Care of the Professional Voice ASSOCIATE EDITOR: Robert T. Sataloff, MD, DMA

Blunt Trauma to the Larynx and Trachea: Considerations for the Professional Voice User

Yolanda D. Heman-Ackah, MD and Robert T. Sataloff, MD, DMA

cation rates as high as fifteen to nized and treated promptly. Singing INTRODUCTION twenty-five percent.2-4 Because of the teachers are often the first profes- Blunt injury to the larynx (the voice potential for untreated laryngeal and sionals in a position to recognize the box) and trachea (the windpipe) is tracheal injuries to cause permanent potential importance of such an appar- the most common cause of laryngo- voice, swallowing, and breathing dis- ently "minor" event. tracheal injury in the United States abilities, early evaluation and treat- today, accounting for sixty percent of ment by an otolaryngologist or LARYNGOTRACHEAL ANATOMY all injuries to the laryngotracheal laryngologist (an otolaryngologist complex.1,2 These injuries result who specializes in the treatment of The larynx is relatively protected from motor vehicle collisions, laryngeal and voice disorders) is from trauma by the overhang of the accidents involving all-terrain imperative. It is essential for singing mandible (the jaw) above, the bony vehicles, bicycle accidents, stage teachers to be familiar with these prominence of the clavicles (the col- injuries, contact sports, strangulation, problems and their proper larbone) and sternal manubrium (the and hanging-type injuries. The management. Symptoms and signs breast bone) below, and by the mass complications associated with such of voice-threatening, and even life- of the neck muscles on the sides. The injuries range from airway threatening, injuries maybe subtle framework (structure) of the larynx obstruction and difficulty breathing and dismissed even by some consists primarily of four cartilages, to voice compromise and permanent physicians as insignificant. Even an the thyroid, the cricoid, and the paired hoarseness, with compli- injury caused by something as arytenoid cartilages. The thyroid innocent as an arm or elbow striking cartilage is shaped like a shield and Journal of Singing, September/October 2002 the neck of a fellow actor, dancer, or forms the protective casing for the Volume 59, No. 1, pp. 41-47 singer during a theatrical perform- vocal folds. The prominence of the Copyright 2002 National Association of Teachers of Singing ance can be disastrous unless recog- thyroid

SEPTEMBER/OCTOBER 2002 41 Yolanda D. Heman-Ackah, MD and. Robert T. Sataloff, MD, DMA

cartilage in the necks of men is often in a vehicle without protective air also become displaced from their joint referred to as the "Adam's apple." The bags. Upon collision, the front seat space, resulting in cricoarytenoid dis- arytenoid cartilages sit on top of the passenger or driver is propelled for- location. If one segment of the thy- cricoid cartilage in the back of the ward with the neck in extension, elim- roid cartilage fails to return to its larynx and serve as points of inating the jaw as a protective shield. normal position, an overlapping attachment for the vocal folds. In the As the front of the neck hits the dash- fracture may occur, resulting in front of the larynx, the vocal folds board or steering wheel, the cartilages malposition of the vocal fold. All of attach to the inner aspect of the of the larynx are crushed against the these injuries will result in thyroid cartilage, and thus span the spine of the neck.'," Lower impact, hoarseness that may not resolve distance between the arytenoid and direct blows to the larynx can occur unless the injured tissues and thyroid cartilages. The cricoid during athletic competition (such as cartilages are repaired; and even cartilage sits below the vocal folds playing basketball, hockey, or foot- then, some permanent voice deficit and is shaped like a signet ring. The ball); during dances, stage fights or is common. ring-like structure of the cricoid other performance activities; while After the thyroid cartilage frac- serves as a stent to help hold open falling forward onto a blunt object tures, the force then impacts the the airway below the vocal folds. The such as the handle bars of a bicycle; cricoid ring, which was previously trachea connects to the bottom with strangulation; or with hanging shielded by the thyroid cartilage. In portion of the cricoid cartilage and of the neck from a suspended rope or a patient with a marked laryngeal serves as the conduit for air to pass wire. Such forces also compress the prominence, multiple fractures of the through the larynx to the lungs. The larynx and trachea against the spine, thyroid cartilage may occur prior to muscles of the vocal folds and the resulting in injury. the distribution of force onto the other muscles of voice production The thyroid and cricoid cartilages cricoid cartilage.' The cricoid has a attach to the thyroid, cricoid, and interact dynamically to protect the relatively thin front arch that blends arytenoid cartilages. If a normal airway from blunt injury' Forces to on the sides into a thicker, more sturdy voice is to be produced, each of the front part of the larynx often are cartilage. The thicker regions on the these cartilages and muscles must encountered first by the thyroid car- sides of the cricoid cartilage provide function properly and lie in its tilage, which bends against the cer- most of the support for this portion correct anatomical location. vical (neck) spine on impact. The of the airway. Lower level impacts, Displaced fractures of the cartilages, thyroid cartilage eventually reaches such as elbow injuries to the neck, tears in the vocal fold and/or a point of maximal flexibility, and a may result in cricothyroid joint laryngeal muscles, or dislocations of fracture occurs often at or near the injuries or in midline fractures of the the arytenoids from their normal midline of the cartilage. cricoid. The airway is maintained by positions on the cricoid cartilage Vocal fold injuries result from ver- the thicker cartilage on the sides of (cricoarytenoid dislocation) often tical fractures of the thyroid cartilage. the cricoid cartilage. With higher result in hoarse or breathy voices and, As the thyroid cartilage snaps back impact forces, secondary fractures occasionally, airway obstruction and from its compression against the cer- can occur on the sides of the cricoid breathing difficulties. Dislocation of a vical spine, the thyroarytenoid mus- cartilage, resulting in airway collapse cricothyroid joint (the joint that cle and ligament (which together and possible injury to the recurrent connects the cricoid and thyroid car- comprise the vocal fold) may tear, laryngeal nerve (the nerve that sup- tilage) may result in loss of the ability resulting in a separation at any point plies motor function to the vocal folds) to change pitch.' along its length. This may be evident due to impingement of the nerve by as lacerations or hemorrhage (bleed- segments of fractured cartilage. ADULT LARYNGOTRACHEAL ing) of one or both vocal folds. The If the force is severe and/or low in INJURIES FROM BLUNT TRAUMA mucosa (the lining tissue) on the ary- the neck, complete separation of the tenoids may be denuded or avulsed. larynx and trachea may occur.' This Laryngotracheal injuries are rela- Because of the traction on the ary- situation is potentially life-threaten- tively rare in adults, except when there tenoids from the spring-like motion ing and requires emergent medical is a direct blow to the neck. In motor of the thyroid cartilage as it snaps back care. Separation usually occurs below vehicle collisions, the typical victim from the spine, the arytenoids may the cricoid cartilage, resulting in dis- of laryngotracheal trauma is an un- placement of the trachea into the chest belted, front seat passenger or driver 42 JOURNAL OF SINGING Care of the Professional Voice

and collapse of neck tissues into the of the airway. In addition, there may specialty trained in the diagnosis and airway, with consequent airway be an associated injury, and possibly treatment of laryngeal injuries. The obstruction and difficulty breath- transection, of both recurrent laryn- professional voice user with symp- ing.8-11 The neck muscles may serve geal nerves that are also compressed toms after laryngeal trauma should as a temporary opening for air until against the cervical spine during the be particularly vigilant about seeking edema (swelling) and hematoma for- injury.11,14 This paralyzes both vocal care from these specialists, as an mation (bleeding into the tissues) folds so they cannot open to breathe; injury that may not be recognized by result in obstruction of this tempo- the resultant immobility of the vocal other physicians can cause significant rary airway. folds can also be devastating to the long-term voice disability. voice. Evaluation and Treatment PEDIATRIC LARYNGOTRACHEAL of the Blunt Trauma Patient INJURIES FROM BLUNT TRAUMA ASSESSMENT OF BLUNT without Airway Distress INJURIES Fractures of the thyroid and cricoid In the patient without immediate cartilage from blunt trauma are un- Initial evaluation and assessment of signs of upper airway compromise, common in children. The greater elas- the blunt trauma patient is similar evaluation proceeds with a complete ticity of a child's cartilages makes them for adults and children. It is impor- evaluation, including examination of more resilient to external stresses. The tant for the physician to understand the neck, assessment of voice quality, child's larynx also sits higher in the the mechanism of injury. A high index and flexible fiberoptic evaluation of neck than in the adult, and the jaw of suspicion for blunt neck injury the larynx and upper airway. Fiber- serves more effectively as a protec- should be maintained in motor vehi- optic laryngoscopy is a procedure that tive shield in the child than it does in cle collisions, even without obvious involves the placement of a thin, the adult.12 Children are more likely to external signs. Knowledge of the speed lighted, flexible telescope into the nose, sustain injuries that result in edema of the vehicle at the time of collision, from which the larynx can be evalu- and hematoma formation in the lar- the use of seat belts by the trauma vic- ated. Fiberoptic laryngoscopy allows ynx and trachea.11"2 This is of par- tim, and the presence and deployment assessment of the mobility of the vocal ticular concern in the child because of air bags can also be helpful in esti- folds, patency of the upper airway, the smaller diameter of the airway mating the amount of force involved. and integrity of the laryngeal mucosa. makes it more susceptible to breath- In the patient with short stature, the If there is an adequate airway for ing problems. force of deceleration against a lock- breathing, intubation (placement of a An individual who falls onto the ing shoulder strap that is draped over breathing tube) is not necessary. handlebar of the bicycle may suffer the neck may also produce significant Because of the potential for the devel- an injury in which the cricoid carti- injury. opment of worsening laryngeal edema lage is dislocated and pushed under- Medical assessment of the patient and airway compromise, serial exam- neath the thyroid cartilage.11-14 These begins with evaluation and stabiliza- inations of the airway should be per- "telescoping" injuries are more com- tion of the airway in those who are formed during the first twenty-four mon in children. With more forceful having or have the potential to develop to forty-eight hours after injury if blows, complete separation of the lar- difficulty breathing. In patients who intubation is initially deemed unnec- ynx and trachea may occur. The ado- have experienced lower impact blows essary; hospital admission is recom- lescent and young adult riding a to the neck and larynx, immediate mended in some cases. snowmobile or an all-terrain vehicle evaluation and treatment are also nec- Management is determined by the may sustain a "clothes-line" type essary to assess for reparable injuries severity of the initial signs and injury to the neck. Upon collision and to prevent late complications. symptoms.'' Patients with any sign of with a cable or wire, the cable presses Any patient with symptoms after laryngeal injury (Table 1) should the larynx and trachea against the blunt laryngeal trauma, regardless of have a computed tomography (CT) cervical spine and can sever them.l4 how "minor" they may seem, should scan of the larynx to evaluate for possible laryngeal framework injury. These can be fatal injuries, especially be evaluated within twenty-four hours 13, 15, 16 when neck tissue collapse into the of injury by an otolaryngologist or CT of other head, neck, chest, space between the severed segments laryngologist. These physicians are and abdominal structures maybe appropriate as

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Table 1. Signs and Symptoms of Laryngeal Injury interfere with and prolong the natu- ral process of wound healing. The Hoarseness Shortness of breath advantage of using steroids is that Stridor (noisy breathing) Laryngeal edema they may minimize the formation of Laryngeal hematoma Air pockets underneath the neck skin scar tissue and decrease laryngeal Laryngeal laceration Neck pain/point laryngeal tenderness swelling.1'ss,I5,17,I8 In the patient with Difficulty swallowing Loss of laryngeal landmarks mild to moderate mucosal edema, Pain with swallowing or talking Impaired vocal fold mobility high-dose steroids are given during Cough productive of blood Cricoarytenoid dislocation , the first twenty-four to forty-eight Bruising of the neck Exposed laryngeal cartilage hours to minimize acute mucosal swelling. well, depending on the suspicion for vical spine injury may preclude the or presence of other injuries. Fractures ability to perform a direct laryn- Evaluation and Treatment of the of the thyroid cartilage can be pres- goscopy. In these instances, surgical Blunt Trauma Patient with Airway ent with very mild laryngeal signs and repair of the laryngeal injuries is Distress should be evaluated. Often, hoarse- begun based on findings on CT scan Signs of upper airway distress ness is the only sign of laryngeal frac- and fiberoptic laryngoscopy. include stridor (noisy breathing), ture, especially with low-impact forces Patients without fractures on CT shortness of breath, and labored such as elbow injuries to the neck scanning and those with minimally breathing. These patients maybe very while playing basketball or blows to displaced, stable fractures can be anxious, because the inability to the neck from an overly playful tod- observed closely. Injuries that consist breathe normally reduces the oxygen dler or dog. If left untreated, the of isolated mucosal lacerations of the supply to the body and can sometimes hoarseness may become permanent; supraglottic larynx (the part of the produce a fear of suffocation. The and the fractured larynx will heal, fus- larynx above the vocal folds), super- patient should be examined for signs ing the fractured segments into their ficial lacerations that do not involve of injury. In the presence of immedi- new, malpositioned locations. the vibrating edge of the true vocal ate, post-traumatic airway distress, Attempts at restoring the voice to fold, small hematomas of the true significant laryngotracheal injury is normal after the fracture segments vocal fold, and/or mild mucosal edema likely. The neck is stabilized to pre- are healed are difficult and often less may also be observed. Management vent worsening of unrecognized cer- vical spine injuries, and the airway is successful than repairs that are of these patients includes the use of 1,6s,n,IS 25 performed within one to two days of antibiotics, antireflux medications, secured with a tracheotomy. - injury. antireflux behavioral modifications, A tracheotomy is an operation that Fractures that appear unstable often voice rest, humidity, and frequent allows a breathing tube to be placed will be evaluated further with direct reexamination. Antireflux behavioral through the neck into the trachea. It laryngoscopy and surgical repair. modifications include elevation of the allows unobstructed breathing in Patients with minimally displaced head of the bed; avoidance of caffeine, patients who have significant swelling fractures that are associated with sig- tobacco products, dairy products, and in the parts of the airway above it. nificant laryngeal injuries also require citrus produce; and the avoidance of Orotracheal and/or nasotracheal intu- direct laryngoscopy and repair. Direct late meals and exercising too soon bation (placement of a breathing tube laryngoscopy is a procedure performed after meals. The use of antireflux through the mouth or nose) in the in the operating room usually under medications and antireflux presence of severe laryngotracheal general anesthesia during which a tel- behavioral modifications help to trauma can lead to further laryngeal escope that allows better examina- limit additional inflammation and injury and airway compromise. These tion of the larynx is placed through delays in wound healing caused by forms of intubation are avoided in the mouth. Because of the high poten- laryngopharyngeal reflux. Humidity favor of tracheotomy when intuba- tial for concomitant cervical spine helps to keep the vocal folds tion is needed. In addition, because injuries, assessment of the cervical lubricated, which aids in the healing the tracheotomy is placed below the spine is always performed prior to process. The benefit of steroids is vocal folds (instead of between them operative intervention for the laryn- controversial. The disadvantage of as is done with orotracheal and naso- geal injuries. The presence of a cer- steroids is that they may

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tracheal intubation), the risk of dam- vocal fold; to repair deep lacerations fractures (crushing injuries) that are age to the vocal folds from the tube of the vocal fold muscle; to restore not amenable to routine external fix- is reduced. the mucosal cover over exposed car- ation, extensive lacerations of mucosa Operative evaluation of the larynx tilage; to reposition the vocal fold; to within the larynx that are not amen- with direct laryngoscopy is performed reposition herniated tissue above the able to repair of at least one side, and/ after securing the airway. If direct vocal folds; to reconnect separated or mucosal injury in the region of the laryngoscopy reveals significant laryn- segments of the vocal folds; to recon- anterior commissure. In these situa- geal injuries, surgical repair is per- nect separated segments of larynx tions, stenting is helpful in providing formed. The presence of obvious and trachea; and to repair displaced internal fixation and in minimizing laryngeal fractures is also an indica- and/or unstable fractures. If not pre- webbing, especially at the anterior tion for surgical repair. If direct laryn- viously done, tracheotomy is per- commissure.15'17 Stents are removed goscopy does not reveal a need for formed to allow intraoperative access in seven to fourteen days. surgery, then a postoperative CT scan to the larynx and postoperative air- of the larynx is obtained to complete way management. Laryngeal Fixation the evaluation. Reduction and fixation of the car- Principles of Repair tilaginous framework is performed Intraoperative Evaluation The basic principles of repair follow after all mucosal injuries have been Intraoperative evaluation begins the primary principles of wound addressed. If a stent is deemed with direct laryngoscopy to assess the healing elsewhere in the body. necessary, it is placed prior to repair extent of endolaryngeal injury, esoph- Repair within the first twenty-four of the framework injuries. The agoscopy (examination of the esoph- hours after injury is most desirable fractures are reduced (placed back to agus through a telescope) to assess for to pre-vent scar tissue formation from their normal positions) and fixated esophageal lacerations, and bron- occur-ring prior to closure."' An (secured) to ensure a stable choscopy (examination of the trachea attempt is made to repair all mucosal reduction. Tradition-ally, and bronchi of the lungs through a lacerations and defects to prevent stabilization has been achieved using telescope) to assess for subglottic and scar formation. The formation of stainless steel wire or nonabsorbable tracheobronchial injuries. The aryte- scar tissue may result in vibratory suture. However, because these noid cartilages are palpated (felt) for dysfunction of the vocal folds, provide only two-dimensional possible dislocation. In the patient stenosis, or webbing (scar tissue fixation, there can be some movement with isolated cricoarytenoid joint that forms bands connecting the of the laryngeal fragments with head dislocation, reduction can usually be vocal folds). turning, neck flexion, and swallow- accomplished endoscopically (by ing. Movement of the fracture seg- operating through the laryngoscope), Endolaryngeal Stenting ments can delay the healing process especially if the dislocation is noted After all mucosal injuries are re- and sometimes can result in malposi- early. With delays in diagnosis, paired, a decision is made regarding tion of the healing segments. The scarring and stiffening of the joint the necessity for an endolaryngeal recent availability of titanium and can begin, making reduction more stent, a spacer placed within the lar- absorbable miniplates, which are tiny difficult and increasing the ynx to hold the vocal folds in posi- plates and screws similar to the ones likelihood of a permanently hoarse tion and keep them from scarring to that are used to repair broken bones voice. If no other injuries that require each other. Endolaryngeal stents were elsewhere in the body, has allowed repair are noted on CT scan or on developed originally to help keep the more rigid fixation of the laryngeal direct laryngoscopy, then open airway open. However, these have framework in three-dimensional exploration is not necessary. fallen out of favor for routine use in planes. This has the advantage over the last twenty-five years because of wire or suture fixation in that it allows Surgical Repair their propensity to move within the for immediate immobilization of the Surgery is performed to repair larynx. This movement may cause fracture segments, can be used effec- mucosal lacerations involving the friction on the repaired mucosa, which tively in most comminuted (splin- anterior commissure (the junction of promotes scar tissue formation.26 tered) fractures, and can decrease the 27,28 the vocal folds in the front of the lar- Endolaryngeal stents are reserved for need for endolaryngeal stenting. ynx) and/or the vibratory edge of the patients with severely comminuted The miniplates can be bent to con-

SEPTEMBER/OCTOBER 2002 45 Yolanda D. Heman-Ackah, MD and Robert t Sataloff, MD, DMA form to the geometry of the laryngeal ings in the early postoperative period. sometimes regard post-traumatic framework, thus preserving the shape of All patients with mucosal injuries are hoarseness as "minor." Recognizing the larynx. Usually, low-profile (thin) placed on an aggressive antireflux the need for prompt, expert evalua- plates provide adequate fixation of the protocol, even in the absence of a his- tion and referring a vocalist appro- laryngeal framework and are not tory of gastro-esophageal reflux, to priately may save a voice and a life. noticeable under the skin. minimize delays in wound healing associated with reflux induced laryn- Notes Recurrent Laryngeal Nerve Repair geal injury.31 Antibiotics are given to 1. S. D. Schaefer, "The Treatment of patients with open cartilage wounds Acute External Laryngeal Laryngotracheal separation injuries Injuries,"Archives of Otolaryngology to minimize the risk of laryngeal car- maybe accompanied by unilateral or Head and Neck Surgery 117 (1991): bilateral recurrent laryngeal nerve tilage infection. 35-39. injuries. The superior laryngeal nerves 2. G. D. Gussack, G. J. Jurkovich, also can be injured. An attempt should be CONCLUSION and A. Luterman, Laryngotracheal made to locate the nerves if the vocal Blunt injury to the laryngotracheal Trauma: A Protocol Approach to a folds exhibit evidence of immobility Rare Injury," Laryngoscope 96 (1986): complex can result from motor vehi- preoperatively. Crushed or otherwise 660-665. cle accidents, bicycle accidents, all- damaged but intact nerves should be left terrain vehicle accidents, contact 3. B. S. Jewett, W. W. Shockley, and alone to regenerate on their own. If a sports, stage performance, strangu- R. Rutledge, "External Laryngeal severed nerve is found, the severed ends Trauma Analysis of 392 Patients," lation, and hanging injuries. The pri- are reconnected either to each other or to Archives of Otolaryngology Head and mary concern in the initial manage- undamaged nerves nearby. If no repair is Neck Surgery 125 (1999): 877-880. ment of these i n j u r i e s is the per-formed, the vocal folds will be para- establishment and maintenance of an 4. G. Minard, K. A. Kudsk, M. A. lyzed and unable to move, and usually the adequate airway for breathing; Croce, J. A. Butts, R. S. Cicala, and voice will be permanently breathy and however, even the patient with T. C. Fabian, "Laryngotracheal hoarse. Although recurrent laryngeal Trauma," American Surgeon 58 (1992): "minor" symptoms, such as hoarse- nerve repair is unlikely to restore full 181-187. ness, should be evaluated, as these function to the vocal fold, it should patients may also have laryngeal frac- 5. R. T. Sataloff, "Structural provide enough tone to the vocal fold tures or soft tissue injuries of the lar- Abnormalities of the Larynx," in R. muscle for long-term vocalization pur- ynx that require repair. If injuries are T. Sataloff, ed., Professional Voice: The poses.29,30 Surgery to "fine-tune" the found, repair should be completed as Science and Art of Clinical Care, voice can be performed one year later, second edition (San Diego: soon as possible to limit permanent after the nerve has had a chance to Singular Publishing Group, Inc., disabilities related to the voice, swal- regenerate. 1997), 537. lowing, and breathing. Usually, injuries to the larynx and trachea are 6. C. L. Pennington, "External POSTOPERATIVE MANAGEMENT best evaluated and treated by oto- Trauma of the Larynx and Trachea: Immediate Treatment and laryngologists or laryngologists, as The goal of postoperative man- Management," Annals-of agement is to promote wound healing other physicians are not as familiar Otolaryngology, Rhinology, and and to limit scar tissue formation. with the intricacies involved in the Laryngology 81 Patients who undergo mucosal repair of assessment, diagnosis, and treatment (1972): 546-554. the vocal folds should exercise strict voice of such injuries. Reconstruction of rest for the first few days to a week after the normal anatomical relationships 7. L. W. Travis, N. R. Olson, J. W. surgery to allow the initial phases of of the larynx and trachea is per- Melvin, and J. G. Snyder, "Static and wound healing to occur. Occasionally, a formed, as needed, in an attempt to Dynamic Impact Trauma of the small flexible feeding tube is placed restore the normal phonatory, respi- Human Larynx," American Academy ratory, and protective functions of the of Ophthomology and Otolaryngology 80 through the nose and into the stomach to (1975): 382-390. allow tube feed- larynx. Singing teachers should be familiar with these principles and 8. D. G. Ashbaugh, and J. H. problems since even good doctors Gordon, "Traumatic Avulsion of the Trachea Associated with Cricoid Fracture,"Journal of Thoracic and Cardiovascular Surgery 69 (1975): 800- 803.

46 JOURNAL OF SINGING Care of the Professional Voice

9. S. M. Gold, M. E. Gerber, S. R. 19. J. B. Bent, J. R. Silver, and E. S. Annals of Otolaryngology, Rhinology, Shott, and C. M. Meyer III, "Blunt Proubsky, "Acute Laryngeal Trauma: and Laryngology 99 (1990): 772-777. Laryngotracheal Trauma in A Review of 77 Patients," Archives 29. R. L Crumley, "Teflon Versus Children," Archives of of Otolaryngology Head and Neck Thyroplasty Versus Nerve Transfer: A Otolaryngology Head and Neck Surgery 109 (1993): 441-449. Comparison," Annals of Surgery 123 (1997): 83-87. 20. C. P. Reece, and C. H. Shatney, Otolaryngology, Rhinology, and 10. D. P. Bryce, "Current Management "Blunt Injuries to the Cervical Laryngology 99 (1990): 759-763. of Laryngotracheal Injury," Advances Trachea: Review of 51 Patients," 30. R. L. Crumley, "Update: Ansa in Otology, Rhinoscopy, Laryngology Southern Medical Journal 81 (1988): Cervicalis to Recurrent Laryngeal 29 (1983): 27-38. 1542-1547. Nerve Anastomosis for Unilateral 11. H. R. Ford, M. J. Gardner, and J. M. 21. P. L. Chodosh, "Cricoid Fracture Laryngeal Paralysis," Laryngoscope Lynch, "Laryngotracheal Disruption with Tracheal Avulsion," Archives of 101 (1991): 384-388. from Blunt Pediatric Neck Injuries: Otolaryngology Head and Neck 31. F. B. Little, J. A. Kaufman, R I. Impact of Early Recognition and Surgery 87 (1968): 461-467. Kohut, and R. B. Marshall, "Effects of Intervention on Outcome," Journal Gastric Acid on the Pathogenesis of of Pediatric Surgery 30 (1995): 331- 22. H. H. Harris, "Management of In- Sublottic Stenosis," Annals of 334. juries to the Larynx and Trachea," Laryngoscope 82 (1972): 1924-1929. Otolaryngology, Rhinology, and 12. C. M. Meyer III, P. Orobello, R. T. Laryngology 94 (1985): 516-519. Cotton, and G. O. Bratcher, "Blunt 23. J. Ogura, "Management of Laryngeal Trauma in Children," Traumatic Injuries of the Larynx and Laryngoscope 97 (1987): 1043-1048. Trachea Including Stenosis,"Journal Yolanda D. Heman-Ackah, MD, is Assistant Professor of Laryngology and 13. C. J. Offia, and D. Endres, "Isolated ofLaryngology and Otolaryngology 85 Professional Voice Care in the Department Laryngotracheal Separation Following (1971): 1259-1261. of Otolaryngology—Head and Neck Blunt Trauma to the Neck,"Journal 24. T. H. Trone, S. D. Schaefer, and H. Surgery at the University of Illinois at of Laryngology and Otolaryngology M. Carder, "Blunt and Penetrating Chicago. She is the director and founder of 111 (1997): 1079-1081. Laryngeal Trauma: A 13 Year the Voice Center at the University of Illinois 14. W. A. Alonso, V. G. Caruso, and E. Review," Archives of Otolaryngology at Chicago. She has authored and coau- A. Roncace, "Minibikes, a New Factor Head and Neck Surgery 88 (1980): thored numerous publications in the fields in Laryngotracheal Trauma," Annals 257-261. of laryngology and professional voice care, of Otolaryngology, Rhinology, and 25. G. M. Fuhrman, F. H. Stieg, and C. including award-winning scientific jour- Laryngology 81 (1973): 800-804. A. Buerk, "Blunt Laryngeal Trauma: nal articles, book chapters, and a book. 15. S. D. Schaefer, and L. G. Close, Classification and Management Robert Thayer Sataloff, MD, DMA, is pro- Protocol," Journal of Trauma 30 "Acute Management of Laryngeal fessor of Otolaryngology—Head and Neck (1990): 87-92. Trauma. Update," Annals of Surgery, Thomas Jefferson University; Otolaryngology, Rhinology, and 26. G. D. Thomas, and M. H. Stevens, Chairman, Department of Otolaryngology Laryngology 98 (1989): 98-104. "Stenting in Experimental Laryngeal —Head and Neck Surgery, Graduate 16. J. A. Schild, and E. C. Denneny, Injuries," Archives of Otolaryngology Hospital; Adjunct Professor, Department "Evaluation and Treatment of Acute Head and Neck Surgery 101 (1975): of Otorhinolaryngology, University of Laryngeal Fractures," Head and Neck 217-221. Pennsylvania; Adjunct Professor, Depart- 11 (1989): 491-496. 27. P. Woo, and R. Kellman, ment of Otolaryngology—Head and Neck 17. N. R. Olson, "Surgical Treatment of "Laryngeal Framework Surgery, Georgetown University School of Acute Blunt Laryngeal Injuries," Reconstruction with Miniplates: Medicine; Chairman, The Voice Founda- Annals of Otolaryngology, Rhinology, Indications and Extended Indications tion; Chairman, The American Institute and Laryngology 87 (1978): 716-721. in 27 Cases," Operative Techniques for Voice and Ear Research. He has authored more than 500 publications, including Otolaryngological Head Neck Surgery 18. E. Lucente, M. Mitrani, S. H. twenty books. Sacks, and H. F. Biller, "Penetrating 3 (1972): 159-164. Injuries of the Larynx," Ear Nose 28. P. Woo, "Laryngeal Framework Throat Journal 64 (1985): 406-415. Reconstruction with Miniplates,"

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