Managing Laryngeal Injuries in Neck Trauma

4TH TRAUMA SYMPOSIUM MANAGEMENT OF LARYNGEAL INJURIES IN NECK TRAUMA Dr. M. NaimManhas E.N.T. Specialist King Abdul Aziz Hospital-Makkah Dr. Naim Manhas 1

trauma symposium—WHY? 2 Dr. Naim Manhas

“purpose of symposium” 5 Dr. Naim Manhas

Blunt injuries of neck Bruises over the neck Hematoma Surgical emphysema 7 Dr. Naim Manhas

Blunt injuries of neck 8 Dr. Naim Manhas

Laryngeal injuries 9 Dr. Naim Manhas

diagnosis of airway injury 10 Dr. Naim Manhas

problematic 12 Dr. Naim Manhas

Emergency airway management 13 Dr. Naim Manhas

pediatric consideration 14 Dr. Naim Manhas

Pediatric airway 15 Dr. Naim Manhas

laryngeal trauma(neck-injury) Dr. Naim Manhas 17

laryngeal trauma(neck-injury) Dr. Naim Manhas 18

surgical exploration 19 Dr. Naim Manhas

surgical exploration Open exploration of neck with open reduction and internal fixation of fracture without thyrotomy Dr. Naim Manhas 20

laryngeal thyrotomy Laryngeal cartilage stable,anteriorcommissure intact ORIF- fractures Repair mucosal laceration Dr. Naim Manhas 21

laryngeal thyrotomy ORIF fractures, repair mucosal laceration and endolaryngeal stent Laryngeal cartilage unstable,anteriorcommissuredisrupted,massive mucosal injuries Dr. Naim Manhas 22

penetrating neck injuries Neck zones Zone -1 thoracic outlet Cricoid cartilage to sternal notch Zone-2 central Cricoid to angle of mandible Zone-3 skull base Angle of mandible to base of skull Dr. Naim Manhas 23

Neck zone concept outdated Dr. Naim Manhas 24

Epidemiology of penetrating neck injuries 40% of penetrating neck injuries do not involve important structures Structures involved:- -major vein: 15-25% -major artery: 10-15% -pharynx or esophagus: 5-15% Larynx or trachea: 4-12% Major nerves: 3-8% Dr. Naim Manhas 25

Debatable issue Some surgeons have advocated mandatory exploration of all penetrating neck wounds on the basis that serious injury can exist in the absence of clinical findings. Others have advocated a selective approach operating only upon patients whose findings suggest a major vascular or visceral injury Dr. Naim Manhas 26

penetrating neck injuries since zone 2nd has all the vital structures and any injury in this area needs immediate neck exploration in case patient is symptomatic. As per the studies it is difficult to make decisions regarding the exact zone for the injuries which are on border line, as the area of neck is small so the indications for immediate surgical exploration---- Dr. Naim Manhas 27

Indication of immediate surgical exploration Dr. Naim Manhas 28

Esophageal injury--diagnosis If missed leads to high morbidity and mortality Contrast swallow study:- Extravasation is diagnostic Negative study is not reliable 50% of leak—missed with gastrograffin 25% of leaks missed with barium Dr. Naim Manhas 30

Recommendations If gastrograffin study is negative then repeat with Barium Avoid gastrograffin in patients without gag / cough reflex or unprotected airway.( causes pneumonitis if aspirated) Endoscopy 50% of injuries can be missed , esp. if the patient is on ventilator. Combination of contrast study with esophagoscopy reduces missed injuries to 5% Dr. Naim Manhas 31

latrogenic laryngeal injuries Dr. Naim Manhas 32

latrogenic laryngeal injuries Dr. Naim Manhas 33

Acute complication of intubation Dr. Naim Manhas 34

Acute complication of intubation Hematoma formation Laceration Avulsion Scarring and granuloma formation Dislocation of arytenoid cartilage Dr. Naim Manhas 36

Sequelae of prolonged intubation Dr. Naim Manhas 37

pathogensis Dr. Naim Manhas 38

pathogensis Dr. Naim Manhas 39

pathogenesis Dr. Naim Manhas 40

Sequelae of prolonged intubation Abduction of the vocal cords are limited Misdiagnosed as bilateral abductor paralysis Peudolaryngeal paralysis Dr. Naim Manhas 42

Prevention of postintubation injuries Dr. Naim Manhas 45

Prevention of postintubation injuries Time of intubation More than 10 days and less than 10 days Dr. Naim Manhas 46

Result of recent studies done at university hospital Vall”Hebron-spain Dr. Naim Manhas 50

Result of serial laryngeal examinations Dr. Naim Manhas 51

conclusion Intubation injury to the larynx is relatively common and all types of injury have been reported . In patients intubated for prolonged period ,certain types of injury can be expected. The surgeon asked to evaluate a patient for intubation injury should have a clear idea of the type of injury that may be encountered as well as through knowledge of the best methods of prevention and intervention. Dr. Naim Manhas 52

conclusion In many cases, the injury will resolve without incident, while in others the injury is irreversible. Frequently the process can be corrected with good results if the proper treatment is instituted. THANK YOU Dr. Naim Manhas 53

Managing Laryngeal Injuries in Neck Trauma

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