1. Airway Trauma Speech-Language Pathologist
Michelle Mekky, MA, CCC-SLP, BRS-S
Speech-Language Pathologist
Memorial Hermann Hospital &
Children’s Memorial Hermann Hospital

2. Purpose
Educate the SLP on the medical diagnosis, medical treatment, and ultimate rehabilitation of voice and swallowing following airway/laryngeal trauma.  

3. Nelson Review Article Why this article
Lack of clinical research on this patient population in the SLP literature

4. Laryngeal Anatomy

5. Anatomy continued

6. Mechanism of Injury Blunt Trauma-fractures/dislocation
Penetrating Trauma
Intubation Trauma
Thermal and Chemical Trauma

7. Blunt Trauma Larynx is relatively well-protected
Lateral shielding by sternocleidomastoid muscle
Posterior protection from cervical vertebrae
Anterior protection by mandible

8. Examples of Blunt Trauma

9. Ex. of Blunt Trauma (cont)

10. Internal Trauma

11. Fractures and Dislocations
Midline or paramedian are most common
Comminution & complex fractures do occur
Surgical Management: ORIF &/or tracheostomy
Use of stents

12. Laryngeotracheal Separation
Severe airway compromise
Many die at the scene of the accident, unless mucosal attachment remains
Tracheostomy performed ASAP
Intubation in the field may do more harm than good
Bilateral recurrent nerve injury and subglottic stenosis are common complications
Ultimate surgical intervention is sometimes a total laryngectomy

13. Penetrating Trauma Car accidents Knifes
Bullets (handgun versus shotgun)
Other accidents: falling on sticks or glass
Blast injuries

14. Vascular Injuries Occur in 25-56% of penetrating neck wounds
Most commonly to the carotid and subclavian arteries-most common cause of death
20-30% of penetrating neck wounds result in laryngeal, tracheal, or esophageal injuries

15. Intubation Trauma
Prolonged intubation leads to trauma in 4-13% of cases
Larger endotracheal tubes cause more trauma
History of smoking or ETOH consumption can be very drying to the mucosa
GERD/LPRD

16. Intubation trauma caused by:
Abnormal anatomy (~10% of the population)
Difficult laryngescopy
Multiple intubations/extubations
Skill of person placing (resident vs. attending)
Emergent versus Elective

17. When trachs are placed
In most hospitals tracheostomies are performed after days of endotracheal intubation
If multiple trips to the OR are required
Policies vary greatly between the different ICUs

18. Reaction to Intubation
Within 48 hours of intubation granulation tissue begins to form
Mucosal ulceration is usually present

19. Immediate Laryngeal Complications
Glottic or subglottic edema
Mucosal laceration
Dislocation of the arytenoids
Avulsion of the epiglottis
Vocal cord paralysis

20. When to refer to ENT post intubation/extubation
Hoarse voice greater than 48 hours
Sore throat greater than 48 hours
Dysphagia
Odynophagia
Stridor

21. Management of Arytenoid Dislocation
Needs to occur by ENT with hours of identification
Can sometimes be treated by direct endoscopy

22. Treatment of Avulsion of the Epiglottis
Open repair
Laser excision

23. True VC Paralysis May occur as result of intubation &/or extubation
Brandwein et al. discovered that the anterior branch of the recurrent laryngeal nerve is vulnerable to compression between the inflated cuff of the ETT, the lateral projection of the abducted arytenoids, and the thyroid cartilage.
Cord is usually lying in the paramedian position

24. Late injuries of Intubation
Intubation granuloma
Cricoarytenoid ankylosis (fibrosis)
Glottic webs
Subglottic stenosis

25. Avoiding Late Injuries of Intubation
Limiting amount of time the pt is intubated
Using the smallest ETT which will permit adequate respiratory support
Using low-pressure cuffs
Careful fixation of the tube to limit movement during assisted ventilation
Use of steroids and antibiotics
Early recognition/tx of such laryngeal injuries

26. Intubation Granuloma Forms when blood supply is poor
Area is exposed to potential contamination
Steroids is a medical tx
Antibiotics to promote healing of the mucosa
Late presentations: voice changes, globus, repetitive medical course of tx
Sometimes permanent

27. Glottic Web
Can result from simultaneous denudation of both VFs near the anterior commissure
When they heal together they produce a web
Probably occurs more often as a complication or surgery rather than from intubation

28. Picture of Glottic Web

29. Medical tx of Glottic Webs
Surgical placement of anterior tantalum keel
Endoscopic management with a laser or mechanical lysis-followed by placement of an internal Teflon keel

30. Subglottic Stenosis
Definition: narrowing of the subglottic space above the inferior margin of the cricoid cartilage and below the level of the glottis
Can be anterior, posterior, or complete

31. Subglottic Stenosis (cont)
Grade I - Obstruction of 0-50% of the lumen obstruction
Grade II - Obstruction of 51-70% of the lumen
Grade III - Obstruction of 71-99% of the lumen
Grade IV - Obstruction of 100% of the lumen (ie, no detectable lumen)

32. Picture of Subglottic Stenosis

33. Tx of Subglottic Stenosis
Tracheostomy
Open reduction
Cricotracheal resection
Medical management of GERD/LPRD if in the patient’s known history
Steroids/Antibiotics
Grafting

34. Consequences of Self-Extubation
Edema
Possible vocal cord damage
Cartilage dislocation

35. Thermal and Chemical Trauma
Inhalation of hot gases (caustic or not) cause trauma
Stabilize the airway
Sudden edema is of primary concern

36. Long term Injuries Loss of mucosal integrity Infection
Chondritis (inflammation of cartilage)
Fibrosis

37. What the MD looks for: Cough Carbon particles Blood in the sputum
Voice change
Stridor
Dyspnea (shortness of breath)

38. Course of Treatment At least admitted for observation
Difficult to determine if tracheostomy is indicated

39. Medical Management of the Airway
Oral intubation after spine is clear
Rarely a cricothyroidotomy is performed for an emergent airway when a trach cannot be completed
Must be revised to a tracheostomy ASAP (within a few hours)

40. Role of the SLP Aphonia/Hoarseness Aspiration/Penetration
Avulsed/Amputated Epiglottis
Edema
Unilateral VC paresis/paralysis
Bilateral VC paralysis
Hearing Loss

41. Aphonia/Hoarseness Get dx from ENT
Medical management is the best course of tx for bringing back voicing
Facilitate communication with a communication board and/or written communication systems

42. Aspiration/Penetration
Determine if postural changes are helpful during MBS/FEES
MUST take into account fatigue on ability to perform maneuvers (respiration and structural)
May try: supraglottic swallow, super-supraglottic swallow, head down, or head rotation.
Diet Modification is usually necessary with or without enteral access

43. Avulsed/Amputated Epiglottis
May lead to initial odynophagia with all oral intake
Chin down or super-supraglottic swallow may be a helpful to try during MBS/FEES

44. Edema
Vocal rest
Medical Management
Steroids
Anti-inflammatories

45. Unilateral VC Paresis/Paralysis
Many patients with unilateral paresis recover in the first 7-10 days post trauma
Those with paralysis usually overcompensate with the good cord in 1-3 weeks
Temporary tx’s by ENT: fat injection
Permanent tx’s by ENT: medialization laryngoplasty or thyroplasty

46. Bilateral Vocal Cord Paralysis
Causes
Paralysis (neurological)
Fixation of the cricoarytenoid joints
Both

47. Tx of Bilateral VC Paralysis
Usually trached and NOT a candidate for a speaking valve
Written communication/Communication board/electrolarynx during acute hospital stay
If permanent with no recovery to either cord then: Speech generating device with or without electrolarynx

48. Hearing Loss
Reported cases of acoustic trauma SN HL following blunt neck trauma
Segal et. al suggests it could be due to sheer forces acting on the cervical spine that transition to the inner cranium
Other theories suggest a neuromuscular mechanism, a neuro-vascular mechanism, or a mechanical vascular obstruction
Tinnitus/Balance difficulties

49. Hearing Loss (cont) Audiological/ENT referral is appropriate
Referral to physical therapy may be indicated
Speech tx for aural rehabilitation

50. Thoughts for the Future
Research in voice recovery s/p airway trauma
Research in swallowing function s/p airway trauma