trauma symposium 2012
DESCRIPTION
presented in Clock tower Masjid HaramMakkahApril-2012TRANSCRIPT
Dr.Naim Manhas 13/30/2012
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LARYNGOTRACHEAL INJURIES ASSOCIATED WITH NECK TRAUMA
DR. NAIM MANHAS F.I.C.S., M.S.,M.B.B.S. E.N.T. SURGEON KING ABDUL AZIZ HOSPITAL MAKKAH
Diagnosis and management of E.N.T. trauma –an update (5thAnnual Trauma Symposium )
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Aim and objectives
Traumatology has become an important medical subject as we all know that trauma related patients have increased since last two decades.
Before major injuries were seen only in world wars, but now the percentage of trauma patients have increased due to increase in vehicular accidents , day to day military conflicts in many countries.
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Aim and objectives
The trauma system was created when it was discovered that more lives could be saved by taking critically injured patients to specialized trauma centre for immediate care.
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Laryngo-tracheal injuriesLaryngeotracheal injury is rare 1 in every 5000 trauma cases
Laryngeal injuries in 30-70% of penetrating neck injuries
Its rarity notwithstanding, it is second to only intracranial injury as the most common cause of death among patients with head and neck trauma
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Aim and objectives
Prevent long term
complications by early
diagnosis and proper
management
In association
with ER surgeons,
trauma surgeons
and Anesthesiol
ogists
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types of laryngeal trauma
Blunt
trauma
Iatrogenic trauma
Intubation injuries
Penetrating trauma
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Management
Management of laryngo-tracheal trauma is based on the extent of injury:-
Initial
evaluatio
n
Endoscopic
evaluatio
n
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Initial Evaluation
Securing the airway
•Intubation:- vocal cords are visible, no visible injuries
•Tracheotomy done under local anesthesia
Obtaining hemodynamic stability
•Controlling of bleeding
Immobilizing the cervical spine
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paediatric patients In contrast to adults pediatric patients are
unlikely to cooperate with a tracheotomy while awake.
Paediatric airway is secured with rigid bronchoscopy while maintaining spontaneous respiration before tracheotomy is performed.
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Initial Evaluation
Identified with physical examination or fiberoptic laryngoscopy
In case exploration of neck is carried
Direct laryngoscopy and bronchoscopy is performed
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Initial Evaluation
Oesophagoscopy is always performed
50% of patients with an airway injury also have associated oesophageal injury
Degree and type of injury is evaluated during endoscopic examination
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Classification of laryngeal injuries
supraglottis transglottis Cricoid/trachea
As per location
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Aim and objectives
Assessment of injury
Level of injury
Severity of injury
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BLUNT TRAUMA
Thyroid cartilage fracture:- Multiple fractures in calcified laryngeal cartilage
as compared to one site fracture in cartilaginous larynx
Mucosa disruption oedma Arytenoid dislocation Laryngeal ligaments tear
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PRESENTATION
dyspnoea dysphagia dysphonia
odynophagiaRespiratory distress
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physical findingsSubcutaneous
•Emphysema
•Tenderness
Oedma
•Hematoma
•ecchymosis
Distoration •Or
•Loss of laryngeal landmarks
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Classification of laryngeal injury
Group 1
Group2
Group3
Group4
Group5
Minor endolaryngeal hematoma : Minimal airway compromise Endolaryngeal hematoma/oedma
associated with compromised airway/non-displaced fracture
Massive endolaryngeal edma with airway obstruction/mucosal tears with exposed cartilage/immobile vocal cords
Same as group3 with more than two fracture lines on imaging/massive dearangement of endolarynx
Laryngotracheal sepration3/30/2012
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MANAGEMENT
Grop 1& 2 are usually managed non surgically with humidied air,head of bed elevation,voice rest
Serial fiberoptic examinations
Streroids:- only usefull if given within first few hours after injury
Group 3 & 4 :- immediate surgical repair and may involve the use of stent
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Aim and objectives
Restore the integrity of the larynx with regard
To phonation,airway and quality of life
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penetrating neck injuries Neck wounds that extend deep to the
platysma are considered penetrating injuries. Incidence of penetrating neck injuries has
increased since world war II because of rise in violent crimes.
The main cause of penetrating neck injury in this country is accidental, while as internationally usually related to violent crimes as well as military conflict
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penetrating neck injuries
Injuries to vascular system----20-56%
Laryngeal, tracheal and oesophageal injuries—20-30%
Mortality rates from oesophageal injuries were found to increase from 11 to 17% after a delay in diagnosis of only 12 hours
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Penetrating laryngeal injuries
hematomaMucosal tears or laceration
Cartilage fractures and dislocation
Laryngo-tracheal
disruption
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Classification of penetrating neck injuries
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Classification of penetrating neck injuries
zone 1. -• Extends from sternal notch to the cricoid
zone 2.• Extends from cricoid to angle of mandible
zone 3.• Extends from the mandible to the skull base
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Management of penetrating neck injuries
Remarkable number of changes in the treatment protocol has been made because of development of new technologies, it may be from non-operative management to routine exploration to selective exploration.
Penetrating neck injuries remain challenging as there are a number of important structures in a small area.
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Management of penetrating neck injuries
Since the introduction of sophisticated ancillary tests and accurate identification of localizing signs and symptoms the surgical exploration of penetrating neck trauma is now done on selective basis:-
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Management of penetrating neck injuries
All patients with hemodynamic instability or airway compromise
Needs surgical exploration
Followed by panendoscopy
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Management of penetrating neck injuries
Injuries in Zone -1. and in Zone-3. of neck are difficult to examine clinically and surgically.
Imaging including angiography is often performed
Zone.1. injuries are subjected with preoperative arteriograhpy and gastrograffin swallow studies
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Management of penetrating neck injuries Zone 3. injuries are studied with
arteriograhphy and all facilities for embolization should be available in case injury is found.
Zone 2. surgical exploration is done even without imaging
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Asymptomatic patients The management of asymptomatic
patients remains controversial but according to the recent retrospective studies made by “Sarkar et al” and “Ramasamy et al” of British military causalities from Iraq and Afghanisthan who sustained penetrating neck injuries, it was observed that percentage of negative exploration was reduced by selective exploration.
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Surgical intervention laceration involving anterior commissure,
Injury to the free edge of the true vocal fold
Exposed cartilage /displaced or comminuted fracture
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Surgical intervention
Vocal fold immobility
Arytenoid cartilage dislocation
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Reduction of laryngeal fractures
Fixation of even minimally displaced or ingulated fractures are important for maintaing the geometry of larynx.
Good results are obtained by using miniplates as compared to previously used stainless-steel wires or absorable sutures.
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Role of stent Use of stent is controversial
because of increased risk of infection and granulation formation.
Recommended only where inadequate fracture fixation is done to give structural stability.
Prevent synechiae formation when used in presence of severe soft tissue disruption or lacerations involving anterior commissure.
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Intubation injuries
The incidence of intubation injury has increased since
The critically ill patients are being sustained longer on
Ventilatory support because of introduction of sophisticated I.C.U.
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Intubation injuries
Scarring of laryngeal structures
Subglottic stenosis•Tracheal stenosis
Granulation tissue formation•Vocal fold paresis or•paralysis
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Intubation injuries
19%
42%
Intubation prolonged more than 7-10 days ,incidence of complications is from 14-19%.
The incidence of complications increases two-folds if intubation is prolonged more than two weeks.
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Fac
tors
determine the severity of intubation injures
Ana
tom
ical
var
iatio
n Difficult intubation or traumatic intubation.
Inexperienced intubation
Iatr
ogen
ic c
ause
s Oversized tubes
Excessive patient movement
Repeated self extubation
Overinflated tube cuffs
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presentation
High endotracheal cuff pressure
Progressive hoarsness of voice or airway obstruction from glottic or subglottic edma
Compressive neuropathies by direct pressure of cuff
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presentation
Dysfunctional vocal cords or paresis
Mucosal injury, result from movement of endotracheal tube,pressure necrosis
Granulation formation ,fixation of cricoarytenoid joint,web formation or stenosis
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Management
Post intubation granulation tissue resolve spontaneously after some times
Treatment includes a combination of voice therapy and antireflux medication
Surgical removal is only indicated when it leads to partial airway obstruction
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Management
Managemnt of stenosis depends on its location and severity.
Presence of thin web in the anterior glottis
Surgically removed and stent is placed to prevent the reformation of web from opposed denuded mucosa
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Management
Posterior laryngeal stenosis and cricoarytenoid joint fixation
Treated with repeated dilation through an endoscopic approach
In severe cases ,open approach through laryngofissure is done
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Management
In cases of failures or more severe cases
Arytenoidectomy or partial posterior cordotomy is done
Subglottic or tracheal stenosis approached with endoscopic laser incision and dilation
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Management
More severe stenosis require laryngotracheal reconstruction or
Vocal fold paralysis with persistent dysphonia or significant aspiration
segmental resection with primary anastomisis
Vocal fold augmentation
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ManagementBilateral vocal fold immbolity present with stridor and airway obstruction
Relieved by partial posterior cordectomy,arytenoidectomy or arytenoid lateralization procedure
In severe cases needs tracheostomy
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conclusion
The initial goal in managing laryngeal trauma is to preserve life.
Secondary goal is to prevent long term complication to the voice and airway.
Intubation injuries can be prevented by proper intubation by experienced E.R. staff.
Early tracheotomy in patients who need prolonged ventilatory life support.
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THANK YOU
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