Repair of laryngeal fractures using adaptation plates

Systematic Review of Laryngeal Fractures and Trends in Operative Management

Study Design

Systematic review of the literature.

Objective

The goal of this study is to review the current literature on the trends in management of laryngeal fractures following trauma.

Methods

Independent searches of the PubMed and MEDLINE databases were performed. Articles from the period of 1963 to 2020 were collected. All studies which described laryngeal fractures using the Boolean method and relevant search term combinations, including "Laryngeal", "Fracture", "Operative", and "Management" were collected.

Results

A total of 588 relevant unique articles were identified for analysis. Of these, 24 articles were deemed appropriate for inclusion in the literature review. Due to variability in study design and outcome measures, formal synthesis of data in the form of a meta-analysis was not possible.

Conclusions

Laryngeal fractures are rare traumatic injuries that require early identification and evaluation with complex management options. This comprehensive review aims to highlight the breadth of the topic with regard to presentation and clinical management. Though there remains no clear best practice for laryngeal fracture management, we review trends in clinical practice throughout the literature.

Laryngeal Trauma Managed with Titanium Mesh Fixation: A Rare Case Report

Laryngeal fractures are though uncommon they can be potentially life threatening. Comminuted laryngeal cartilage fractures are difficult to manage and various fixation techniques have been described in literature. Outcome results of fixation with different materials can be varied. We report a case of 27 years old male who sustained laryngeal cartilage fracture following accidental fall. Patient underwent emergency tracheostomy and early surgical repair of fractured laryngeal thyroid cartilage with one of the newest techniques "titanium mesh fixation". After a month of surgery tracheostomy tube was removed and patient recovered with good laryngeal function. Titanium mesh fixation gave immediate effective fixation and stability to laryngeal fracture leading to good surgical outcome.

Go-karting injury: a case of laryngeal trauma

We report a case of accidental strangulation and crush injury to the anterior neck resulting in laryngeal trauma. This extremely uncommon mechanism of injury provides a safety warning regarding precautions with neck wear, and the unusual resulting injury represents an opportunity to review best practice in management of laryngeal trauma.

Surgical management for isolated cricoid fracture causing arytenoid immobility

Cricoid cartilage fractures usually occur concurrently with disorders of laryngeal function. In, particular, displaced cricoid lamina fractures can affect arytenoid movement. However, functional, recovery may require proper repositioning of the cricoid lamina, which is associated with a high rate of, complications. Here we present a case in which an isolated cricoid cartilage fracture with arytenoid, immobility due to displacement of the fracture in the cricoarytenoid joint space was successfully, treated. Our findings suggest that a combination of external approaches with temporary, cricothyrotomy and wide suturing of the entire cricoid framework has the potential to improve, arytenoid movement and prevent associated complications.

Management of acute blunt and penetrating external laryngeal trauma

OBJECTIVES/HYPOTHESIS

Improve the care of acute external laryngeal trauma by reviewing controversies and the evolution of treatment.

DATA SOURCE

Internet-based search engines, civilian and military databases, and manual search of references from these sources over the past 90 years.

REVIEW METHODS

Utilizing the above-mentioned sources, electronic and manual searches of primary topics such as laryngeal trauma or injury, emergency tracheotomy, airway trauma, intubation versus tracheotomy, cricothyrotomy, esophageal trauma, and emergent management of airway injuries in civilian and combat zones. Citations were reviewed, selected reports analyzed, and the most relevant articles referenced.

RESULTS

Optimal treatment of acute laryngeal trauma includes early identification of injuries utilizing a directed history and physical examination. Timely management of the wounded airway is essential. The choice of intubation, tracheotomy, or cricothyrotomy must be individualized. Computed tomography (CT) may assist in differentiating patients who can be observed versus those who require surgical exploration. In selected patients, laryngeal electromyography and stroboscopy may also be useful. Surgery should begin with direct laryngoscopy and rigid esophagoscopy to evaluate the hard and soft tissues of the larynx, and to visualize the pharynx and esophagus. Minor endolaryngeal lacerations and abrasions may be observed, whereas more significant injuries require primary closure via a thyrotomy. Laryngeal skeletal fractures should be reduced and fixated. Endolaryngeal stenting is reversed for massive mucosal trauma, comminuted fractures, and traumatic anterior commissure disruption.

CONCLUSIONS

Acute external injury to the larynx is both life threatening and a potential long-term management challenge. Although a rare injury, sufficient experience now exists to recommend specific treatments, and to preserve voice and airway function.

Near-complete supraglottic transection of the larynx after a motorbike accident

Severe laryngeal trauma is rare in the civilian environment and requires appropriate and timely surgical intervention. We report a case from Sydney, Australia, which was managed with open reduction and internal fixation of the larynx with resorbable plates. The use of resorbable plates for operative fixation of the larynx has rarely been reported in literature but may be a viable alternative.

Pseudarthroses of the cornu of the thyroid cartilage

OBJECTIVE: Injuries to the cartilaginous larynx are rare disorders that usually undergo good spontaneous healing and rarely require surgery.

STUDY DESIGN: Case series with chart review from patients with pseudarthrosis of the cornu of the thyroid cartilage.

SETTING: ENT department of a level I trauma center.

SUBJECTS AND METHODS: We examined the medical records of seven patients treated for impaired healing of the cornu of the thyroid cartilage at a level I trauma center between 1997 and 2009.

RESULTS: Seven patients were treated as a result of impaired healing of injuries to the cornu of the thyroid cartilage caused by trivial trauma (e.g., car accidents). The principal symptom was odynophagia. Computed tomography was used to confirm the diagnosis. Treatment involved resecting the cornu of the thyroid cartilage. Histology showed a hypertrophic pseudarthrosis at the base of the cornu. All patients were free of symptoms 10 days after resection.

CONCLUSION: Pseudarthrosis of the cornu of the thyroid cartilage is a previously undescribed condition. Pseudarthrosis of the laryngeal skeleton should be excluded in patients with odynophagia.

© 2010 American Academy of Otolaryngology-Head and Neck Surgery Foundation. All rights reserved.

Thyroid cartilage fracture: Treatment with biodegradable plates

A 29-year-old man fractured his thyroid cartilage while playing rugby. It was treated successfully with an Inion biodegradable plating system. Biodegradable plates are recommended for laryngeal reconstruction.

Laryngeal fractures: clinical findings and considerations on suboptimal outcome

CONCLUSION

We recommend early surgical exploration and fixation for patients with dislocated or comminuted laryngeal fractures to avoid long-term voice complications. One-third of 33 fracture patients rated their voice after the fracture had healed as fair but altered.

OBJECTIVES

To examine the indications for and the outcome of surgical management in patients with laryngeal fractures.

PATIENTS AND METHODS

The study was carried out in a tertiary care referral university hospital and was a retrospective study of case series. Thirty-three consecutive patients, aged 14-84 years, presented with various types of laryngeal fractures. Patients were staged according to the type of the fracture and surgical correction was performed when indicated. Voice outcome was documented and patients with subjectively suboptimal result were further evaluated by phoniatric specialist.

RESULTS

In all, 32 of 33 laryngeal fracture patients had blunt trauma and the main causative factors were sport injuries (39%) and physical assault (33%). All of the 33 laryngeal fracture patients had a good airway outcome. The subjective voice outcome was good for 20 (61%) and fair for 13 (39%) patients. The mean follow-up time was 39.5 months (range 2-114 months). In phoniatric evaluation most (six of eight) patients with fair voice outcome could not produce high pitched voices because of inability to stretch the vocal folds.

Comparison of pullout strength of resorbable screws and titanium screws in human cadaveric laryngeal cartilage

OBJECTIVES

To compare the pullout strength of titanium screws and resorbable screws from human fresh-frozen cadaveric laryngeal cartilage. The importance of drill hole diameter, screw diameter, and whether the drill hole was tapped (resorbable screws only) was also determined.

STUDY DESIGN

Prospective.

METHODS

Sixteen cartilage specimens were tested after debridement of connective tissue and perichondrium. Linear pullout strength of screws was measured using a load cell. Titanium and resorbable screw sizes of 1.5 and 2.0 mm were tested using drill hole diameters of 1.1 and 1.5 mm. For the resorbable-tapped group, screw diameters of 1.5 and 2.0 mm were tapped with 1.5 and 2.0 mm taps, respectively. All tested screws were 6 mm in length.

RESULTS

We found a uniformly constant difference between the three screw types (P < .001). Post hoc analysis indicated a significant difference between the resorbable-untapped screw and both the resorbable-tapped screw and the titanium screw. We failed to find a significant difference, however, between the resorbable-tapped screw and the titanium screw. We also found a significant effect in regard to screw size (P = .0133), with post hoc analysis demonstrating the 1.1/1.5 mm combination to be inferior to the 1.1/2.0 and 1.5/2.0 mm combinations. There was no significant difference between the 1.1/2.0- and 1.5/2.0-mm combinations.

CONCLUSIONS

Resorbable screws with untapped drill holes result in higher resistance to linear loads than both titanium screws and resorbable screws with tapped drill holes. The 1.1/2.0- and 1.5/2.0-mm drill/screw combinations are superior to the 1.1/1.5-mm combination when considering untapped resorbable screws.

Repair of a laryngeal fracture using miniplates

Injuries to the larynx (voice box) can lead to loss of vital functions; the airway may be obstructed, the voice distorted or lost, and the protection of the airway during swallowing may fail. In order to preserve these functions, a stable repair that restores the anatomy as closely as possible is needed. The repair should interfere minimally with the neuromuscular functions of the larynx. The case is described of a 59-year-old male who suffered a severe laryngeal fracture in a work-place accident. Utilizing miniplates, the fracture was reduced and fixed in the correct position. After healing, the patient could be decannulated and has regained his voice, swallows without difficulty and has a patent airway. The results have been sustained over a 2-year follow-up.

Management of Penetrating Neck Injuries: A New Paradigm for Civilian Trauma

PURPOSE

Improvements in imaging technology, particularly computed tomographic angiography (CTA), have altered the management of patients with penetrating neck injuries. Although some centers still advocate routine exploration for all zone 2 neck injuries penetrating the platysma, many civilian centers in the United States have adopted a policy of selective exploration based on clinical and radiographic examination. The purpose of this retrospective study is to evaluate our 5-year experience with the management of penetrating neck injuries, to further elucidate the role of CTA in clinical decision-making, and to assess treatment outcome.

PATIENTS AND METHODS

One hundred thirty-four consecutive patients were identified from the Legacy Emanuel Trauma Registry as having sustained penetrating neck injuries from 2000 to 2005. Using data collected from the Trauma Registry, as well as individual chart notes and electronic records, variables were collected and evaluated including age, gender, mechanism of injury, number of associated injuries, and the Injury Severity Score, Glasgow Coma Scale on admission, initial hematocrit, airway management techniques, diagnostic and therapeutic modalities, missed injuries, length of hospital stay, disposition, and outcome. Descriptive statistics were used to describe demographics, treatment, and outcome.

RESULTS

One hundred twenty patients met the inclusion criteria, 55 of which had only superficial injuries that did not penetrate the platysma. The primary study group consisted of 65 patients who sustained more significant injuries that violated the platysma including deep, complex, and/or avulsive wounds, vascular injuries, injuries to the aerodigestive tract, musculoskeletal system, cranial nerves, or thyroid gland. The overall mortality rate for the 65 patients with injuries penetrating the platysma was 3.0% (n = 2). Complications occurred in 7 of the surviving 63 patients (10.7%): 2 patients with zone 3 internal carotid artery injuries developed hemispheric ischemic infarcts and hemiplagia; as well as other complications including: infection (n = 2); deep venous thrombosis (n = 1); aspiration pneumonia (n = 1); and hematoma (n = 1). All surviving patients except the 2 stroke patients eventually healed uneventfully without significant functional deficit. The use of CTA as a guide to clinical decision-making led to a significant decrease in the number of neck explorations performed and a virtual elimination of negative neck explorations.

CONCLUSION

The management of stable patients with neck injuries that penetrate the platysma has evolved at our institution into selective surgical intervention based on clinical examination and CTA and has resulted in minimal morbidity and mortality.

Management of laryngo-tracheal injuries associated with craniomaxillofacial trauma

PURPOSE

Laryngeal fractures can occur in association with maxillofacial injuries and may lead to life-threatening airway obstruction. Because of a low incidence and a paucity of peer-reviewed information, there is no universally accepted treatment protocol and few clinicians have extensive experience with complex laryngo-tracheal trauma. The purpose of this retrospective analysis is to validate a treatment protocol for the management of laryngo-tracheal injuries occurring in severely injured patients by assessing the outcome of a consecutive series of patients who were treated by the same surgeons over a 12-year period.

PATIENTS AND METHODS

All patients with laryngeal fractures admitted to the trauma service at Legacy Emanuel Hospital and Health Center (LEHHC; Portland, OR) from 1992 to 2004 were managed by the same surgeons, using a standard protocol based on the stability of the airway, and were retrospectively identified using the LEHHC Trauma Registry. Using information from the Trauma Registry and individual physician chart notes, a database was created for the purpose of assessing outcome. The following data were collected: age, gender, mechanism of injury, number of associated injuries and the Injury Severity Score, Glasgow Coma Scale on admission, initial hematocrit, airway management techniques, length of hospital stay, LEHHC laryngeal injury classification, treatment modality, disposition, and any available follow-up. Descriptive statistics were used to describe demographics, treatment, and outcome. Outcome measures were defined as complications, airway patency, speech, and deglutition.

RESULTS

A total of 16,465 patients were identified from the Trauma Registry as having sustained head, neck, or facial injuries, of which 37 patients were diagnosed with laryngeal fractures. Complete patient records were available for 27 patients (mean age, 35.5 +/- 15.3 years; range, 8 to 80 years; 23 males, 4 females) who were classified according to the LEHHC laryngeal injury classification scheme. Most patients sustained injuries as the result of blunt trauma (n = 23; 85.1%) and almost all of them had concomitant maxillofacial injuries (n = 26; 96.3%). Twenty patients (74.1%) required advanced airway intervention (tracheostomy, 14; endotracheal intubation, 5; emergent cricothyrotomy, 1), of which 13 patients underwent neck exploration. Eight of these patients required open reduction and internal fixation with titanium plates and screws, and 2 patients required the addition of an endolaryngeal stent. There was a general trend toward poorer outcome with increased LEHHC laryngeal injury classification. However, all patients were successfully decannulated, maintained patent airways, and ate a normal diet. Hoarseness was common in patients who underwent surgical exploration; however, long-term perioperative complications were rare and included infection requiring hardware removal (n = 1), unilateral vocal cord paralysis (n = 1), and subjective dysphagia.

CONCLUSION

Fractures of the larynx are uncommon injuries that are frequently associated with maxillofacial trauma and are potentially associated with significant morbidity. Management of laryngo-tracheal injuries using a protocol based on airway status as described in this report results in airway patency, functional vocal quality, and normal deglutition for almost all patients.

Internal fixation of comminuted cartilaginous fracture of the larynx with mini-plates

Acute laryngeal trauma is an uncommon injury. Such trauma is not generally encountered by oral and maxillofacial surgeons. We illustrate a patient who sustained a severe penetrating laryngeal injury. His subsequent management was optimised by the joint intra-operative surgical collaboration between otorhinolaryngology and maxillofacial disciplines.

The management of laryngeal fractures using internal fixation

BACKGROUND

Laryngeal fracture is a rare injury with the potential to affect all functions of the larynx. Restoration of the laryngeal framework is critical for the rehabilitation of laryngeal function.

OBJECTIVE

To ascertain the efficacy of adaptation plate fixation (APF) to repair the laryngeal skeleton.

STUDY DESIGN

Retrospective review of the clinical data of all patients who underwent APF of laryngeal fractures from January 1989 to September 1999.

RESULTS

Our series consisted of 16 men and 4 women presenting with laryngeal fractures caused by blunt (n = 16) or penetrating (n = 4) trauma. Most of these patients presented with severe fractures classified as category III (n = 6), IV (n = 10), or V (n = 1), according to the Schaefer-Fuhrman classification. All patients who required a tracheotomy (n = 13) were de-cannulated. Nineteen of the 20 patients recovered a social voice. The exception was a patient with aphasia secondary to head trauma No patient had aspiration problems. We encountered no complication associated with the use of APF.

CONCLUSION

APF is an effective and well-tolerated method to repair laryngeal fractures.