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Operative Techniques in Otolaryngology (2007) 18, 140-143

lunt and penetrating trauma to the larynx andpper airway

odd Preston, MD, Fred G. Fedok, MD, FACS

rom the Department of Surgery, Division of Otolaryngology–Head and Neck Surgery, Penn State College of Medicine,

enn State Milton S. Hershey Medical Center, Hershey, Pennsylvania.

Larynx and upper airway trauma are uncommon but potentially devastating injuries. These injuries mayrapidly progress with lethal consequences. In the United States, the incidence of laryngeal trauma isestimated to be between 1 in 5,000 to 1 in 137,000 emergency room visits. The most common etiologyof airway trauma is a blunt force impact to the anterior neck. With penetrating wounds there may beassociated tissue loss, injury to the nearby carotid sheath structures, or injury to the esophagus andpharynx. There is an overall mortality of 40% for blunt injuries and 20% for penetrating injuries.Evaluation and treatment are directed at preserving life and maintaining and restoring laryngealfunction.© 2007 Elsevier Inc. All rights reserved.

KEYWORDSLarynx;Laryngeal trauma;Laryngeal fractures;Laryngealemergencies;Stridor

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Larynx and upper airway trauma are uncommon butotentially devastating injuries. These injuries may rapidlyrogress to lethal consequences in a somewhat unpredict-ble fashion. In the United States, the incidence of laryngealrauma is estimated to be between 1 in 5,000 to 1 in 137,000mergency room visits.1,2 The most common etiology ofirway trauma is a blunt force impact to the anterior neck.1

aryngeal trauma also occurs by penetrating injuries to theeck, carrying a greater degree of urgency for control ofhe patient’s airway as the amount of tissue injury issually greater than that occurring by blunt force im-act.3,4 With penetrating wounds, there may be associ-ted tissue loss, injury to the nearby carotid sheath struc-ures, or injury to the esophagus and pharynx.4 Care muste taken not to overlook the extent of injury duringvaluation and management as the size of the externalound may not reflect the overall degree of injury. There

s an overall mortality of 40% for blunt injuries and 20%or penetrating injuries.5

Address reprint requests and correspondence: Fred G. Fedok, MD,ACS, Otolaryngology–Head and Neck Surgery, H091, Penn State Milton. Hershey Medical Center, 500 University Drive, PO Box 850, Hershey,A 17033-0850.

pE-mail address: ffedok@psu.edu.

043-1810/$ -see front matter © 2007 Elsevier Inc. All rights reserved.oi:10.1016/j.otot.2007.05.005

nitial evaluation and treatment

atients should be evaluated in accordance with basic traumarinciples, as delineated by the American College of Surgeons’dvanced Trauma Life Support protocol.6 There should be

pecial attention paid to the evaluation of the airway in patientsith a history of trauma to the anterior or anterolateral regionsf the neck. A significant injury should be suspected in patientsith hoarseness, shortness of breath, pain, or a globus sensa-

ion. Physical examination findings include the presence ofubcutaneous air, a change of the contour of the thyroid carti-age, hematoma, hemoptysis, and the presence of lacerations orcchymosis. The physical examination of the patient who isuspected of having significant laryngeal injury should includen examination of the endolarynx. Depending on the clinicalituation, this can be done via fiberoptic laryngoscopy. Thisan also be performed during the establishment of a definitiveirway.

For patients with an unstable airway, priority must be giveno the establishment of a definitive one by performing a tra-heotomy.2 This typically should be done with a minimum ofedation as sedation may decrease the patient’s ability to coughnd may lead to aspiration or respiratory collapse. In mostases, cricothyroidotomy should be avoided as this may com-lete a partial cricotracheal separation injury, leading to theoss of the airway.2 In stable patients with normal anatomicandmarks, a trial of endotracheal intubation may be cautiously

erformed under direct fiberoptic visualization.3

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141Preston and Fedok Trauma to the Larynx and Upper Airway

maging

ypically, computed tomography without contrast may be per-ormed to establish the extent and location of injury and pro-ide information for definitive treatment planning7,8 (Figure 1).n cases of suspected great vessel injury, however, contrastay be added to investigate these injuries. It also may reveal

ccult injuries in the case of penetrating wounds or foreignodies.3

efinitive treatment

or patients with type I injuries consisting of a greenstickracture or a nondisplaced fracture of the thyroid cartilage and

igure 1 Noncontrasted axial computed tomography scan demon-trating a left paramedian fracture of the thyroid cartilage, with sig-ificant amounts of air present within the soft tissues of the neck.

Figure 2 Subperichondrial dissection showin

ithout significant mucosal tear, conservative treatment maye considered, consisting of observation for at least 24 hoursith continuous oxygen saturation monitoring.3,4,8 This groupf patients may be managed with the administration of cool airr supplemental oxygen and treated with a brief course of IVteroids, antibiotics, H2 blockers, and a soft diet.3,4,8

Type II injuries consist of patients with a linear fracture ofhe thyroid cartilage and, without evidence of significant en-olaryngeal injury, should be explored via an open approach toest expose, reduce, and fixate the fractured airway skeleton.his can be done through a horizontal skin incision at the levelf the cricothyroid membrane, with the creation of subplatys-al soft-tissue flaps. The lateral limits of these soft-tissue flapsay be extended to explore the pharynx, esophagus, and ca-

otid sheath structures. Exposure of the thyroid cartilage thenroceeds in a subperichondrial plane (Figure 2). Once expo-ure of the fracture is complete, titanium plates are used toigidly fixate the fracture segments.1 It is thought that the usef plate and screw fixation produces better fracture stabiliza-ion, especially during speaking and swallowing and in youn-er, more pliable cartilage. Some authors recommend the usef a 4-hole miniplate (Figure 3) or titanium mesh stabilizationver a fracture.1 The use of low-profile plates of 1.3 mm or 1.5m is generally recommended.1 After completion of this sta-

ilization, the wound is irrigated and closed in layers over arain, with careful approximation of the perichondrium.

For type III injuries, including significant injury to thendolaryngeal mucosa, involvement of the anterior commis-ure, or extensive comminution of the thyroid cartilage,pen exploration by laryngofissure is indicated. This expo-ure is performed in the same way as described above butncludes a vertical thyrotomy made in midline, extendinghrough the entire thyroid cartilage (Figure 4). Via thispproach, the entire endolarynx can be exposed, evalu-ted, and treated. Through this exposure, evacuation of

g the exposed thyroid cartilage fracture.

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142 Operative Techniques in Otolaryngology, Vol 18, No 2, June 2007

ematomas and repair of significant lacerations should beerformed. Coverage of all exposed cartilage should beerformed through primary repair if possible or via ad-ancement flaps by using 5-0 or 6-0 absorbable suture.3,4

Figure 3 Fixation of thyroid cartilage f

Figure 4 Surgical thyrotomy with e

iscussion and controversies

arge areas of exposed cartilage should be avoided becausef the risk of granulation or subsequent scar and synechiae

using 4-hole plate and screw technique.

xposure of the airway lumen.

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143Preston and Fedok Trauma to the Larynx and Upper Airway

ormation. Free grafts consisting of buccal mucosa, dermis,r split-thickness skin grafts may be used where mucosaldvancement is impossible but may themselves lead to thencreased formation of granulation tissue.

Thyroid cartilage loss and fractures with comminutionhould generally be corrected or supported because of the riskf a poor voice or difficulty with decannulation. Correction ofoss of skeletal support may be performed with autogenousartilage grafts, alloplastic stents, or titanium mesh. Someuthors recommend simply using titanium mesh to span gaps,hus stabilizing the cartilage without the use of stents and theirssociated risk of granulation tissue formation.1 Injuries at theevel of the cricoid ring may be repaired by using mesh,ermanent suture,7 or keel placement. Stents may be placed athe level of the thyroid cartilage for additional support and totabilize soft-tissue grafts. It is recommended that stents placedor the correction of loss of skeletal support be left in place for4 days, and for the support of grafts, 8 days.4 Longer periodsf time may promote granulation formation. Stents are securedn place by passing at least 2 transcutaneous permanent sutureshrough the stent and securing it over skin buttons (Figure 5).ome authors also recommend placing additional superior and

nferior sutures for additional security.3 Stents should be de-

igure 5 Schematic depicting the placement and securing of sondolaryngeal laceration or grafting. (A) Anchoring suture placemnchoring sutures through skin and secured over buttons. (All to

igned to be easily removed using endoscopic techniques.

The above principles of evaluation and treatment areesigned to give an overview of safe and effective treat-ents for both preserving life and maintaining and restoring

unction in patients suffering from blunt and penetratingnjury to the larynx.

eferences

. de Mello-Filho FV, Carrau RL: The management of laryngeal fracturesusing internal fixation. Laryngoscope 110:2143-2146, 2000

. Bent JP 3rd, Silver JR, Porubsky ES: Acute laryngeal trauma: a reviewof 77 patients. Otolaryngol Head Neck Surg 109:441-449, 1993

. Schaefer SD, Stringer SP: Laryngeal Trauma (ed 3). Philadelphia, PA,Lippincott, Williams and Wilkins, 2001

. Lucente FE, Mitrani M, Sacks SH, et al: Penetrating injuries of thelarynx. Ear Nose Throat J 64:406-415, 1985

. Atkins BZ, Abbate S, Fisher SR, et al: Current management of laryn-gotracheal trauma: case report and literature review. J Trauma 56:185-190, 2004

. American College of Surgeons: American College of Surgeons ATLSGuidelines (ed 7). Chicago, IL, American College of Surgeons, 2007

. Richardson JD: Outcome of tracheobronchial injuries: A long-termperspective. J Trauma 56:30-36, 2004

. Butler AP, Wood BP, O’Rourke AK, et al: Acute external laryngealtrauma: Experience with 112 patients. Ann Otol Rhinol Laryngol 114:

laryngeal stent as might be used in the management of extensiverough stent before closure of thyrotomy. (B) The positioning ofoved several weeks after primary operation.)

ft endoent th

361-368, 2005