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Management of Laryngeal Trauma

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Management of Laryngeal Trauma Management of Laryngeal Trauma Nadir Elias, DMDa, James Thomas, MDb, Allen Cheng, MD, DDSc,* KEYWORDS Laryngeal trauma Laryngotracheal injury Laryngofissure KEY POINTS The key step in treatment of any laryngeal injury is the establishment of a secure airway. Early intervention (within 24–48 hours) is an important factor for improved patient outcomes (func- tional speech, swallowing, and airway patency). An awake tracheostomy is the airway of choice with grade II or higher laryngeal injuries. INTRODUCTION Whereas blunt injuries have been described as be- ing associated with greater length of hospitaliza- The larynx is a complex anatomic structure and a tion,5 our experience has been that penetrating properly functioning larynx is essential for breath- airway injuries, often associated with ballistic ing, voice, and swallowing. Injuries to the larynx wounds, are much more likely to be associated and trachea can result in significant and potentially with greater endolaryngeal disruption. The types fatal consequences. Laryngeal trauma is often of tissues involved have been divided into hard associated with other injuries, including intracra- and soft tissue injuries. Locations of injuries have nial injuries (17%), penetrating neck injuries been classified as injuries that affect the supraglot- (18%), cervical spine fractures (13%), and facial 1 tic larynx, the glottis, and subglottic larynx. fractures (9%). Laryngeal injuries are rare, occur- Lynch5 was the first to classify traumatic injuries ring in only 1 of 5000 to 137,000 emergency room based on location. In 1969, Nahum6 described visits1–3 and among only 1 in 445 patients with se- 4 laryngeal injuries based on injury location and likeli- vere injuries. Because of this, even surgeons with hood of recovery with and without intervention. In a great deal of experience in managing maxillofa- 1980, Schaefer and colleagues developed what cial trauma have limited exposure to management has become the most popular classification system of laryngeal and tracheal injury. This article dis- to assess the severity of such injuries.7 This classi- cusses the evaluation, diagnosis, and manage- fication describes laryngeal injuries on a scale of ment of patients with laryngeal and tracheal injury. I-IV. Schaefer’s classification was later modified by Fuhrman and colleagues8 to include laryngotra- CLASSIFICATION OF LARYNGEAL INJURIES cheal separation (Table 1) and again by Verschue- ren and colleagues4 in 2006 to include the use of Several classification systems have been computed tomography (CT) imaging in staging (Ta- described to assist in developing an algorithmic ble 2). In this article, the discussion of the initial approach to managing these difficult and rare in- evaluation and management of a patient with laryn- juries. These classification systems have been geal trauma is within the framework of the Legacy based on mode of injury, types of tissues involved Emanuel Classification, as outlined by the algorithm in the injury, anatomic locations of injury, and in Fig. 1. However, the principles are generalizable severity of the injury. Modes of injury have been and can be applied to whichever system the reader divided into blunt and penetrating injuries. finds most helpful in their practice. a Advanced Craniomaxillofacial and Trauma Surgery, Legacy Emanuel Medical Center, 1849 NW Kearney Street, Suite 300, Portland, OR 97209, USA; b Private Practice, Voicedoctor.net, 909 NW 18th Avenue, Portland, OR 97209, USA; c Oral/Head and Neck Oncology, Legacy Good Samaritan Cancer Center, Portland, OR, USA * Corresponding author. 1849 Northwest Kearney, Suite 300, Portland, OR 97209. E-mail address: [email protected] Oral Maxillofacial Surg Clin N Am 33 (2021) 417–427 https://doi.org/10.1016/j.coms.2021.04.007 1042-3699/21/Ó 2021 Elsevier Inc. All rights reserved. oralmaxsurgery.theclinics.com Descargado para BINASSS Circulaci ([email protected]) en National Library of Health and Social Security de ClinicalKey.es por Elsevier en julio 15, 2021. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados. 418 Elias et al Table 1 Fuhrman-Schaefer classification of laryngeal injuries Stage Injury I Minor laryngeal hematoma, edema, laceration; no detectable fracture II Edema, hematoma, mucosal disruption with no exposed cartilage, nondisplaced fractures III Significant edema, noted mucosal disruption, exposed cartilage with or without cord immobility, displaced fractures IV Significant edema, noted mucosal disruption, exposed cartilage with or without cord immobility, displaced fractures with 2 or more fracture lines, skeletal instability/anterior commissure trauma V Complete laryngotracheal separation INITIAL EVALUATION AND INITIAL begins with the primary survey as outlined in MANAGEMENT Advanced Trauma Life Support algorithms. Because the larynx and trachea are critical com- The initial evaluation of a patient suspected of hav- ponents of the airway, prompt identification and ing laryngeal or tracheal injury, as with any trauma, management of these injuries are prioritized. This Table 2 Legacy Emanuel Medical Center laryngeal injury classification Stage Diagnostic Findings Management I Minor airway symptoms Observation Æ Voice changes Humidified air No fractures Head of bed elevation Small lacerations II Airway compromise Immediate awake Nondisplaced fractures tracheostomy if airway not No cartilage exposure already secured in the field Voice changes Humidified air Æ Subcutaneous emphysema Head of bed elevation Æ ORIF III Airway compromise Immediate awake Edema tracheostomy if airway not Mucosal lacerations already secured in the field Palpable laryngeal fractures Direct laryngoscopy Exposed cartilage Exploration and ORIF Subcutaneous emphysemas Voice changes IV Airway compromise Immediate awake Mucosal lacerations tracheostomy if airway not Exposed cartilage already secured in the field Palpable displaced laryngeal Direct laryngoscopy fractures with skeletal Exploration/ORIF instability Consider stenting Subcutaneous emphysemas Voice changes Abbreviation: ORIF, open reduction internal fixation. Adapted from Verschueren DS, Bell RB, Bagheri SC, Dierks EJ, Potter BE. Management of laryngo-tracheal injuries asso- ciated with craniomaxillofacial trauma. J Oral Maxillofac Surg. 2006 Feb;64(2):203-14; with permission. Descargado para BINASSS Circulaci ([email protected]) en National Library of Health and Social Security de ClinicalKey.es por Elsevier en julio 15, 2021. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados. Management of Laryngeal Trauma 419 Fig. 1. Protocol for management of laryngotracheal injuries at Legacy Emanuel Hospital and Health Center in Portland, Oregon. ORIF, open reduction internal fixation. (From Verschueren DS, Bell RB, Bagheri SC, Dierks EJ, Potter BE. Management of laryngo-tracheal injuries associated with craniomaxillofacial trauma. J Oral Maxillofac Surg. 2006 Feb;64(2):203-14; with permission.) begins with a quick survey of the injuries. Patients precedence. The fiberoptic examination may help with either blunt or penetrating injury to the neck to verify that the patient’s airway is stable enough must be ruled out as having airway injury. The for transfer to the scanner. An awake fiberoptic ex- mechanism of the injury should also raise one’s amination also has the benefit of allowing visualiza- suspicion. In a review of laryngeal injuries from tion of the larynx in function. This examination is 1992 to 2004, high speed motor vehicle accidents meant to be performed quickly and efficiently so were the most common mechanism (49%), fol- as to not impede overall trauma management. The lowed by sports-related injuries (29%).4 Certain evaluating surgeon must keep in mind that trauma- mechanisms of injury, such as hanging, gunshot tized airways that appear stable tend to deteriorate wounds, or work-related high-energy injuries to over time because of the onset of edema, expansion the neck, should obviously generate an elevated of hematomas, and other contributory factors. level of suspicion. The next step is a CT scan of the head and neck, which is done in addition to CT scans of chest, abdomen, and pelvis that are routinely performed Stable Versus Unstable Airway as part of the trauma survey (Fig. 2). In stable pa- The first essential question is to establish whether tients with penetrating neck injury, a CT angiogram the airway is secured and whether the patient is is also included to evaluate for vascular injury. CT stable. If the patient is stable and protecting their imaging allows for rapid and accurate identifica- airway, there is time for a more deliberate exami- tion of hard tissue injuries to larynx and trachea nation. This is important because occult trachea- and identification of soft tissue air emphysema.10 laryngeal disturbance can occur with minimal If the airway is not secure and/or is unstable, external signs of trauma. or the patient is unstable for other reasons, the The initial airway physical examination starts patient is taken emergently to the operating with visual inspection for swelling, soft tissue injury room where securing the airway followed by sta- overlying the airway, loss of anatomic landmarks in bilization of the patient is the immediate priority. the neck, and signs of troubled breathing. A Traditionally, this is via an oral endotracheal intu- cursory examination
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