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Laryngeal Trauma Dr Chris Acott.

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Presentation on theme: "Laryngeal Trauma Dr Chris Acott."— Presentation transcript:

1 Laryngeal Trauma Dr Chris Acott

2 Dr Russell M Davies

3 “He sat in bed supporting himself with stiffened arms: his head was thrown forwards, and he had the distressed anxiety so characteristic of impending suffocation …. His inspirations were crowing and laboured, and there was a very frequent forced attempt to swallow, attended by extreme pain, … He spoke in a muffled whisper, and confined his answers, when possible, to monosyllables, or substituted signs by head or hand. …” Sir William MacEwen BMJ July pp 123

4 Laryngeal trauma Penetrating Blunt 4

5 Laryngeal Trauma: incidence
Rare 1/5000 – 1/137,000 Current Opinion Otolaryngology 2000; 8(6): 1/14,000 – 1/42,000 American Association Oral Maxillofacial Surgeons 2006: 5

6 Laryngeal Trauma: incidence
Rare – Why? under reported - paucity of peer reviewed data - American Association Oral Maxillofacial Surgeons 2006: Current Opinion Otolaryngology (6): patients die before reaching hospital – not reported in data larynx well protected & flexible mandible - superiorly; sternocleidomastoids – laterally; clavicles – inferiorly. 6

7 Laryngeal Trauma: Diagnosis
DIAGNOSIS OF SUSPICION laryngeal trauma NEEDS to be excluded diagnosis may not be obvious in a patient with an uncompromised airway symptoms & signs unrelated to degree of trauma this may also be reason for under reporting Once diagnosed the extent of injury must be defined before any attempt at intubation ETT across injured larynx can convert mucosal laceration to a more complex problem ETT can cause complete laryngo-tracheal separation 7

8 Laryngeal Trauma: Morbidity/mortality
0-18% J Trauma (1):87-93 Delay in diagnosis increases morbidity & mortality pharyngeal, oesophageal & vessel injury must be excluded Concurrent occult oesophageal injury significantly contributes to morbidity & mortality evaluation of oesophagus mandatory - NB before placement N/G tube 8

9 Laryngeal trauma: Diagnosis of Suspicion
HISTORY Hoarseness - 90% Tenderness - 90% Subcutaneous emphysema - 60% Anterior neck contusion - 40% SOB - 40% Current Opinion Otolaryngology (6):

10 Laryngeal trauma: Diagnosis of Suspicion
Inability supine - 30% Pain - 30% Tracheal deviation - 20% Haemoptypsis - 20% Dysphagia - 10% Aphonia - 10% Current Opinion Otolaryngology (6):

11 Associated injuries Chest trauma - 40% Facial #s - 30%
Facial laceration - 30% Long Bone #s - 30% Oesophageal laceration - 10% Head injury - 10% Pharyngeal trauma/perforation - rare None - 30% Current Opinion Otolaryngology (6):

12 Laryngeal trauma: History may give some idea of injury
Complete L-T separation associated with: hyperextension injuries: avulsion of larynx – tearing of fibrous ring between CC & 1st tracheal ring strangulation rarely associated with blunt trauma ASSOCIATED WITH # CRICOID CARTILAGE # Thyroid Cartilage: neck hyperflexion Knife or Gunshot wounds evaluate the oesophagus

13 Multiple threats to airway:
Direct penetration Distorted tissue planes Haematoma Oedema Excessive blood & secretions

14 Multiple threats to airway: ..2
IPPV & coughing: worsen air leaks s/c emphysema Cricoid pressure: lead to laryngo-tracheal separation

15 Multiple threats to airway: ..3
Cricothyroidotomy: may compound injury ETT: mucosal disruption false passage laryngo-tracheal separation

16 Airway can become unstable at anytime
Laryngeal trauma: Airway Unstable Stable Airway can become unstable at anytime 16

17 Inability to tolerate supine position – URGENT TRACHEOSTOMY
Laryngeal trauma: Airway Unstable Stable Inability to tolerate supine position – URGENT TRACHEOSTOMY 17

18 Laryngeal Injuries: ..1 Vocal cord injury
Arytenoid swelling & dislocation Crico-tracheal separation usually associated with death Soft tissue contusion Superficial mucosal laceration

19 Laryngeal Injuries: …2 Thyroid cartilage fracture Epiglottic fracture
most common site of fracture Epiglottic fracture Mixed injuries Shattered calcified thyroid cartilage in elderly

20 Investigations: Plain Xray (may not be helpful due to extensive s/c emphysema) pneumomediastinum & pneumothorax air in tissues # Cx spine CT cartilage & soft tissue injury airway patency

21 Investigations: .2 Laryngoscopy vocal cord paralysis
mucosal & cartilage separation haematoma Laceration Arytenoid displacement

22 Fractured Larynx: Management
Tracheostomy under LA vs GA Management is NOT A LEARNING EXPERIENCE HELIOX FOB & Cricothyroidotomy may not be appropriate Intubation may not be appropriate may cause complete separation

23 WHY HELIOX? Less dense – work of breathing less.
Decrease amount of subcutaneous emphysema

24 Helium - Upper airway obstruction
“When it is available an even better effect can be expected from inhalation of 79% Helium with 21% Oxygen” Wylie Churchill Davidson pp 382

25 Reynold’s Number < 2000 laminar flow 2000 -10000 transitional flow
> turbulent flow

26 Turbulent flow Turbulent flow F ~ P1/2/Lρ1/2
Density important Turbulent flow F ~ P1/2/Lρ1/2 F = flow; P = pressure; ρ = density; L = length. (Radius important but not expressible as a power of the diameter - as radius decreases flow decreases also) Turbulent flow: flow greater with Heliox than air or O2

27 Relationship between pressure and flow during turbulent flow
Heliox Even if flow is turbulent there is less work of breathing and greater flow with given pressure change O2 Comparison between Heliox (black) & air or O2 (yellow)

28 Why Helium? Hylegaard et al
O2 breathing initial bubble growth O2 > He solubility in fat build up O2 around bubble in tissue Helium breathing bubble constantly shrunk

29 Helium mixtures: Physics /Gas flux
GAS FLUX = diffusion x solubility coefficient He>N2 diffusibility (smaller atomic wt) He<N2 solubility in fatty tissue, water & blood He<O2 solubility in fatty tissue therefore:- N2 or O2 flux into fatty tissue > He flux HENSE ANY AIR POCKETS WILL SHRINK.

30 WHY HELIOX? HELIOX WILL GAIN PATIENT’S CONFIDENCE AND MAKE BREATHING EASIER AND MAY DECREASE THE AMOUNT OF S/C EMPHYSEMA.

31 Heliox on Anaesthetic Machine

32 5 Case Histories Maybe others – but not recognised.
trauma patients on ICU ventilator – laryngeal oedema when extubated a couple of days later – ‘floppy epiglottis’ on intubation 1. Walker in mountains hoarse voice in GP’s surgery GA - laryngoscopy – unable to identify any structures, unable to intubate (fortunately!!) obstructed during tracheostomy with retractors 2. Motorcyclist on farmer’s property intubated at scene

33 5 Case Histories 3. MVA – car rolled.
hanged by seat belt upside down complete tracheal/laryngeal separation partial obstruction with palpation of neck - GA 4. Motorcyclist – MVA – Modbury Hospital gaseous induction complete obstruction during tracheostomy – retractors again 5. And ….

34 …. patient number 5.

35 Able to speak and say “EEEE” Air bubbling freely from thyroid holes
covered with wet drape CT scan –no # Cricoid!! found to have one No s/c emphysema No respiratory distress Able to lie flat

36 TRACHEOSTOMY

37 SURGICAL TRACHEOSTOMY
Head extended exposing the neck. Neck palpated. LA injected. May not be able to extend the head. Palpation of structures may press on trachea & cause anxiety. LA stings – may increase anxiety. Horizontal 6 cm incision to anterior borders sternocleidomastoid muscles. Skin, subcut tissue, platysma to deep fascia. Veins may be enlarged due to inspiratory/expiratory pressures

38 Self retaining retractor placed, dissection to strap muscles
Strap muscles divided & retracted. Langerbech retractors placed. Retractor placement important – to much pressure can obstruct airway.

39 Trachea is exposed Thyroid isthmus exposed, clamped , divided and
ligated, rotated externally & sutured. Retractor placement again important – to much pressure can obstruct airway. Trachea is exposed

40 Tracheal incision sited over 2nd & 3rd or 3rd & 4th tracheal rings.
Tracheostomy tube inserted Placement of tube may cause some distress

41 Summary: Rare – diagnosis of suspicion Mortality ~20%
increases if unrecognised Concurrent oesophageal injury increases morbidity & mortality needs to be excluded Inability to lie supine – indication immediate tracheostomy

42 Summary: ..2 Consider Heliox if available
Avoid coughing – may make s/c emphysema worse and airway impossible Awake tracheostomy vs SV GA? careful palpation care with retractors

43 3rd SIG Airway Meeting Lorne March 9-11 2012 “Everything airways including problems outside the OT”

44 Thank You 44

45 Laryngeal Trauma Dr Chris Acott

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49 Head extended exposing the neck.** Neck palpated. LA injected.*
Horizontal 6 cm incision. Anterior borders sternocleidomastoid muscles. Skin, subcut tissue, platysma to deep fascia. Self retaining retractor placed, dissection to strap muscles.* Strap muscles divided & retracted. Langerbech retractors placed.**

50 Trachea is exposed Thyroid Isthmus divided.
Sited over 2nd & 3rd or 3rd & 4th tracheal rings


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