J R Army Med Corps: first published as 10.1136/jramc-141-01-03 on 1 February 1995. Downloaded from J fI /\nll)' Med Corps 1995: 141: 16- 19 Reconstruction of Laryngotracheal War Injuries with the Median Layer of the Deep Cervical Fascia o Danic MD o Milicic MD o Prgomet MD Dept oJ OlOrhirwlaryngolog), and Cervicofacial Surgel)', General Hospital" Dr Jasip Bencevic" Slavonski Brad, Andri)e Stalllpara 42. 55000 Slavomki Brod. Croalia. S Simovlc MD Clinic of Otorhinolm)'flg%gy and Cervicofacial Sftrger),. Medical School Zagreb. Salata 4, 41000 Zag reb. Croatia. by guest. Protected copyright. SUMMARY: Surgical exploration and immediate reconstruction with the median layer of the deep ccnical fascia (MLDCF) was performed in 8 of 22 patients with exogenous war injuries of larynx and cervical trachea. A surgical technique of reconstruction with the median layer of the deep cervical fascia is described. The 7 surviving patients had good respiration without signs of stenosis of the larynx and/or the trnchea. Four had good and 3 satisfactory, phonation, and none had swaUowing difficulties. Owing to tbe simplicity of the surgical approach, its size and biological properties, the median layer of deep cervical fascia pro\'ed itself to be a suitable material in the immediate reconstruction of exogcnerous war injuries 01' the larynx and cef\'ical trachea. Introduction functional resul ts of reconstructi .... e intervention, prompted Despite the superfi cial positio n of the larynx and many authors to use different covering materials. with trachea, the in cidence of injury by exogenous factors is varying success. Krajina has used fa scia of the very rare during both peace-time and war ( I). There were sternohyoid muscle in the reconstruction of the larynx 13 patients treated at our department ror exogenous injury lume n in various types of partial laryngectomy sincc of the larynx and th e trachea during the period 1975 to 1969, with excell ent results ( 11). In the war situation we 1984, representi ng 0.94% of all hospitaliz.ed pmients wi th made use of this technique, improving it and widening http://militaryhealth.bmj.com/ its head and neck injuries during that period (2). indicati ons. A fl ap formed from the median layer of the Data on the incidence of combat related laryngotracheal deep cer vical fascin ( MLDC F) be ing used in the injuries is rarely found in the literature. Zayton et ai, i rnmediate reconstruction of 8 cases of laryngotracheal recorded 54 such patients among 1.021 wounded with trauma. head and neck injuries during the ten-year Lebanon war (3). The data on the incidence of such injuries could vary Patients and Methods greally during the same war, for example in the n Mobile During the 199111992 war in ereatia (12, 13),7.043 Surgical Hospita l in Soul.h Vietna m , am o ng 1,011 wounded were treated at the Medical Center in Slavonski wounded there were only 6 tracheal and cricoid cartilage Bred (the reg ion of Brodska Posavin a, East Croatia) from injuries in the year 1966 lO 1967 (4). However, from 1967 July I 1991 to December 3 1 1992. Our department ofthe lo 1968, 22 laryngotracheal i njuri e~ wcre registered in the Otorhinolaryngology Hnd Cervicofacial Surgery treated on September 29, 2021 "241h e .... acuation hospital in Vietnam" (5). 728 hcad and neck injuries, of whom 22 (0.3 1%) had A number of authors have offered differing principles laryngeal and cervical trachea injuries. Sixteen of them of treatment for peace-time injuries. These differing views had an injury or the larynx, 4 of the larynx and trachea, I and opinions are with regard to all stages of care; from of the trachea and I of the recurrent laryngeal ner .... e indications, ti me o f initial s urg ic al c are throug h to (Table I). de finiti ve surgical management (6- 10). The absence of Splinters of shells, mines and hand grenades caused thyro id cartilage or e xposure of tracheal cartil age injuries in 18, rifl e bullet in 2 and plastic explosive in I. A s urfaces, which favours infec tion a nd dimini s hed contusion was responsible for onc other (Table 2). J R Army Med Corps: first published as 10.1136/jramc-141-01-03 on 1 February 1995. Downloaded from Laryngotracheal War Injuries 17 All wounded were male, 20 were soldiers and 2 were Table 3 civilians, their ages rangIng from 5 to 43 years. We Surgical treatment of 21 patients with laryngotracheal war hospitalised 21 patients, the patient with the laryngeal wounds. contusion being treated as an outpatient. Twenty wounded Group 1 No. Treatment were hospitalised within the first three hours of injury. Hematomas, small 4 Surgical treatment of the The patient with laryngeal contusion was treated on the lesions of laryngeal wound without the exploration second day after being wounded. The patient with the mucosa or cartilage of the larynx explosive laryngeal injury was transferred from another Group 2 medical institution on the fifth day of the injury. Large lesions of mucosa 4 Exploration of the larynx, Only 2 of the wounded had isolated injuries of the especially at frontal conservative debridement, junction, small fractures primary suture of mucosa larynx or trachea while the others had associated injuries of the cartilage of the neck and head or the neck and/or other parts of the Group 3 body. Large mucosal lesions, 10 Exploration of the larynx, Endoscopic techniques, classical X-ray and eT-scan multiple fractures with MLDCF* reconstruction in were used for pre-operative diagnosis. defects of cartilage, 7 patients The largest number of wounds were transglottic (nine), preserved stability of supraglottic (eight), glottic (three) and cricoid (six). cartilaginous skeleton Tracheal lesions were located in the cartilaginous skeleton Group 4 Instability of the 3 Exploration of the larynx, up to the fourth tracheal ring and one of the wounded had cartilaginous skeleton MLDCF reconstruction in a posterior membranous wall injury. one patient, stent Twenty-one wounded were surgically treated, the one * MLDCF - median layer of deep cervical fascia used for with the larynx contusion being treated conservatively. reconstruction of laryngotracheal war injuries. by guest. Protected copyright. Eight of the 21 surgical patients were managed with median layer of the deep cervical fascia. 1. Four patients had hematomas, or small lesions of Surgically treated patients were divided into four endolaryngeal mucosa, and injury to the perichondrium groups (Table 3): but without fracture of the larynx or tracheal cartilage. These were treated surgically without exploration of Table 1 the larynx or the trachea. War wounds of the head and neck treated in the General 2. Four patients had minor lesions of the endolaryngeal Hospital ''Or Josip Bencevic" Slavonski Brod from July 1 mucosa, especially in the area of the anterior 1991 to December 311992. commisure and smaller linear fractures of thyroid or tracheal cartilage but without any large dislocation or a defect. The lesions of perichondrium were not No. (%) of patients/treatment Outpatient Hospitalized Total significant. These were treated by exploration, and conservative debridement. The continuity of the mucosa was secured primarily by absorbable stitches 4-0 or 5-0. Head 187 (67) 354 (78) 541 (74) 3. Ten patients had large lesions of endolaryngeal mucosa Neck 60 (21) 57 (14) 117 (6) with damage to vocal cords and/or ventricular folds, http://militaryhealth.bmj.com/ Head and neck 32 (2) 38 (8) 70 (0) multiple fractures of thyroid and cricoid cartilages, Total 279 (38) 449 (62) 728 (lOO) with defects in perichondrium and cartilage but with a preserved stability of cricothyroid ring. Seven patients were managed with use of the median layer of the deep cervical fascia. In 5 a reconstruction Table 2 of the laryngeal lumen was performed by use of this The localization and etiology of war wounds of the larynx and tissue. The sixth patient also had a partial defect of the trachea in 22 patients in General Hospital "Dr Josip first two tracheal rings so that the median layer of the Bentevfc" Slavonski Brod from July 11991 to December 31 deep cervical fascia was used for the reconstruction of 1992. the lumen of both the larynx and the trachea. The seventh patient, in addition to damage to the cricoid Localization (No.) Etiology (No.) and first tracheal ring, also had a penetrating wound of on September 29, 2021 the' oesophagus and seventh cervical vertebra. In the reconstruction of the cricoid and trachea a strap muscle Larynx 16 Shells 18 flap, according to Miller-Duplechain (7), was used Trachea 1 Bullets 2 beside the median layer of the deep cervical fascia for Larynx and trachea 4 Plastic explosive the prevention of tracheoesophageal fistula. Recurrent nerve Contusion 4. Three patients had massive lesions of the endolaryngeal structures, comminuted fractures and large defects of J R Army Med Corps: first published as 10.1136/jramc-141-01-03 on 1 February 1995. Downloaded from 18 D Danic, D MiliCit, D Prgomet and S Simovit thyroid and cricoid cartilage causing instability of the treatment. In all cases of war injuries to the larynx and/or cricothyroid ring. The median layer of the deep trachea, the wound is drained after treatment and the skin cervical fascia was used for reconstruction in one primarily closed. Postoperatively, antibiotic prophylaxis patient. (Penicillin G 4 x 2000000 i.u. i.v. a day + Gentamicin 5 mg/kg body weight i.v. a day in three doses + Surgical Technique Metronidasol 3 x 500 mg i. v. a day) is given to all The median layer of the deep cervical fascia consists of patients, after the recommendation of the Croatian - strong fibrous tissue encompassing only the anterior plane Ministry of Health Care (14).