomy
◦ Zone 2
 Collar incision
 Apron incision
◦ Zone 3
 Consult neuroSx

67. Blunt neck trauma
 motor vehicle accidents and sports
 result in laryngeal, vascular, and
digestive injury
 easily underdiagnosed because their
onset can be delayed
 occult cervical spine injury
 Strangulation
 Blows from fists or feet
 Excessive manipulation

68. Blunt Neck Trauma
 Blunt trauma to the neck is less
frequent in occurrence
 Mechanism is often related to motor
vehicle collisions
◦ Hyperextension
◦ Rotation
◦ Hyper flexion
◦ Direct blows against a non mobile object
(most commonly seatbelts)

69. Laryngotracheal Injury
 Signs and symptoms:
◦ Difficulty swallowing
◦ Pain with swallowing
◦ Difficulty breathing (feeling breathless)
◦ Hoarseness of voice (or change in voice)
◦ Subcutaneous emphysema
◦ Tracheal deviation
 However signs and symptoms may be
absent even with a major injury

70.  Common 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.
 Common signs of laryngeal injury include
stridor, subcutaneous emphysema, hemoptysis,
hematoma, ecchymosis, laryngeal tenderness,
vocal cord immobility, loss of anatomical
landmarks, and bony crepitus.

71. Laryngotracheal Injury
 Blunt trauma to neck with swelling and
subcutaneous emphysema

72. Anterior neck bruise (see arrow)
in a middle-aged woman
involved in a motor vehicle

73. CT scan (A) revealing a paramedian fracture (see arrow) from an acute blunt laryngeal
trauma . This young man presented 1 week after being struck on the left side of the neck
with a hockey stick. Note that the 3D reconstruction (B) provides valuable information as
to the shape of the fracture and demonstrates that the anterior commissure has been
displaced

74. 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

75.  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.

76. 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

77. Group Symptoms Sign Management
Group 1 Minor airway
symptoms
Minor hematomas
Small Lacerations
No detectable
fractures
Observation
Humidified air
Head of bed
elevation
Group 2 Airway compromise Edema/hematoma
Minor mucosal
disruption
No cartilage exposur
Tracheostomy
Direct laryngoscopy
Esophagoscopy
Group 3 Airway compromise Massive edema
Mucosal tears
Exposed cartilage
Vocal cord
immobility
Tracheostomy
Direct laryngoscopy
Esophagoscopy
Exploration/repair
No stent necessary
Group 4 Airway compromise Massive edema
Mucosal tears
Exposed cartilage
Vocal cord
immobility
Tracheostomy
Direct laryngoscopy
Esophagoscopy
Exploration/repair
Stent required

78. Laryngotracheal Injury
 Management:
◦ High index of suspicion is required to
diagnose these types of injuries especially in
the absence of classic symptoms
◦ Securing an airway is the initial focus.
 Endotracheal intubation should be attempted by the
most experienced person
 Other authors suggest immediate tracheostomy to
avoid creating a false path or further injury to the
unstable airway
 Cricothyrodotomy should be avoided as this may
worsen the injury

81. Fractured thyroid cartilage closed with wires

82. Various methods for laryngeal
cartilage stabilization

83. Intraoperative photo graphs of the patient from Figure 34–2 . The first photograph (A)
was taken
before rigid fixation using a plating system; the second photograph (B) was taken after
the plate was inserted. Note that the plate is carefully bent to restore the proper anterior

84. (A) Vocal granulation tissue funned as a result of endotracheal
Intubation coalescing. If undivided this will become a mature scar
tissue (B) and lead to ankylosis of cricoarytenoid joints.

85. Laceration repair

86. The anterior cartilaginous
sutures are placed and then tied
once all have been placed.
Vicryl and Prolene sutures are
alternated for this portion of the
closure.

87. Sutures are placed submucosally
around tracheal rings with the knot tied
externally.

88. Complications
Acute Chronic
 AcuteAirway
obstruction
 Aphonia
 Dysphonia
 Odynophagia
 Dysphagia
 Postoperative
complications (eg,
hematoma, infection)
 Voice compromise (21-
25%)
 Chronic obstruction (15-
17%)
 Vocal cord injuries (eg,
paralysis, fixation)
 Fistula
(tracheoesophageal,
esophageal, or
pharyngocutaneous)
 Cosmetic deformity
 Chronic aspiration

89.  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.
 More significant stenosis may require
anterior or posterior cricoid splits with
cartilage grafting.

90. McCaffrey system of
laryngotracheal stenosis
classlficatlon.

91.  The most common problem in the immediate
postoperative period is the development of
granulation tissue and ulceration from exposed
cartilage.
 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.
 Debulking granulation tissue through
endoscopy is probably the most effective
alternative treatment currently available.

92. Laryngeal trauma complications can manifest as
inadequate voice and failure to decannulate. These can
be prevented or treated in the following ways
Granulation tissue
 Covering all exposed
cartilage to prevent
 Avoiding stents when
possible
 Careful excision
Laryngeal stenosis
 Excision with mucosal
coverage
 Stenting selected
cases
 Laryngotracheoplasty
 Tracheal resection
with reanastomosis
Vocal fold immobility
 Observation
 Vocal fold injection
 Thyroplasty-type vocal
fold medialization
 Arytenoidectomy and
vocal fold lateralization
for bilateral paralysis