Repair of a laryngeal fracture using miniplates

Current Trends in Head and Neck Trauma

The practicing otolaryngologist frequently encounters consultation for injuries in the head and neck. Restoration of form and function is essential to normal activities of daily living and quality of life. This discussion intends to provide the reader with an up-to-date discussion of various evidence-based practice trends related to head and neck trauma. The discussion focuses on the acute management of trauma with minor emphasis on secondary management of injuries. Specific injuries related to the craniomaxillofacial skeleton, laryngotracheal complex, vascularity, and soft tissues are explored.

Traumatic Airway Injuries: Role of Imaging

Airway Injuries are rare but often immediately life threatening. Incidence ranges from 0.5-2 % in blunt and 1-6 % in penetrating trauma. Upper airway injuries (UAI) are often clinically apparent and get shunted during the primary survey in the emergency department. Few UAI and majority of lower airway injuries (LAI) are occult on primary survey and need a high suspicion index. Clinically, the diagnosis of tracheobronchial injury is delayed in many patients because the airway column is maintained by the peribronchial tissue. Imaging in the form of MDCT, in conjunction with endoscopy, plays a role in delineating the exact site and extent of injury and ruling out associated vascular and esophageal injuries for definitive management of UAI. Chest radiographs and ultrasonography help raise suspicion of LAI by detection of pneumomediastinum, persistent pneumothorax and/or subcutaneous emphysema and should be followed up with multidetector computed tomography (MDCT) which is the mainstay of diagnosis. However, it requires careful evaluation of the airway tract and a thorough knowledge about the mechanism of trauma for detection of subtle injuries. Reconstructions in multiple planes and use of various post-processing techniques including minimum intensity projection (MinIP) images enhance the detection rate. The specific signs of LAI on CT include discontinuity in the tracheobronchial tree, focal intimal flap projecting in the lumen, focal soft tissue attached to the tracheal/bronchial wall, complete cut off of the bronchus/trachea and the fallen lung sign. We, hereby, illustrate the imaging spectrum of traumatic airway injuries in detail and discuss their management implications.

Management of laryngeal fractures--a 10-year experience

OBJECTIVES

Laryngeal fracture patients can present with a spectrum of clinical findings ranging from normal to airway collapse and death. We will therefore examine and emphasize clinical presentation, an algorithm for appropriate diagnosis and acute airway management, and radiological or physical examination findings and demonstrate the appropriate surgical approach for optimum clinical outcome in cases of blunt and penetrating laryngeal injury. Herein, we present one of the largest series of management of laryngeal and tracheal fractures from a tertiary care level I trauma center.

STUDY DESIGN

A retrospective chart review from 1998 to 2008.

METHODS

A retrospective chart analysis on patients presenting to the head and neck trauma service. Institutional review board approval was obtained before the start of the research.

RESULTS

Our series consisted of 11 men and one woman with a mean age of 41.8 years presenting with laryngeal fractures caused by blunt (n=10) or penetrating (n=2) trauma. One patient presented with complete laryngotracheal separation, which was successfully managed by immediate tracheotomy and early surgical intervention. The other 11 patients had a combination of conservative (n=6) and surgical (n=5) management. All patients who required a tracheotomy (n=7) were decannulated.

CONCLUSIONS

Early suspicion and diagnosis of acute laryngeal and tracheal injuries are crucial. The airway must be secured via tracheotomy when possible. Computed tomography scans play a central role in diagnosis. Proper restoration of the laryngeal framework with appropriately timed open reduction and internal fixation is critical for optimal recovery of the airway, voice, and swallowing.

Upper airway injury and its management

Injuries to the upper airways are rare, but carry a significant morbidity and mortality. The degree of injury and presentation varies; thus recognition often requires a high index of suspicion based on mechanism. Effective management of laryngotracheal injuries begins with immediate control of the airway whether by orotracheal and surgical route. Definitive management of upper airway injuries relies on an understanding of the anatomy of the larynx, trachea and surrounding structures. Associated injuries are common and must be addressed concomitantly. Postoperative complications are frequent, requiring perioperative vigilance and long-term follow-up to ensure best outcome.