Case report: Acute management of external laryngeal trauma.

Abstract

External laryngeal trauma is rare, accounting for less than 1% of all trauma cases seen at major centers. We report the case of a man who experienced multiple injuries, including an external laryngeal trauma. The primary signs and symptoms of his laryngeal trauma were hoarseness, hemoptysis, the loss of his laryngeal prominence (Adam's apple), neck tenderness, traumatic emphysema in the neck, and a small penetrating wound to the right of the laryngeal prominence. The patient underwent immediate tracheostomy and surgical exploration. On long-term followup, his voice quality and airway patency improved. This case illustrates the importance of rapid identification and early management of laryngotracheal trauma in a patient with multiple injuries.

Introduction

The incidence of acute laryngotracheal trauma has declined significantly since seat belts became widely used in automobiles. Laryngotracheal trauma now comprises less than 1% of all blunt trauma cases seen at the major trauma centers of North America and Europe. [1,2] External trauma to the larynx can threaten both life and quality of life. Restoration of the skeletal framework and epithelial lining of the larynx is essential to preserve its vocal and airway-protecting functions. The keys to a good outcome are early recognition, an accurate evaluation, and proper treatment. [3]

Patients with laryngeal trauma can appear to be normal. This deceptive appearance increases the risk of a missed diagnosis and mismanagement, which could result in serious airway problems and impaired voice function. [4] The estimation of the extent of a laryngeal injury following blunt trauma often requires the use of flexible and rigid laryngoscopy and computed tomography (CT). We report our experience with a patient who had a major laryngeal trauma along with many other fractures.

Case report

An otherwise healthy 18-year-old man was admitted to the emergency room after he had been in a motorbike accident. The initial assessment by the ER resident revealed that the patient had fractures of his facial bones and right leg. He was not in shock. Other than the facial fractures, there appeared to be no other head injury.

During a more detailed examination, the patient reported slight hemoptysis and a change in the quality of his voice. The ENT service was consulted, and we performed a thorough laryngologic examination with indirect mirror laryngoscopy and fiberoptic endoscopy. This examination revealed that there was a mucosal tear exposing the laryngeal cartilage and that the left vocal fold was fixed. Examination of the neck revealed traumatic emphysema, loss of the laryngeal prominence, and a small penetrating wound on the right side of the prominence. There was no airway distress, but there was some pooling of blood in the hypopharynx, and the patient had definite hoarseness.

The patient was taken immediately to the operating room, where he underwent a tracheostomy under local anesthesia. Direct laryngoscopy in the OR confirmed our findings that the mucosa in the left pyriform sinus was torn, exposing the cricoid cartilage. Open surgical exploration of the neck revealed a vertical fracture in the center of the thyroid cartilage and two fractures in the cricoid cartilage. The fractures were sutured with 2-0 Prolene, and the perichondrium was repaired. The long tear in the mucosa of the left pyriform fossa was repaired with 3-0 Vicryl.

Postoperatively, the patient was prescribed antibiotics and put on nasogastric tube feeding for 10 days until he could swallow liquids. At 1 week postoperatively, the tracheostomy tube was plugged, which the patient tolerated comfortably. After 8 days, oral clear liquids were started, which initially caused slight aspiration. But after several days, the patient was able to take liquids freely. The tube was removed 2 weeks postoperatively.

On long-term followup, the quality of the patient's voice improved, although his left vocal fold remained paralyzed. There was no evidence of laryngeal or subglottic stenosis.

Discussion

External laryngeal trauma is rarely seen in ENT emergency practice. When it is seen, the most common causes are traffic accidents, accidental strangulation, assaults, falls, and other accidents. [5] Seat belts help prevent laryngeal trauma in automobile passengers, but riders of two-wheel motorized vehicles are at higher risk. [6]

The path to successful management of laryngeal trauma begins in the emergency room. A rapid clinical assessment should include the recording of signs and symptoms in the upper aerodigestive tract, an examination of the neck for the presence of neck emphysema and obliteration of the laryngeal prominence, and a laryngeal examination with the help of indirect mirror laryngoscopy and flexible endoscopy. Indirect laryngoscopy and flexible endoscopy are easy at the bedside in cooperative patients. [7] In uncooperative or severely injured patients, direct laryngoscopy is a better option.

Our patient had symptoms of hoarseness and hemoptysis. There was no airway distress. Both indirect mirror laryngoscopy and flexible endoscopy were possible at the bedside, and they detected a mucosal tear and exposure of the underlying cartilage. On examination of the neck, there was traumatic emphysema and a loss of the laryngeal prominence. No x-rays or CT scans were taken of the larynx because the clinical examination suggested that there were cartilage fractures, and therefore radiologic examination would have been unlikely to influence the plan to manage the patient surgically. Some authors recommend CT in selected cases in order to assess the extent of damage to the laryngeal framework, especially in cases of blunt laryngeal trauma. [7,8]

Laryngeal injuries are classified as major or minor. [9] Major injuries include large laryngeal tears in which cartilage is exposed, severe endolaryngeal edema, fracture displacement of laryngeal cartilage, and vocal fold fixation. Minor injuries are generally small lacerations that do not expose cartilage. Our patient had a major injury.

The maintenance of an adequate airway is of principal importance, but the method of achieving it is controversial. Some physicians prefer endotracheal intubation, [1] which is safe and effective, while others prefer tracheostomy. [7,10] Orotracheal intubation can exacerbate a laryngeal injury and is not recommended. [11] Our patient was not in respiratory distress, but because exploration of the larynx had been planned, a tracheostomy was performed under local anesthesia.

An important determinant of final outcomes in terms of voice quality and airway patency is the timing of surgery. Studies show that patients who are treated early have good outcomes irrespective of the severity of their [5,9,10] Our patient underwent early surgical intervention, and his outcome in terms of voice quality and airway patency was satisfactory. Another objective of early surgical intervention is the repair of exposed cartilage in order to prevent chondritis. [12] We also took steps to prevent chondritis by prescribing prophylactic, intravenous, broad-spectrum, triple-antibiotic therapy.

Although external laryngeal trauma is rare, it should still be ruled out by an otolaryngologist in cases of head and neck trauma. The consequences of blunt laryngeal trauma can be masked by the patient's initial appearance, so it is important that these patients are not overlooked or taken lightly.

From the Department of Otolaryngology--Head and Neck Surgery, Aga Khan University Hospital, Karachi, Pakistan.

References

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