Complete cricotracheal separation and third cervical spinal cord transection following blunt neck trauma: a case report of one survivor

We report the case of a patient who sustained a scissors-type blunt neck trauma and survived the following injuries: comminuted cricoid fracture, complete cricotracheal separation, interruption of the recurrent laryngeal nerves bilaterally, multiple cervical vertebral fractures, and a third cervical cord transection. He was rendered apneic instantly at the accident site and was immediately resuscitated by coworkers by mouth-to-mouth resuscitation. Attempts at endotracheal intubation to establish an initial airway caused acute airway occlusion and an emergency tracheostomy was then successfully performed. He was treated by immediate stabilization of the cervical spine, emergency neck exploration, and early primary repair of the airway injury. Any patient with cervical airway injury should be assumed to have cervical spine injury and should have neck immobilization from the beginning of resuscitation.

Anterior cricoid suspension and tracheal stomal closure for children with cricoid collapse and peristomal tracheomalacia following tracheostomy

Nearly 10% of infants with long-standing tracheostomies (> 1 year) have severe peristomal tracheomalacia and/or significant cricoid cartilage collapse. Tracheal decannulation in these small children may be complicated by upper airway obstruction, recurring respiratory tract infections, and an unsightly cervical scar. We have developed a simple one-stage method of surgically alleviating severe cricoid collapse and peristomal tracheomalacia that permits immediate extubation. After excising and transversely closing the tracheocutaneous fistula, an anterior cricoid/tracheal suspension is accomplished by suturing the adherent fibromuscular tissue overlying the cricoid and peristomal trachea to the musculofascial insertions of the cervical strap muscles adjacent to the sternum. Once tied, these sutures significantly elevate the anterior cricoid and peristomal trachea by pulling the cervical airway ventrally and inferiorly. The strap muscles cover the tracheal suture line and the skin and soft tissue are closed in a transverse fashion. This procedure has been performed in 9 children (ages 1 to 4 years). All were extubated within 24 to 72 hours. No perioperative or long-term complications were observed with follow-up averaging 20 months (range, 6 months to 4 years). Postoperative endoscopy demonstrated substantial improvement in the airway lumens of all children. The final cosmetic appearance has been excellent. This operative method of dealing with cricoid collapse and peristomal tracheomalacia is simple, safe, and effective.

An in vitro model for studying growth and effect of trauma and external agents on the cricoid at the cellular level

Over the past several years it has become evident that expansion laryngotracheal surgery is effective in the treatment of laryngotracheal stenosis. Several clinical and animal studies have been performed to study the process of laryngotracheal stenosis and its treatment. However, there are still many questions that cannot be addressed by currently used clinical and animal research. Further indepth study of the behavior of the subglottis at the cellular level is necessary. We present an in vitro model for studying chondrocyte metabolism of the bovine cricoid. Cartilage was successfully grown in an explant culture system, and it was shown that the chondrocytes were metabolically active and responded to external agents. This model will serve to study the mechanism of growth and effects of trauma and external agents on the cricoid at the cellular level.

Experimental blunt injury to the larynx

This article deals with the fracture line distribution and severity of laryngeal trauma. Laryngeal trauma was experimentally inflicted on 100 human laryngeal specimens with the impact of a 2.0-kg weight falling by gravity from a height of 100 cm. According to the previous pilot experiment and clinical experiences, the author classified the severity of fracture into four grades. The results showed no significant sex difference in the severity of fracture with reference to age distribution, especially severe injury in older age groups. The pattern of fracture lines of the laryngeal cartilage was observed and traced in four selected locations, including the thyroid notch, central zone of the thyroid cartilage, cricothyroid region, and cricoid. The distributions of fracture lines are illustrated. The experiment is described in detail.

Initial evaluation and management of upper airway injuries in trauma patients

STUDY OBJECTIVE

To examine and compare the mechanism of injury, diagnostic findings, initial methods of airway management, and outcome of patients who had upper airway injuries.

DESIGN

A retrospective review of hospital records.

SETTING

A large metropolitan, university-affiliated trauma center.

PATIENTS

Forty-six cases of upper airway injuries admitted between 1984 and 1988.

INTERVENTIONS

Diagnostic methods included clinical examination, cervical and thoracic radiographs, bronchoscopy and computerized tomographic (CT) scan. Therapeutic interventions ranged from conservative management with or without endotracheal intubation to operative reconstruction.

MEASUREMENTS AND MAIN RESULTS

Mechanism of injury was knife stab wound in 9 cases, gunshot wound in 17 cases, and blunt trauma in 20 cases. Location was the larynx in 13 cases, trachea in 24 cases, cricoid cartilage in 5 cases, and multiple sites in 4 cases. Diagnostic findings varied considerably according to the mechanism of injury, but radiographic evidence of soft tissue air and wounds opening into the airway were common findings. CT scan and bronchoscopy also were useful diagnostic tools. Overall mortality was 24%, which did not vary according to patient age or mechanism of injury. The airway injury itself was a primary or contributory cause of death in four cases, two of which were tracheal injuries and two injuries at the cricotracheal junction.

CONCLUSIONS

In any patient with possible upper airway injury, plain radiographs of the chest and neck should be obtained to aid in the diagnosis. Elective intubation should be attempted only with a surgical team present and prepared for emergency tracheotomy. Fiber-optic bronchoscopy could be a valuable aid for both intubation and evaluation in such cases.

Trauma of the cricoid and interlocked stress

In young rabbits the effects were studied of an anterior midline and a bilateral split with and without traumatisation of the perichondrium and subperichondrial cartilage on the inner side of the ring. Various interventions produced specific patterns of distortions. It is concluded that release of interlocked stress in the cartilage is of paramount importance for the development of deformities. A specific feature of the circular cartilaginous structure seems to be that the tensile forces on the outer side of the ring exceed those on the inner side.

Crico-tracheal disruption and common carotid artery occlusion: a case of blunt trauma

A case of blunt trauma to the neck is presented. While driving an all terrain vehicle (ATV), a 20-yr-old male was struck across the anterior neck by a cord suspended between two poles. Initial findings were suggestive of an isolated laryngeal injury; 48 hours later, however, a dense left hemiplegia became manifest. A CT scan demonstrated a large right frontoparietal cerebral infarct, and an angiogram confirmed occlusion of the right common carotid artery. Intractable cerebral oedema developed, and the patient died five days after the initial insult. Such injuries should alert the clinician to the possibility of major vascular injury, and if suspected, angiography is warranted.

Cricotracheal separation in blunt neck injury--the sign of hyoid bone elevation. A case report

A case of a 23-year-old man who sustained a traumatic cricotracheal separation after a closed neck injury is reported. Hyoid bone elevation above the level of the superior surface of the body of the third cervical vertebra was present on lateral cervical radiography. The importance of the recognition of this sign is discussed.

Cricoarytenoid subluxation: complication of blind intubation with a lighted stylet

Transillumination of the cervical airway with the light wand for blind intubation is a valuable adjunct to anesthesiologists and emergency room physicians, particularly for management of the complicated airway in which direct visualization of the larynx is not possible. However, as an alternative to traditional methods, this technique should be practiced in simple cases before it is attempted in more difficult airway cases. The technique is easy to learn but requires practice to master. The incidence of complications remains low but complications may be serious when they occur. We present a case of cricoarytenoid subluxation after blind intubation with a lighted stylet.

Post traumatic disruption of the laryngo-tracheal junction

Of 43 tracheo-bronchial ruptures, 19 patients presented with disruption of the laryngo-tracheal junction which would appear to be a very specific anatomical lesion. The disruptions were secondary to blunt cervical trauma in 11 cases and strangulation in 8 cases. The disruption was complete in 14 cases and incomplete in 5. The lesion is very complex and involved the retraction of the lower part of the trachea into the mediastinum (14 cases), fracture of the cricoid ring (9 cases), bilateral recurrent nerve tears (14 cases), unilateral (4 cases) and retraction of the laryngeal mucosa with exposure of the cricoid cartilage in all cases. According to the complexity of the lesion, the treatment was: laryngo-tracheal resection and end-to-end anastomosis with treatment of the vocal cord palsy in 13 patients; simple end-to-end anastomosis in 4 patients who had an unilateral vocal cord palsy; 2 patients with a partial disruption were treated medically with endoscopic stenting and laser photocoagulation. All had restoration of airway patency and recovery of voice. The results contrast with the failures and reoperations reported in the literature and underline the necessity of complete evaluation and treatment of these complex lesions.

Histologic study of the growth of the subglottis after interruption of the circular structure of the cricoid

In a previous study in growing rabbits it was demonstrated that after resection of a ventral part of the cricoid the lumen of the subglottic airway developed normal size during further growth up to the adult stage. Histologic investigations of these cases suggest that a subepithelial network of elastic fibres, ventrally suspended to the thyroid and the tracheal rings, ensures the airway lumen and prevents the development of a subglottic stenosis. Resection of a ventral part of the cricoid including the adjacent soft tissue lining of the airway causes an irreversible loss of the supporting elastic layer and the formation of scar tissue resulting in a stenosis. It was concluded that the larynx and trachea can be considered as an inner, elastic tube (= conus elasticus) lined with epithelium, suspended to an outer, segmented cartilaginous tube. At the level of the subglottis an intact conus elasticus is of more importance for the normal development of the airway lumen in young rabbits than an intact ventral half of the cricoid ring.

Complete cricotracheal separation following blunt trauma to the neck

We report a case of complete cricotracheal transection with wide separation of the ends, a rare injury. Because of the good general and respiratory condition of the patient on admission, the pathognomonic signs of laryngeal injury were not noticed, causing an unnecessary delay in treatment. Deteriorating respiratory status with progressing cervical subcutaneous emphysema brought up the diagnosis of laryngotracheal injury. Treatment was immediate and included tracheotomy and primary end-to-end anastomosis.

Cricoarytenoid subluxation, computed tomography, and electromyography findings

A case of cricoarytenoid subluxation secondary to endotracheal intubation and documented by computed tomography (CT) and electromyography (EMG) is reported. Successful endoscopic reduction of the displaced arytenoid is confirmed by CT. The normal anatomy and physiology of the cricoarytenoid joint is presented and the literature regarding this rarely reported injury is reviewed. Based on this review and the case reported, a treatment plan is proposed.

[Therapy of ankylosis of the cricoarytenoid joint following intubation]

The immobility of the vocal cord following endotracheal intubation is often misinterpreted as a paralysis. Possibilities are pointed out to differentiate between vocal cord paralysis and ankylosis of the cricoarytenoid joint. Furthermore it is shown another simple therapeutic procedure to mobilize the fixed joint.

Laryngotracheal trauma: a protocol approach to a rare injury

Laryngotracheal trauma is rare and complications are frequent. Twelve major series totalling 392 cases have been published over the past decade, with complication rates as high as 40%. We have treated over 30,000 trauma victims at our Level I Trauma Center over the past 5 years, of which 109 had neck injuries, but only 12 suffered cervical laryngotracheal trauma. The mechanism of injury was penetrating in eight and blunt trauma in four. The time to tracheostomy decannulation varied from 7 to 60 days. Airway patency was assured without stenosis or significant granulation tissue in 10 of the 12 patients. Three patients suffered permanent voice changes. Based on review of the 392 previously reported cases and a critical analysis of our 12 cases, a detailed management algorithm is proposed.

Orotracheal intubation in suspected laryngeal injuries

Airway control in patients with suspected laryngotracheal injury following blunt trauma is a challenging problem. Tracheostomy remains the treatment of choice in most instances. This report describes a patient with a laryngotracheal injury in whom initial airway control was achieved using orotracheal intubation. The indications for this method are discussed, and an approach to initial airway management in these injuries is outlined.

A study of endotracheal tube injury to the subglottis

An endotracheal tube presses against distinct pressure points within the airway. These areas are the shaft of the tube against the arytenoids and posterior cricoid and the cuff-tube tip in the trachea. An ulcerative injury occurs at these interfacing points from motion occurring between tube and tissue. Minimizing this inherent movement is possible by tube modification and, in the presented animal model, prevents injury.

Delayed cricoid reconstruction by use of a free graft of autogenous "patient banked" cartilage

Avulsed cartilage may be "banked" or preserved by subcutaneous implantation in the traumatized patient for delayed reconstruction of the defect when immediate reconstruction is contraindicated. The perichondrium of the avulsed cartilage should be preserved if possible. In the reconstructive procedure the cartilage graft must be surrounded by vascularized flaps developed from adjacent neck tissue. These vascularized flaps increase the local vascular supply for revascularization of the free graft. In addition, they allow complete separation of the free graft from the airway to minimize the possibility of secondary infection arising from the airway. Mucosal coverage of the defect does not appear to be necessary as long as well-vascularized soft tissue is available for complete coverage of the defect. The use of this technique may be considered for patients with avulsion of portions of the laryngeal cartilages when immediate reconstruction is contraindicated or when the viability of adjacent soft tissue necessary for reconstruction is uncertain. The success of this procedure may be related to the adequacy of the closure or separation of the airway from the free cartilage graft, and the ability to provide coverage of the graft with vascular tissue to allow graft revascularization. This new technique follows the traditional principles vital for successful management of laryngotracheal injuries. This procedure provides an additional method of therapy for those patients with an avulsion injury of the laryngeal cartilage. Additional surgical procedures must be performed utilizing the indications and principles presented here before this method is universally accepted for the management of severe laryngotracheal injury.

[Uncommon injuries of the larynx following intubation. Recurrent paralysis, torsion and luxation of the cricoarytenoid joints]

19 laryngeal injuries are reported. 16 were secondary to orotracheal intubation and 3 were sequelae of gastroscopy, laryngoscopy and a nasogastric tube. In 6 patients, the trauma followed prolonged nasotracheal intubation, 10 cases followed a single endotracheal intubation. The main symptom was hoarseness. In 6 cases dislocation of an arytenoid cartilage was diagnosed, in 1 case a vocal cord paresis and in the other cases contusion or distortion of the arytenoid joint. In the cases of subluxation the arytenoid cartilage was dislocated posterolaterally, with the cord in the abducted position. For treatment we recommend closed reduction and injection of Cortison-Crystal-suspension into the joint. The outcome is good after single endotracheal intubation, but bad in prolonged nasotracheal intubation because of ankylosis of the cricoarytenoid joint.

Neck markings and fractures in suicidal hangings

Over a 10-year period in which both a retrospective and prospective study of suicidal hangings was made, fractures of the thyroid cartilage alone, or the hyoid bone alone, or of both together were noted in 20% of the cases. In the prospective study, an incidence of 46% was found. This contrasts sharply with the incidence of 15% in the retrospective study. This wide discrepancy indicates the need for longer periods of a controlled prospective study by properly trained prosectors. Fractures were found in all age groups above 19 years of age and occurred whether suspension was complete or incomplete, whether the ligature was soft or hard, narrow or wide, and whether decedents did or did not jump from a platform. The higher incidence of fractures occurring among women is unexplained. The presence of reddish or pink bands or linear streaks (with or without superimposed abrasions) along one side of the neck, separated by bands of pale skin, canting upwards towards the back of the neck and revealing the imprint of a folded cloth permits the diagnosis of ante-mortem hanging in the absence of very strong proof to the contrary. As in any type of Medical Examiner's case, a knowledge of the circumstances and investigation of the scene are required before a final determination of the cause and manner of death can be considered.

Laryngeal injuries secondary to nasogastric tubes

Laryngeal complications secondary to nasogastric intubation have been reported rarely in recent literature. Recent experience with three patients who developed laryngeal injuries related to nasogastric tubes prompted retrospective, experimental, and prospective studies to determine the mechanism of laryngeal injury. A review of the literature, as well as the clinical findings in our three patients, point to midline tube placement and the subsequent development of cricoid chondritis as the underlying etiology. An experimental study using anesthetized dogs was designed to compare histologically the effect on the larynx with nasogastric tubes placed in the midline, as opposed to nasogastric tubes in the lateral position. Results of the histologic study confirmed that midline tubes generate severe inflammation in the postcricoid region. One hundred patients were then evaluated roentgenographically to determine the incidence of midline tube placement in a random sample. Six percent of the patients had nasogastric tubes in the midline. Patients who have nasogastric tubes in place for more than three days or have a severe amount of discomfort should have an x-ray film to determine position of the tube. Midline tubes should be removed or replaced.

[Laryngoscopy of laryngeal damage in long-term intubated intensive care patients]

67 long intubated, critically ill patients were examined by direct laryngoscopy between the 3rd and 14th day of intubation. It was found that even after 5 days most of the patients investigated had severe laryngeal damage. Damage occurs preferentially on the vocal cord (laryngeal granuloma), on the arytenoid vocal process and on the cricoidal plates (ulcerations). It is concluded that laryngoscopy should be performed after 5 days of intubation at the latest to determine the extent of laryngeal damage. If necessary, secondary tracheotomy should be considered.

The effects of cricoid cartilage injury and antibiotics in cricothyroidotomy

Until recent years cricothyroidotomy has been condemned as an elective surgical procedure because of reports of a high incidence of subglottic stenosis. In this study of cricothyroidotomy the effects of trauma, denudation of the mucous membrane of the anterior half of the cricoid cartilage, and the prophylactic administration of antibiotics (ampicillin) on the development of subglotttic airway narrowing were evaluated in 40 mongrel dogs. Two of the dogs developed minimal anterior narrowing of the airway. None of the dogs developed clinically important stenosis.

Laryngotracheal separation

The popularity of the motorcycle, specifically trail bike riding, in the past several years has produced an increasing incidence of severe "clothesline" injuries to the larynx and trachea. Even at moderately high speed the impact of a horizontal cable with the neck of the rider causes a sudden hyperextension of the neck, and an avulsion of the larynx from the trachea, separating at the relatively rigid fibrous connective tissue between the cricoid cartilage and the first tracheal ring. Interruption of the strap muscles, the recurrent laryngeal nerves, laceration of the esophagus, and compression fracture of the cervical vertebral bodies can occur. The unseated rider requires immediate assistance, airway obstruction being his greatest problem. In the early minutes after the accident he must be transported to an emergency facility where tracheostomy and resuscitation can be provided. Mediastinal infection, tracheoesophageal fistula, subglottic stenosis, and intermittent depression many follow the initial repair. Rehabilitative measures include permanent tracheostomy, the use of neuromuscular pedicle graft, hyoid bone graft, intracordal injection of teflon paste, and carbon dioxide laser excision of webs and cicatricial tissue.

Crico-arytenoid joint obliteration following longterm intubation in the premature infant

Twin male premature infants suffering from hyaline membrane disease were intubated with Cole endotracheal tubes. One died at 25 weeks of age of cor pulmonale, still intubated. The other died at 32 weeks, six weeks after tracheotomy. Both larynges were serially sectioned and compared to normal. The crico-arytenoid joints were destroyed by inflammatory granulation tissue, and later obliterated by fibrous tissue. The probable pathogenesis and implications are discussed.