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Thieme-Verlag Sommer-Druck Ernst WN 023832/01/01 20.6.2006 Frau Langner Feuchtwangen Head and Neck Trauma TN 140001 Kap-14 14 Diagnosing Injuries of the Larynx and Trachea Flowchart and Checklist Injuries of the Neck, Chap- Treatment of Injuries of the Larynx, Pharynx, Tra- ter 3, p. 25. chea, Esophagus, and Soft Tissues of the Neck, Chapter 23, p. 209. Surgical Anatomy Anteflexion of the head positions the mandible so that it n The laryngeal muscles are divided into those that open the affords effective protection against trauma to the larynx glottis and those that close it. The only muscle that acts to and cervical trachea. Injury to this region occurs if this open the glottis is the posterior cricoarytenoid (posticus) protective reflex function is inhibited and the head is muscle. prevented from bending forward on impact. Spanning the ventral aspect of the cartilage framework, The rigid framework of the larynx is formed by four the cricothyroid muscle is the only laryngeal muscle inner- cartilages: vated by the superior laryngeal nerve. All other muscles are Q thyroid cartilage; supplied by the inferior (recurrent) laryngeal nerve, which Q epiglottic cartilage; originates from the vagus nerve and, after it loops in the Q arytenoid cartilage; thorax, travels cranially between the trachea and esopha- Q the cricoid cartilage. gus (Fig. 14.1). The thyroid cartilage is made up of two laminae, which The trachea extends from the cricoid cartilage to its bi- meet at approximately a right angle in men and at ca. furcation, a distance of 10–13 cm, or in topographic 120 in women. The epiglottis petiole attaches to the in- terms of the vertebral column, from the sixth cervical ner side of the thyroid cartilage. The dorsal cricoid lam- vertebra to the fourth thoracic vertebra. The tracheal ina extends into the interior of the thyroid cartilage framework is made up of 15–18 horseshoe-shaped carti- frame, articulating with it and with the arytenoids. The lage rings which are closed off dorsally by the membra- vocal ligament and vocalis muscle are secured at the vo- nous portion of the trachea (Fig.14.2). cal process of the arytenoids. Fig. 14.1 Anatomy of the outer and inner larynx (modified from Richter 1 1992). 1 epiglottis, 2 hyoid bone, 3 superior laryngeal nerve, 4 superi- 2 3 or thyroid notch, 5 superior horn of 6 thyroid cartilage, 6 thyrohyoid mem- 5 13 brane, 7 cricothyroid muscle, 8 an- nular ligament, 9 pyriform sinus, 10 plica vestibularis (ventricularis, 4 9 vestibular ligament), 11 laryngeal 10 14 ventricle (sinus of Morgagni), 12 vo- cal fold (vocal ligament), 13 supra- 11 glottic space (this level is described 7 15 as the transglottic space, which com- 12 prises the vestibular ligament, Mor- gagni’s ventricle, and vocal fold). 8 121 Ernst/Herzog/Seidl, Head and Neck Trauma (ISBN 3131400013, 9783131400017), 2006 Georg Thieme Verlag KG Thieme-Verlag Sommer-Druck Ernst WN 023832/01/01 20.6.2006 Frau Langner Feuchtwangen Head and Neck Trauma TN 140001 Kap-14 14 Diagnosing Injuries of the Larynx and Trachea Fig. 14.2 Anatomy of the trachea, Upper dental arch bronchial tree, and segments (modi- fied from Richter 1992). 14 cm a Bronchial tree and segments— Membranous lengths. portion Glottis b Cross-section of the trachea. of trachea 13–20 mm 10–13 cm Cartilage ring a Right upper lobe Left upper lobe 1–1.2 cm Apical Apical 4.5–5 cm Posterior Posterior Anterior 6.5–8 cm Superior Lingual segments Anterior Inferior Bifurcation Left lower lobe Right middle lobe Apical Lateral 6.5–8.5 cm Apical Medial Right lower lobe Cranial Anterior basal Diagnostik Anterior basal Lateral basal b Lateral basal Posterior basal Pathomechanism and Classification Injuries of the larynx (Figs.14.3,14.4) and trachea can be Classification by degree of severity has proven itself clin- grouped according to pathomechanism as follows: ically, as it also provides information useful for deriving Q Direct trauma: necessary therapeutic measures (Table 14.1). – blunt extraluminal causes of trauma: impact, blow, strangulation, entrapment, sudden longitudinal pull from dorsal reflection of the head; Table 14.1 Clinical classification of severity of trauma to the – blunt intraluminal causes of trauma: long-term intuba- larynx tion, endoscopy, violent coughing, blunt foreign bodies; Grade Description – sharp extraluminal causes of trauma: penetrating injury, cut, missile wound, rotating objects; 1 Visible hematoma, hemorrhage, no fracture – sharp intraluminal causes of trauma: sharp, aspirated 2 Hematoma, swelling, nondisplaced stable fracture foreign bodies; – sharp perforating trauma: missile wound, puncture, 3 Free cartilage, vocal cord dysfunction, unstable cut; moveable fracture – endolaryngeal mucosal lesions: caustic injury, scalding, 4 Open laryngeal injury, laryngotracheal separation thermal burn. Q Indirect trauma. 122 Ernst/Herzog/Seidl, Head and Neck Trauma (ISBN 3131400013, 9783131400017), 2006 Georg Thieme Verlag KG Thieme-Verlag Sommer-Druck Ernst WN 023832/01/01 20.6.2006 Frau Langner Feuchtwangen Head and Neck Trauma TN 140001 Kap-14 Pathomechanism and Classification 1 2 1 ab 3 1 1 c d Fig. 14.3 Schematic illustration of injuries of the larynx (modified c Multiple fracture or comminuted fracture of the larynx. This frac- from Richter 1992). ture form is most suited to calcified cartilage. The harder carti- a Linear vertical laryngeal fracture. A common form of fracture in lage better protects the soft tissues of the transglottic space. noncalcified cartilage skeleton; associated with injuries of inter- However, the epiglottis is often separated at the petiole and nal structures, which are destroyed as a result of elastic deform- covers the entrance to the larynx. Visualization of the interior of ity of the inward and outward movement of the cartilage lami- the larynx is then only possible with transnasal pharyngo- nae. 1 Destruction of the soft tissues on one side. laryngoscopy. 1 Supraglottic constriction. b Linear oblique fracture of the larynx. The fracture line is above the d Cricoid fracture. proximity of the recurrent nerves causes palsy level of the glottis (supraglottic fracture). The cranial thyroid of the vocal cords with unilateral or bilateral medialization of cartilage fragment can be considerably displaced toward the hy- the vocal folds. The mucosa of the subglottic space is injured oid, so that there is marked diastasis, which can be observed in and heals with formation of granulation tissue, which may de- the intrinsic structures as separation and mucosal tears in the velop into subglottic stenosis. 1 Cricoid fracture and fracture of Morgagni’s ventricle. The region around the arytenoids is edem- the first tracheal ring; 2 view of the vocal fold level with com- atous and hemorrhagic. Dislocation of the arytenoid cartilage is plete vocal fold closure (medialization): severe respiratory dis- possible. 1 Edematous arytenoid. tress, voice good; 3 subglottic granulation. 123 Ernst/Herzog/Seidl, Head and Neck Trauma (ISBN 3131400013, 9783131400017), 2006 Georg Thieme Verlag KG Thieme-Verlag Sommer-Druck Ernst WN 023832/01/01 20.6.2006 Frau Langner Feuchtwangen Head and Neck Trauma TN 140001 Kap-14 14 Diagnosing Injuries of the Larynx and Trachea Anteroposteriorly Directed Trauma Anteroposteriorly directed trauma compresses the thy- roid cartilage against the cervical spine, dislocating the arytenoid cartilages to dorsal. The “elastic strength” of the cartilage skeleton causes the thyroid cartilage to re- bound to ventral, resulting in internal injury: Q Avulsion of the thyroarytenoid muscle (vocal ligament) at the vocal process of the arytenoid cartilage, which fold into the lumen. Q Avulsion of the thyroarytenoid muscle (vocal ligament) at the anterior commissure near the macula flava. Q Wide separation of the inner perichondrium of the thy- roid cartilage. Q Dislocation and overlapping of thyroid cartilage laminae with impaction of the cartilage in the inner musculature. The vocal ligament on the side of impact cannot move. a In addition, disarticulation of the cricothyroid joints may occur with cranial displacement of the thyroid cartilage laminae into the base of the tongue. The thyroepiglottic ligament avulses and there is prolapse of fatty tissue from the pre-epiglottic space into the laryngeal lumen. n The most common thyroid cartilage fracture is the vertical midline fracture. Diagnostik Lateral Trauma Laterally directed force causes the cartilage to break at two points. Segmental fractures of the thyroid cartilage laminae occur in the ventral portions. Usually the aryte- noid cartilage is dislocated or also fractured. Delayed se- quelae include unilateral or bilateral ankylosis of the cri- b coarytenoid joints. Fig. 14.4 Laryngeal injuries. a Hematoma in the vocal folds and edema over both arytenoid cartilages following laryngeal trauma. Supraglottic Injuries b Disarticulated right arytenoid cartilage after laryngeal trauma. n Supraglottic structures include the hyoid bone, thyrohyoid membrane, and supraglottic larynx. In supraglottic injuries the thyroid cartilage is disrupted horizontally. Fractures The epiglottis and vestibular ligament are avulsed from n The dynamics of laryngeal fractures vary. Fracture dynam- the anterior commissure. The posterior wall of the phar- ics are determined by the direction and force of the blow, ynx is often also injured. and by the maximum bending or fracture behavior of the cartilage. Compression testing has shown that the laryn- geal lumen closes with a compression force of 15–20 kg Transglottic
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