Laryngeal Trauma

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Laryngeal Trauma

Trauma
Author Credentials 

Robert L. Eller, MD
Associate Professor of Otolaryngology
Department of Otolaryngology Head and Neck Surgery
San Antonio Military Medical Center
Fort Sam Houston, Texas

Author’s note: For a full discourse on the topic of the management of acute laryngeal trauma, please see the appropriate chapter in Otolaryngology/Head and Neck Surgery Combat Casualty Care in OIF and OEF. US Government Publishing Office. 2015. Portions of this module were adapted from that publication.

Module Summary

Laryngeal trauma is rare, but can be life threatening and life altering. An astute physician will suspect a laryngeal injury whenever there is a change in the voice after a traumatic event or when there are signs of injury to the anterior neck. Careful management of the airway, correct classification of the injury, and thoughtful reconstruction techniques will enable the patient to return to normal function.

Module Learning Objectives 
  1. Explain laryngeal anatomy as it relates to trauma.
  2. Classify laryngeal injuries based on pattern and severity.
  3. Learn treatment modalities available for each type of injury.

Anatomy

Learning Objectives 
  1. Review the framework of the larynx and its position in the neck, highlighting features which afford protection.
  2. The laryngotracheal complex is largely protected from external forces by the mandible superiorly, manubrium inferiorly, and vertebral column posteriorly. Its ability to move within the neck adds additional protection from external forces. As we age, the larynx descends from the level of the C4 vertebrae to C7 and undergoes progressive calcification (men > women). Calicification begins in early adulthood, and starts in the posterior-inferior thyroid cartilage and the posterior portion of the cricoid cartilage. The increased exposure to external forces and increased brittleness due to calcification correlate with increased risk of fracture as we age.
  3. Laryngeal injuries differ based on age and gender. Subglottic and cervical trachea injuries are more commonly observed in women secondary to their tendency towards long, thin necks. Elderly patients have a higher incidence of comminuted laryngeal fractures secondary to advanced calcification. Pediatric patients typically have less severe laryngeal injuries and are less likely to experience laryngeal fractures. This is the result of the more elastic cartilage and the superior location of the larynx, which allows better protection by the mandible. Unfortunately, soft tissue damage is more common in children, as there is less fibrous-tissue support and mucous membranes have loose attachments. By this pathway, injuries that do not cause much swelling in adults can cause significant swelling in children.
References 
  1. Turkmen S, Cansu A, Turedi Set al. Age-dependent structural and radiological changes in the larynx. Clin Radiol. 2012;67:e22-26.
  2. Garvin HM. Ossification of laryngeal structures as indicators of age. J Forensic Sci. 2008;53:1023-1027.
  3. Mupparapu M, Vuppalapati A. Ossification of laryngeal cartilages on lateral cephalometric radiographs. Angle Orthod. 2005;75:196-201.
  4. Gluckman JL. Laryngeal trauma: surgical therapy in the adult. Ear, nose, & throat journal. 1981;60:366-372.
  5. Sidell D, Mendelsohn AH, Shapiro NL, St John M. Management and outcomes of laryngeal injuries in the pediatric population. The Annals of otology, rhinology, and laryngology. 2011;120:787-795.
  6. Gold SM, Gerber ME, Shott SR, Myer CM, 3rd. Blunt laryngotracheal trauma in children. Archives of otolaryngology--head & neck surgery. 1997;123:83-87.

Pathogenesis

Learning Objectives 

Understand sources of blunt and penetrating trauma.

  1. Blunt laryngeal trauma involves a distributed force across the larynx. Common events causing injury include:
    1. Impact with vehicle parts (steering wheel/dashboard/the rim of the hatch of an armored vehicle)
    2. Impact with sporting equipment
    3. Martial arts
    4. Falls
  2. Thyroid cartilage injuries:
    1. Posterior force: The larynx is driven against the vertebrae and thyroid cartilage splays, stressing the anterior lamina. It usually snaps off-midline, like a chicken wishbone. In young children this portion is actually softer, allowing it to significantly flex without breaking. Posterior dislocation can also disrupt the cricothyroid joint, injuring the RLN which courses directly posterior to this joint.
    2. When force is directed from the side, parasagittal displaced fractures of the thyroid cartilage tend to occur. The fractures usually occur anterior to the oblique line of the thyroid lamina as the insertion of the thyrohyoid and inferior constrictor muscles cushion and stabilize the cartilage posteriorly.
    3. Blunt forces that strike the anterior larynx at the level of the glottis often cause both an anterior vertical fracture and a horizontal fracture. The downward pull of the cricothyroid muscle along the posterioinferior border of the thyroid cartilage and the action of the sternothyroid muscle at the inferior tubercle can cause displacement of this fracture line. Cohn reported that a cruciate fracture occurs when the trauma is at the level of the glottis, below the thyroid prominence. When it is superior to that, a horizontal fracture can be produced.
  3. Cricoid injuries: The signet ring-shaped cricoid cartilage usually fractures in two places. Because the cricoid has more significant mass posteriorly, the fractures usually occur laterally and anteriorly. Posterior fractures occasionally occur.
  4. Arytenoid injuries: Unfortunately, there is little data in the literature regarding the biomechanics of arytenoid injury due to trauma. Miles et al. experimentally created blunt anterior laryngeal injury in dogs in 1971. They describe gross dislocation, fracture, and hemarthrosis in one dog, and frequently found vocal process fractures that were healing at the post-mortem histological examination
References 
  1. Cohn AM, Larson DL. Laryngeal injury: a critical review. Arch Otolaryngol. 1976;102:166-170.
  2. Schaefer SD. Management of acute blunt and penetrating external laryngeal trauma. The Laryngoscope. 2013.
  3. Miles WK, Olson NR, Rodriguez A. Acute treatment of experimental laryngeal fractures. The Annals of otology, rhinology, and laryngology. 1971;80:710-720

Incidence

Learning Objectives 
  1. Provide the student with statistics for both civilian and military populations.
  2. Civilian Data: In 2006, Verschueren et al. published their results of a 12-year review at tertiary care center. Of 16,465 patients who had head, neck, or facial injuries, 37 had laryngeal fractures (0.2%). Of those, 85% were caused by blunt trauma, and 96% of those also had maxillofacial trauma. Of the 27 with available records, 8 (29%) required open reduction and internal fixation (ORIF) of the laryngeal fracture and 2 (7%) required a stent. Attempting to determine if mechanism altered the pattern of injury, Stassen et al. analyzed 15 patients with a laryngeal injury in a civilian trauma center. Fully 60% had blunt trauma, and 88% of those were due to MVA. Blunt trauma was twice as likely to cause isolated laryngeal trauma without injury to the trachea, while penetrating trauma was more balanced.
  3. Military Data: Brennan et al. reviewed the emergency airway interventions and penetrating neck trauma from the beginning of Otolaryngology’s involvement in 2004 to near the end of the surge in 2007. The authors inspected their personal op logs to mine the details during a time when systematic data collection was lacking. This period of time included the Fallujah offensive and the most violent portions of the civil war and the Coalition “surge.” The data demonstrated that 28/112 (25%) patients who underwent neck exploration had injury to the laryngotracheal complex. Narrowing the aperture some, in patients with penetrating neck injury that required a surgical airway, 25/59 (42%) had laryngotracheal trauma. Lastly, a secondary review of the j-FAINT data14 revealed that there were 104 laryngeal cartilage injuries, 46 hyoid fractures, 32 tracheal injuries, 2 vocal cord injuries, 1 esophageal injury, 2 hyoid fractures, and 6 pharyngeal injuries. (personal communication)
References 
  1. Verschueren DS, Bell RB, Bagheri SC, Dierks EJ, Potter BE. Management of laryngo-tracheal injuries associated with craniomaxillofacial trauma. Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons. 2006;64:203-214.
  2. Stassen NA, Hoth JJ, Scott MJet al. Laryngotracheal injuries: does injury mechanism matter? The American surgeon. 2004;70:522-525.
  3. Brennan J, Lopez M, Gibbons MDet al. Penetrating neck trauma in Operation Iraqi Freedom. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. 2011;144:180-185.
  4. Brennan J, Gibbons MD, Lopez Met al. Traumatic airway management in Operation Iraqi Freedom. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. 2011;144:376-380.
  5. Feldt BA, Salinas NL, Rasmussen TE, Brennan J. The joint facial and invasive neck trauma (J-FAINT) project, Iraq and Afghanistan 2003-2011. Otolaryngology--head and neck surgery: official journal of American Academy of Otolaryngology-Head and Neck Surgery. 2013;148:403-408.

Patient Evaluation

Learning Objectives 

History:

  • Mechanism of injury is critical.
  • What was the patient’s functional status was before the injury? Professional singer or hermit? Can the patient talk? How well? Dyspnea? Stridor?

 

Physical exam:

  • Look: During the primary survey, one should look for injury to the mandible, cervical contusions, and hemoptysis or blood in the suction.
  • Listen: How does the voice sound to you? To the patient? Did anyone hear the voice before intubation?
  • Feel: Is there laryngeal framework instability or crepitance? Subcutaneous emphysema?
  • *Data used to create figures 1 and 2 was compiled from selected reports from 1942-2011 which are tabulated in a recent publication by Schaefer.

Decision Point:

  • If the primary survey suggests that there is laryngeal trauma and the patient is experiencing airway obstruction, a surgical airway is immediately indicated. If palpation of the larynx suggests that there is continuity of the cricoid and trachea and that the cricoid is not fractured, a cricothyroidotomy is the most expeditious. Otherwise, a formal tracheotomy is preferred.

Endoscopy:

  • If the primary survey suggests a laryngeal injury, and the patient is ventilating and currently, flexible laryngoscopy should be employed if it is available.
  • Look for anatomic integrity, edema, ecchymosis, and an intact sensory and motor systems.

Decision Point:

  • Does the patient need a definitive airway before further workup? If so, the most experienced person available should perform the intubation.

Imaging:

  • Computed tomography (CT) is the current study of choice in the trauma workup. CT angiography (CTA) is now standard of care in the evaluation of penetrating neck trauma.
  • CT can clearly delineate arytenoid malposition, laryngeal framework fractures, parapharyngeal space hematomas, and hyoid fractures, and may suggest disruption of the hyoepiglottic ligament.
References 
  1. Patterson BO, Holt PJ, Cleanthis Met al. Imaging vascular trauma. Br J Surg. 2012;99:494-505.
  2. Schaefer SD. Use of CT scanning in the management of the acutely injured larynx. Otolaryngol Clin North Am. 1991;24:31-36

Measurement of Functional Status

Learning Objectives 

Learn the Schaefer/Fuhrman classification of laryngeal injury.

Table 1.

Fuhrman’s modification of the Schaefer Classification 50

Group

Characteristic

I

Minimal or no compromise; minor endolaryngeal hematoma; no fractures

II

Endolaryngeal hematoma or edema associated with compromised airway; nondisplaced fracture on computed tomography scan; minor mucosal lacerations without cartilage exposure

III

Massive endolaryngeal edemawith airway obstruction; mucosal tears and cartilage exposure; immobility of vocal fold(s)

IV

Same as grade III with more than 2 fracture lines on imaging; massive endolaryngeal derangement

V

Laryngotracheal separation

 

 

 

 

 

 

 

 

 

 

 

 

References 
  1. Fuhrman GM, Stieg FH, 3rd, Buerk CA. Blunt laryngeal trauma: classification and management protocol. The Journal of trauma. 1990;30:87-92.

Treatment

Learning Objectives 
  1. Learn an algorithmic approach to caring for airway trauma.
  2. The operative goals are to:
    1. Provide a safe airway.
    2. Ensure that related injuries are identified and treated.
    3. Restore anatomical relationships.
    4. Repair mucosal injury.
  3. The optimal timing of this has been the subject of several reports, and there is consensus that laryngeal trauma should be repaired as soon as the patient is medically stable to proceed.

 

This chart is copied from Shaefer8

References 
  1. Butler AP, Wood BP, O'Rourke AK, Porubsky ES. Acute external laryngeal trauma: experience with 112 patients. The Annals of otology, rhinology, and laryngology. 2005;114:361-368.
  2. Mendelsohn AH, Sidell DR, Berke GS, John MS. Optimal timing of surgical intervention following adult laryngeal trauma. The Laryngoscope. 2011;121:2122-2127.
  3. Jewett BS, Shockley WW, Rutledge R. External laryngeal trauma analysis of 392 patients. Archives of otolaryngology--head & neck surgery. 1999;125:877-880.

Medical Therapies

Learning Objectives 

Objectives:

Understand the role of medications in laryngeal trauma.

  1. Corticosteroids:
    1. Corticosteroid use in laryngeal trauma is commonplace but not well studied. Previous animal studies suggest a positive effect.
    2. Steroids are proven to be valuable therapy in other laryngeal pathologies.
      1. Microflap surgery.
      2. Steroids are standard of care in croup.
      3. Very effective in reducing edema in autoimmune laryngeal inflammatory conditions.
    3. Recommended in trauma for 24-36 hours.
  2. Antireflux medications:
    1. Not widely studied in the setting of external laryngeal trauma
    2. A 2009 study by Kantas et al found better surgical outcomes and lower mean Reflux Finding Score and Reflux Symptom Index scores in subjects treated with PPIs in patients with surgically-induced endolaryngeal trauma compared to control cases.
    3. Reflux also plays a direct role in the perpetuation of vocal process granulomas.
    4. Therefore, PPI use in laryngeal trauma is recommended.
  3. Antibiotics:
    1. P. aeruginosa and S. aureus are the main pathogens that lead to catastrophic infections, but infections are frequently polymicrobial.
    2. In the acute setting, broad-spectrum coverage to include anaerobic pathogens is recommended:
      1. large internal tears
      2. hardware placed
      3. communication between the lumen and the repair
      4. stent is used
      5. repair is delayed
References 
  1. Campagnolo AM, Tsuji DH, Sennes LU, Imamura R. Steroid injection in chronic inflammatory vocal fold disorders, literature review. Brazilian journal of otorhinolaryngology. 2008;74:926-932.
  2. Coleman JR, Jr., Smith S, Reinisch Let al. Histomorphometric and laryngeal videostroboscopic analysis of the effects of corticosteroids on microflap healing in the dog larynx. The Annals of otology, rhinology, and laryngology. 1999;108:119-127.
  3. Russell KF, Liang Y, O'Gorman K, Johnson DW, Klassen TP. Glucocorticoids for croup. Cochrane Database Syst Rev. 2011:CD001955.
  4. Kantas I, Balatsouras DG, Kamargianis N, Katotomichelakis M, Riga M, Danielidis V. The influence of laryngopharyngeal reflux in the healing of laryngeal trauma. European archives of oto-rhino-laryngology: official journal of the European Federation of Oto-Rhino-Laryngological Societies. 2009;266:253-259.
  5. Beltsis A, Katsinelos P, Kountouras Jet al. Double probe pH-monitoring findings in patients with benign lesions of the true vocal folds: comparison with typical GERD and the effect of smoking. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies. 2011;268:1169-1174.
  6. Jewett BS, Cook RD, Johnson KL, Logan TC, Shockley WW. Effect of stenting after laryngotracheal reconstruction in a subglottic stenosis model. Otolaryngology--head and neck surgery: official journal of American Academy of Otolaryngology-Head and Neck Surgery. 2000;122:488-494.
  7. Simoni P, Wiatrak BJ. Microbiology of stents in laryngotracheal reconstruction. The Laryngoscope. 2004;114:364-367.

Surgical Therapies

Learning Objectives 

Understand the options and techniques for repairing laryngeal trauma.

  1. Rigid Endoscopy:
    1. If the patient’s condition permits, rigid endoscopy should be accomplished prior to embarking on laryngeal repair. Factors to consider include:
      1. Injured patients cannot always cooperate well enough to allow the same thorough flexible examination that can be obtained in routine office visits
      2. Tissue swelling, blood in the pharynx, and other pitfalls are frequently frustrating.
      3. Some lacerations may not be evident initially.
      4. Swallowing action can sweep away blood from an injury
      5. Telltale signs of wound healing are not apparent in the acute stage.
      6. The post-cricoid area and esophagus are better examined with a rigid endoscope.
  2. Endolaryngeal Injury Repair:
    1. Endoscopic Repair:
      1. Endoscopic suturing and tissue glues can be helpful at securing realigned edges. Keels can be secured to prevent anterior glottic webbing.
    2. External Repair
      1. A laryngofissure is useful to gain access for repair of significant endolaryngeal mucosal injuries.
      2. Anterior Commissure repairs should be made with a 5-0 monofilament and secured to the external thyroid cartilage perichondrium to ensure stability.
  3. Framework repair:
    1. Function depends on form: Careful attention needs to be paid to reconstructing the native shape of the thyroid cartilage. Careful review of the CT scan will help inform this process. Remember that the thyroid cartilage is more like a house with walls and a roof than just an A-Frame structure.
    2. Rigid fixation is best
      1. Miniplates secured with screws
      2. Make sure the drill hole is “too small” for the screw to improve thread bite into the soft cartilage.
      3. Wire or monofiliament suture can also be used to secure the plates, but should not be used without plates as there is a tendency to cheese-wire through the cartilage.
    3. Cricoid reconstruction may require an internal support such as a stent in addition to miniplates depending on how comminuted the fracture is.
  4. Stents and Keels
    1. Keels are used to keep the vocal folds apart during mucosal healing. They are secured in the anterior midline. An ideal keel should be easy to place and remove, and should not do additional damage. The author has found that a keel of soft goretex held in place by a large monofiliament suture which traverses the anterior commissure meets all of these criteria.
    2. Stents are used to maintain the lumen of the system. Tracheotomy is required. They can support a fractured cricoid, splay the arytenoids while the posterior commissure heals, and be used to hold grafts in place. Due to infectious risk, stents should generally should be removed within 7-14 days, depending on the reason for placement. e.g. Highly comminuted Cricoid fractures may require a longer-term stent. Several commercial and surgeon-fabricated options exist.

Case Studies

A 52 year old woman was injured in a motorcycle accident.Among her other injuries, she had a displaced right thyroid ala fracture. Direct laryngoscopy demonstrated diffuse edema and moderate ecchymosis. Intraoperative photographs show displaced right paramendian fracture, with subsequent exposure, realignment, and repair. The 10-hole plate allowed more than two points of fixation on either side of the fracture. Although difficult to appreciate in the photo, the plate is bent the most between the left-most sets of screws, and the larynx is being rotated to the left for the picture.

 

 

 

Review

Review Questions 

1. What is the incidence of laryngeal trauma in a civilian setting?

  1. 1/100 patients with face, head, or neck injuries
  2. 1/250 patients with face, head, or neck injuries
  3. 1/500 patients with face, head, or neck injuries
  4. 1/1000 patients with face, head, or neck injuries

Verschueren DS, Bell RB, Bagheri SC, Dierks EJ, Potter BE. Management of laryngo-tracheal injuries associated with craniomaxillofacial trauma. Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons 2006; 64:203-214

2. A 37 yo man falls from a ladder and strikes his neck on the way down.  Several hours after injury, flexible laryngoscopy demonstrates ecchymosis and edema of the vocal aryiepiglottic folds and piriform sinus on the right.  The right false vocal fold has a eccymotic bulge, but there are no lacerations. His right vocal fold is sluggish.  His airway is patent and no intervention is needed.  CT scan demonstrates a right single thyroid cartilage fracture which is displaced.  According to the Schaefer classification of laryngeal trauma, what is his injury group?

  1. 1
  2. 2
  3. 3
  4. 4

Schaefer, S. D.,The acute management of External Laryngeal trauma, a 27 year experience, Archives of Otolaryngology Head and Neck Surgery.,Vol 118, June 1992, 598-604.

3. What method has been proven to best stabilize reduced laryngeal cartilage fractures?

  1. Heavy nylon suture in figure of 8 pattern
  2. Miniplate fixation
  3. Stainless steel wire
  4. Fibrin glue

Dray TG, Coltrera MD, Pinczower EF. Thyroid cartilage fracture repair in rabbits: comparing healing with wire and miniplate fixation. Laryngoscope. 1999 Jan;109(1):118-22.

4. A 31 year old police officer is wounded with a handgun round to the larynx causing a complex thyroid cartilage fracture with minor bilateral vocal fold lacerations anteriorly but preservation of Broyles’ ligament.  The cricoid cartilage is intact.  You plan to stabilize the framework with miniplates.  What is the best way to prevent vocal fold webbing and promote healing of the superficial lamina propria?

  1. Perform a laryngofissure and suture the vocal fold lacerations with 4-0 chromic.
  2. Place an endolaryngeal finger-cot stent after plating
  3. Place a soft anterior commissure keel and secure it on the anterior thyroid cartilage or skin prior to plating the thyroid cartilage.
  4. Keep the patient intubated trans-glottically for a week

Eller, Dion, Spardaro.  Acute Laryngeal Trauma, in Otolaryngology/Head and Neck Surgery Combat Casualty Care in OIF and OEF. US Government Publishing Office. 2015

Answers: 

Question 1: C: 16,465 head, neck, and face injury patients reviewed by Verschueren had 37 laryngeal fractures.

Question 2: C. The scale increases in severity. While this patient does not have exposed cartilage or endolaryngeal lacerations, there is a displaced cartilage fracture and reduced vocal fold mobility with significant endolaryngeal ecchymosis. 

Question 3: B.  Miniplates have been shown in several studies to stabilize laryngeal cartilage fractures better than either heavy suture or wire.  Both of the latter cannot immobilize the cartilage in three dimensions and are prone to cheese wiring through the cartilage.  Miniplates using a large self-drilling and self-tapping screw.  An unpublished but effective alternative is to use wire to secure the miniplate.  This overcomes the difficulties of getting the screw to remain seated in the soft cartilage.

Question 4: C. With minor vocal fold lacerations, suture repair may not be necessary, and even if it is, fine resorbable sutures are best, especially with a trach in place to prevent coughing.  An endolaryngeal stent would prevent webbing but may cause injury to other parts of the glottis and certainly requires a tracheostomy for ventilation.   A soft keel, perhaps of GoreTex or silastic firmly secured in the anterior commissure with a heavy monofiliament suture will prevent web formation without further damaging the remaining vocal fold vibratory surface. Place the keel endoscopically prior to plating so that the force from the DL does not undo the fixation. Trans-glottic intubation will keep the vocal folds apart, but may induce posterior glottis injury.

References 
  • Verschueren DS, Bell RB, Bagheri SC, Dierks EJ, Potter BE. Management of laryngo-tracheal injuries associated with craniomaxillofacial trauma. Journal of oral and maxillofacial surgery: official journal of the American Association of Oral and Maxillofacial Surgeons. 2006;64:203-214
  • Schaefer, S. D.,The acute management of External Laryngeal trauma, a 27 year experience. Archives of Otolaryngology Head and Neck Surgery. June 1992;118;598-604.
  • Dray TG, Coltrera MD, Pinczower EF. Thyroid cartilage fracture repair in rabbits: comparing healing with wire and miniplate fixation. Laryngoscope. 1999 Jan;109(1):118-22.
  • Eller, Dion, Spardaro. Acute Laryngeal Trauma, in Otolaryngology/Head and Neck Surgery Combat Casualty Care in OIF and OEF. US Government Publishing Office. 2015