CaseReport:EndoscopicManagementofPenetratingLaryngealTraumaJulieP.Shtraks,MD;AhmedM.S.Soliman,MD

Dept.ofOtolaryngology- Head&NeckSurgery,LewisKatzSchoolofMedicineatTempleUniversity,Philadelphia,PA

ABSTRACT

INTRODUCTION

CASEREPORT

DISCUSSION

Isolatedlaryngotrachealtraumaisarareclinicalscenario.Penetratinglaryngealtraumaisusuallytreatedviaopensurgicaltechniques.Wepresentacaseofapatientwhosustainedagunshotwoundthroughthelarynxwithsignificantmucosaldestructionfromtheblastinjurywhowasmanagedcompletelyendoscopicallywithanexcellentclinicaloutcome.

• Externaltraumatothelaryngotrachealcomplexisrare• Accountsfor<1%oftraumacases,1/30,000EDvisitsperyearintheUnitedStates1,2

• Bluntpenetratingtraumaismorecommonthanpenetrating,howeverpenetratinglaryngealtraumaisincreasing• Knife,gunshot,andblastinjuriesaccountformajorityof

penetratingtraumaintheU.S.2• Injurytotheaerodigestivetractoccursin5-15%ofpenetratingneck

traumas3• Patientswithmassiveedema,mucosaldisruption,exposedcartilage,

vocalfoldimmobility,ordisplacedlaryngealcartilagerequiresurgicalintervention2

• Penetratinglaryngealtraumacausedbygunshotresultsinblastinjuryandcartilageframeworkfractures• Usuallyrequiresopenthyrotomy

• Wepresentacaseofapatientwhosustainedagunshotwoundtotheneck,resultinginblastinjury,whowasmanagedwithendoscopicdebridementandlaryngealstent

• A25yearoldmalepresentedtotheTempleUniversityHospitalEmergencyDepartmentaftersustainingagunshotwoundtotheleftneck

• Hewasorotracheallyintubatedinthetraumabay• CTangiogramoftheneckdemonstratedextravasationfromtheright

externalcarotidarteryanditsproximalbranches• HewastakenemergentlytotheoperatingroomIOR)bytheTrauma

serviceforneckexplorationandcontrolofhemorrhage• Otolaryngologywasconsultedintraoperatively• Directlaryngoscopyidentifieddiffuseedemaandecchymosisofthe

supraglotticstructuresobscuringvisualizationofthevocalfolds• 48hourslater,hewastakentotheORbyOtolaryngologyfor

tracheotomyandlaryngealcartilagerepair• Microlaryngoscopyrevealedextensiveleftsidedsupraglottic

devitalizedtissueinvolvingthearytenoid,falsevocalfoldandventricle

• Inblastinjuries,theseverityoftheinjuryisdirectlyrelatedtothekineticenergyconveyedbythemissileontothelaryngealtissue4

• Generally,civiliangunshotwoundsarelower-velocity,thoughhigh-velocityhandgunsdocontributetociviliancrime

• WedescribethecaseofapatientwhopresentedtoourinstitutionaftersustainingapenetratingzoneIInecktraumaresultinginblastinjurytotheendolarynx

• Theprimarilysupraglotticlocationoftheinjuryandtherelativesparingofthevocalfoldslentitselfwelltoendoscopictreatmentandhisexcellentvoiceandairwayoutcome

• Thesignificantneckedemaandextensivevascularrepairrequiredmadeneckexplorationandopentreatmentmorechallengingandpotentialrisky

• Thistechniquemaybeapplicableforuseinotherpatientswhosustainblastinjurytotheneckbothincivilianandmilitaryenvironments,andshouldbeinthetoolboxofotolaryngologists

CONCLUSIONSEndoscopicmanagementofendolaryngealinjuryfrompenetratinglaryngealtraumaisafeasibleoptioninselectpatientswithsignificantmucosaldestructionresultingfromblastinjurytotheneck

• DevitalizedtissuewasremovedwiththelaryngealmicrodebriderTricut®blade(MedtronicInc.,Minneapolis,MN)untilhealthyappearingtissuewasseen

• AsoftendolaryngealstentwasfashionedfromasterileglovefingerfilledwithVaselinegauzewasplacedendoscopically

• HereturnedtotheOR7dayslaterforstentremovalatwhichtimemarkedimprovementinsupraglotticedemaandapatentglotticairwaywasseen

• Hewasdischargedhomewithhistracheotomyinplace• Hereturnedtotheoutpatientcliniconemonthafterendoscopic

repairandwasusingaPassyMuirvalvewithoutissues• Onflexiblelaryngoscopy,hissupraglotticandglotticairwaywas

patentandhistruevocalfoldmobilitywasnormal• He was decannulated 6 weeks after his initial injury

Figure1A,B.(A)AxialCTscanatthelevelofthethyroidcartilagedemonstratingtheentrypointofthebulletintheleftneckwithsurroundingmetallicbulletfragments;(B)CoronalCTscanshowingextensivesofttissueswellingwithsubcutaneousemphysemaandscatteredbulletfragments.

Figure2A-F.(A)Intra-operativeviewofextensivedevitalizedsupraglottictissue;(B)DevitalizedtissueremovedwithlaryngealmicrodebriderTricutblade(MedtronicInc.,Minneapolis,MN);(C)Supraglottisafterdebridementofnecrotictissue;(D)Laryngealstentremoval;(E)Decannulation;(F)Outpatientlaryngoscopyrevealedapatentglottiswithnormaltruevocalfoldmobility

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Experience.JVoice.2011;25(4):473-9.2. SchaeferSD.Theacutemanagementofexternallaryngealtrauma.A27year

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PenetratingNeckTrauma.Laryngoscope. 2014;124:S1-S9.4. HoltGR,KostohryzG.Woundballisticsofgunshotinjuriestotheheadand

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