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Management of Laryngeal and Tracheal Blunt Trauma

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Management of Laryngeal and Tracheal Blunt Trauma J. Jpn. Bronchoesophagol. Soc. 日 気 食 会 報, 37 (2), 1986 Vol. 37 No. 2 pp. 77-83 (Special Lecture) Management of Laryngeal and Tracheal Blunt Trauma James B. Snow, Jr. M.D. Department of Otorhinolaryngology and Human Communication, University of Pennsylvania School of Medicine, Philadelphia Blunt trauma to the larynx and trachea has become a common problem in rural agricultural and urban industrial areas. It results from vehicular accidents, horseback riding and interper- sonal conflict. In vehicular accidents, blunt trauma to the larynx and trachea occurs in deceleration impacts in which the larynx and trachea are crushed between the object against which the deceleration occurs and the cervical vertebrae. In automobile accidents these injuries are likely to be to the driver who is thrown forward against the steering wheel with the neck extended. A similar injury results when a motorcyclist, horseback rider or bicyclist strikes their neck against a taut line. Children may sustain these injuries by falling with the neck extended against the handle bars of a bicycle. In contact sports, deceleration or acceleration impacts may occur to the larynx and trachea resulting in crushing the larynx or trachea against the cervical vertebrae. In interpersonal conflicts, acceleration blows to the larynx and trachea may occur with a fist or hand held weapon, and compression injuries occur in manual strangulation and hangings. Vehicular accidents cause the majority of these injuries in the United States. Blunt trauma has replaced infections as the leading cause of laryngeal stenosis. Blunt trauma results in fractures and dislocations of the laryngeal cartilages, separation of the cricoid cartilage from the trachea, laceration or transection of the trachea and transection or avulsion of the recurrent laryngeal nerves. The fractures of the larynx may be categorized as supraglottic, glottic and transglottic2). The thyroid cartilage is usually fractured in all three types. In addition to the fracture of the thyroid cartilage, there may be dislocation of the epiglottis in supraglottic fractures. The thyroepiglottic ligament may be lacerated allowing posterior and inferior displacement of the epiglottis. The hyothyroid membrane may be lacerated resulting in separation of the hyoid bone from the thyroid cartilage. The superior laryngeal nerves may be injured resulting in laryngeal hypesthesia and, if only one superior laryngeal nerve is injured, in tilting of the larynx on phonation due to the uneven pull of the cricothyroid muscles. Severe disruption of the supraglottic structures may result in supraglottic stenosis. Individuals with long, slender necks are more likely to sustain this type of laryngeal fracture. Severe glottic fractures are characterized by comminuted fractures of the thyroid cartilage and dislocation of the arytenoid cartilages. The laceration of the mucous membrane and the *Presented at the 37th Annual Meeting of the Japan Broncho -esophagological Society, Fukuoka, November 1985. **Request reprint: Dr. James B. Snow, Jr., Department of Otorhinolaryngology and Human Communi- cation, University of Pennsylvania School of Medicine, Philadelphia, PA, U.S.A. 9-77 日気 食 会 報, 37 (2), 1986 displacement of fragments of the thyroid cartilage into the glottic lumen are of particular importance in these fractures because they contribute to the development of phonatory disability and glottic stenosis. Exact reduction of even a non-comminuted fracture of the thyroid cartilage is of great importance in the restoration of the voice as recently pointed out by Hirano et al.3) The foreshortening of the anterior-posterior dimension of the glottis results in difficulty in achieving high-frequency phonation. Transglottic fractures involve the cricoid cartilage as well as the thyroid cartilage and may result in subglottic stenosis. Vehicular accidents as well as strangulation are likely to result in thyroid and cricoid cartilage fractures1). Restoration of the cricoid ring is of paramount importance in maintaining an adequate subglottic airway. Transglottic fractures are more likely to occur in heavy-set individuals with short, muscular necks. This injury is more likely to occur to men than women. Travis et al. demonstrated that in older males with prominent, calcified thyroid cartilages, fracture of the thyroid cartilage occurs in static tests prior to cricoid cartilage loading while in women the load was shared by the cricoid cartilage earlier4). The situation appears to be similar to what occurs in strangulation and hanging. Dynamic testing resulted in cricothyroid joint dislocation as well as fractures of the thyroid and cricoid cartilages. This situation is also similar to vehicular accidents. The most common thyroid cartilage fracture is vertical in the midline or paramedial. These fractures produce submucosal edema and hemorrhage but may not produce lacerations of the mucous membrane, dislocation of thyroid cartilage fragments or dislocation of the arytenoid cartilages. Splaying of the thyroid lamina without fracture can occur with impact forces up to 15 kg. The slender anterior arch of the cricoid cartilage gradually becomes a stronger buttress anterior to the cricothyroid articulations. If the cricoid cartilage were a uniform ring, an anterior impact would be expected to fracture each lateral arc and the anterior arch would be depressed into the lumen. Actually, at low force, the fracture is in the midline or paramedian position. With higher impact force, lateral arc fractures do occur with depression of the anterior arch into the airway. Mean static force required to fracture the thyroid cartilage is 15.8 kg while 20.8 kg are required for fracture of the cricoid cartilage. Fractures of the cricoid cartilage are often associated with separation of the cricoid cartilage and trachea and transection of the trachea. Fractures of the cricoid cartilage and transection of the trachea are frequently associated with transection or avulsion of one or both recurrent laryngeal nerves. The patient may present with hemoptysis, subcutaneous emphysema, hoarseness, aphonia, dysphagia, upper airway obstruction and neurologic deficits. The patient may be in urgent need of establishing an airway or may be breathing surprisingly easily initially even with transection of the trachea. The airway obstruction tends to become worse over the first 24 hours after the injury. Differential Diagnosis Hemoptysis or subcutaneous emphysema following blunt trauma to the neck must be considered indicative of a fracture of the larynx, transection of the trachea or pharyngeal or esophageal perforation until proven otherwise. Hemoptysis is an indication that the laryngeal 10-78 日気 食 会 報, 37 (2), 1986 or tracheal mucous membrane has been lacerated, and intralaryngeal and intratracheal lacer- ations ordinarily do not occur with blunt trauma unless the laryngeal cartilages or the tracheal wall have been fractured. However, laryngeal fractures, particularly the midline or paramed- ial fracture of the thyroid cartilage, can occur without laceration of the mucous membrane of the larynx and therefore without hemoptysis. With laryngeal fractures or transection of the trachea, the hemoptysis may consist of frank blood or streaks of blood in mucus. Subcutaneous emphysema is the usual finding in fractures of the larynx and transection of the trachea. It suggests that the airway has been disrupted, but it can also occur with pharyngeal or esophageal perforation and these possibilities must be excluded. Subcutaneous emphysema following trauma may also be due to extension of mediastinal emphysema secondary to rupture of a bronchus or other intrathoracic injury. Subcutaneous emphysema produces crepitus and moderate tenderness. Absence of subcutaneous emphysema is not strong evidence against a laryngeal fracture or tracheal transection. The voice may be normal or there may be hoarseness or aphonia with fractures of the larynx or transection of the trachea. There may be pain on swallowing and difficulty handling the patient's saliva. Soft tissue swelling usually precludes accurate palpation of the laryngeal and tracheal cartilages for crepitus, point-tenderness and displacement. The initial evaluation of the patient is directed toward determination if there is an adequate and stable airway. The pulse and blood pressure may indicate hypovolemia. The manage- ment of associated head, thoracic and abdominal injuries may take precedence over the management of laryngeal and tracheal injuries. The possibility of dislocation or fracture of the cervical vertebrae must be considered during the initial evaluation of the airway and in establishing an adequate and secure airway. The neck must not be flexed or extended until posterior-anterior and lateral radiographs of the neck show that all seven cervical vertebrae are normal. Demonstration of all seven cervical vertebrae is accomplished by asking the patient to lower the shoulders by reaching for the knees. The order of the diagnostic steps is of great importance. If there is stridor and inadequate ventilation, a tracheotomy is required. Lifesaving tracheotomy is often required at the site of the accident. The airway must be established without flexion or extension of the neck because of the possibility of a fracture or dislocation of the cervical vertebrae. Endotracheal intuba- tion is usually not a satisfactory means of establishing an airway if there is disruption of the laryngeal lumen or transection of the trachea. Assuming that the airway is adequate
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