Trauma symposium 2012

3/30/2012 Dr.Naim Manhas 1

Diagnosis and management of
E.N.T. trauma –an update
(5thAnnual Trauma Symposium )


Aim and objectives
 Traumatology has become an important
medical subject as we all know that
trauma related patients have increased
since last two decades.
 Before major injuries were seen only in
world wars, but now the percentage of
trauma patients have increased due to
increase in vehicular accidents , day to
day military conflicts in many countries.


Aim and objectives
 The trauma system was created when
it was discovered that more lives
could be saved by taking critically
injured patients to specialized trauma
centre for immediate care.


Laryngo-tracheal injuries
Laryngeotracheal injury is rare 1 in every
5000 trauma cases

Laryngeal injuries in 30-70% of
penetrating neck injuries

Its rarity notwithstanding, it is second to
only intracranial injury as the most
common cause of death among patients
with head and neck trauma


Aim and objectives

Prevent long term In association with
complications by ER surgeons,
early diagnosis trauma surgeons
and proper and
management Anesthesiologists


types of laryngeal trauma

Iatrogenic
trauma
Intubation
injuries


Management
 Management of laryngo-tracheal trauma
is based on the extent of injury:-

Initial Endoscopic
evaluation evaluation


Initial Evaluation

Securing the Obtaining Immobilizing the
airway hemodynamic cervical spine
stability

• Intubation:- vocal
cords are visible, no • Controlling of
visible injuries bleeding
• Tracheotomy done
under local
anesthesia


paediatric patients
 In contrast to adults pediatric patients are
unlikely to cooperate with a tracheotomy
while awake.

 Paediatric airway is secured with rigid
bronchoscopy while maintaining
spontaneous respiration before tracheotomy
is performed.


Initial Evaluation
Identified with physical
examination or fiberoptic
laryngoscopy

In case exploration of neck is
carried

Direct laryngoscopy and
bronchoscopy is performed


Initial Evaluation
Oesophagoscopy is always
performed

50% of patients with an
airway injury also have
associated oesophageal injury

Degree and type of injury is
evaluated during endoscopic
examination


Classification of laryngeal
injuries

As per location

supraglottis transglottis Cricoid/trachea


Aim and objectives
 Assessment of injury

 Level of injury

 Severity of injury


BLUNT TRAUMA
 Thyroid cartilage fracture:-
 Multiple fractures in calcified laryngeal cartilage
as compared to one site fracture in cartilaginous
larynx
 Mucosa disruption
 oedma
 Arytenoid dislocation
 Laryngeal ligaments tear


PRESENTATION

dyspnoea dysphagia dysphonia

Respiratory odynophagia
distress


physical findings

Subcutaneous Oedma Distoration
• Or
• Emphysema
• Hematoma
• Loss of
laryngeal
• Tenderness • ecchymosis landmarks


Classification of laryngeal injury
 Group 1  Minor endolaryngeal hematoma :
 Minimal airway compromise
 Group2  Endolaryngeal hematoma/oedma
associated with compromised
airway/non-displaced fracture
 Massive endolaryngeal edma with
 Group3 airway obstruction/mucosal tears with
exposed cartilage/immobile vocal
cords
 Group4  Same as group3 with more than two
fracture lines on imaging/massive
dearangement of endolarynx
 Group5
 Laryngotracheal sepration

MANAGEMENT
Grop 1& 2 are usually managed non
surgically with humidied air,head of bed
elevation,voice rest

Serial fiberoptic examinations
Streroids:- only usefull if given within first
few hours after injury

Group 3 & 4 :- immediate surgical repair
and may involve the use of stent


Aim and objectives
Restore the integrity
of the larynx with
regard

To phonation,airway
and quality of life


 Neck wounds that extend deep to the
platysma are considered penetrating injuries.
 Incidence of penetrating neck injuries has
increased since world war II because of rise
in violent crimes.
 The main cause of penetrating neck injury in
this country is accidental, while as
internationally usually related to violent
crimes as well as military conflict



Injuries to vascular system----20-56%

Laryngeal, tracheal and
oesophageal injuries—20-30%

Mortality rates from oesophageal
injuries were found to increase
from 11 to 17% after a delay in
diagnosis of only 12 hours

Penetrating laryngeal
injuries

Cartilage
hemato
Mucosal fractures Laryngo-
tears or and tracheal
ma dislocation
laceration disruption


Classification of penetrating
neck injuries


Classification of penetrating
neck injuries
zone 1. -
• Extends from sternal notch to the cricoid

zone 2.
• Extends from cricoid to angle of mandible

zone 3.
• Extends from the mandible to the skull base


Management of penetrating neck
injuries
Remarkable number of changes in the
treatment protocol has been made because
of development of new technologies, it may
be from non-operative management to
routine exploration to selective exploration.
Penetrating neck injuries remain challenging as
there are a number of important structures in
a small area.


Management of penetrating neck injuries

 Since the introduction of
sophisticated ancillary tests and
accurate identification of
localizing signs and symptoms
the surgical exploration of
penetrating neck trauma is now
done on selective basis:-


Management of penetrating neck injuries

All patients with hemodynamic
instability or airway
compromise

Needs surgical exploration

Followed by panendoscopy


injuries
Injuries in Zone -1. and in Zone-3. of neck are
difficult to examine clinically and surgically.
Imaging including angiography is often
performed

Zone.1. injuries are subjected with
preoperative arteriograhpy and gastrograffin
swallow studies


injuries
 Zone 3. injuries are studied with
arteriograhphy and all facilities for
embolization should be available in case
injury is found.

 Zone 2. surgical exploration is done even
without imaging


Asymptomatic patients
 The management of asymptomatic
patients remains controversial but
according to the recent retrospective
studies made by “Sarkar et al” and
“Ramasamy et al” of British military
causalities from Iraq and Afghanisthan
who sustained penetrating neck injuries,
it was observed that percentage of
negative exploration was reduced by
selective exploration.


Surgical intervention
laceration
involving anterior
commissure,

Injury to the free
edge of the true
vocal fold

Exposed cartilage
/displaced or
comminuted fracture

Surgical intervention

 Vocal fold immobility

 Arytenoid cartilage
dislocation


Reduction of laryngeal fractures
 Fixation of even minimally
displaced or ingulated
fractures are important for
maintaing the geometry of
larynx.
 Good results are obtained
by using miniplates as
compared to previously
used stainless-steel wires
or absorable sutures.


Role of stent
 Use of stent is controversial
because of increased risk of
infection and granulation
formation.
 Recommended only where
inadequate fracture fixation is
done to give structural
stability.
 Prevent synechiae formation
when used in presence of
severe soft tissue disruption
or lacerations involving
anterior commissure.

Intubation injuries

The incidence of intubation injury
has increased since

The critically ill patients are being
sustained longer on

Ventilatory support because of
introduction of sophisticated
I.C.U.

Intubation injuries

Scarring of Subglottic Granulation
laryngeal stenosis tissue
structures • Tracheal formation
stenosis • Vocal fold
paresis or
• paralysis


Intubation injuries
 Intubation prolonged
more than 7-10 days
,incidence of
19% complications is from 14-
19%.
30%
 The incidence of
42% complications increases
two-folds if intubation is
prolonged more than two
weeks.


Factors Oversized

Iatrogenic causes
tubes
Difficult

Anatomical variation
determine intubation or Excessive
the severity traumatic patient
of intubation. movement
intubation Inexperienced Repeated self
injures intubation extubation
Overinflated
tube cuffs


presentation
High endotracheal cuff
pressure

Progressive hoarsness of
voice or airway obstruction
from glottic or subglottic edma

Compressive neuropathies by
direct pressure of cuff


presentation
Dysfunctional vocal cords or
paresis

Mucosal injury, result from
movement of endotracheal
tube,pressure necrosis

Granulation formation ,fixation
of cricoarytenoid joint,web
formation or stenosis


Management
Post intubation granulation
tissue resolve spontaneously
after some times

Treatment includes a
combination of voice therapy
and antireflux medication

Surgical removal is only
indicated when it leads to
partial airway obstruction


Management
Managemnt of stenosis depends on
its location and severity.

Presence of thin web in the anterior
glottis

Surgically removed and stent is
placed to prevent the reformation of
web from opposed denuded mucosa


Management

Posterior laryngeal stenosis
and cricoarytenoid joint fixation

Treated with repeated dilation
through an endoscopic
approach

In severe cases ,open
approach through
laryngofissure is done

Management
In cases of failures or more
severe cases

Arytenoidectomy or partial
posterior cordotomy is done

Subglottic or tracheal stenosis
approached with endoscopic
laser incision and dilation

Management
More severe stenosis require
laryngotracheal reconstruction or

segmental resection with primary
anastomisis

Vocal fold paralysis with persistent
dysphonia or significant aspiration

Vocal fold augmentation


Management
Bilateral vocal fold immbolity
present with stridor and airway
obstruction

Relieved by partial posterior
cordectomy,arytenoidectomy or
arytenoid lateralization procedure

In severe cases needs
tracheostomy


conclusion
 The initial goal in managing laryngeal
trauma is to preserve life.
 Secondary goal is to prevent long term
complication to the voice and airway.
 Intubation injuries can be prevented by
proper intubation by experienced E.R.
staff.
 Early tracheotomy in patients who need
prolonged ventilatory life support.


Trauma symposium 2012

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