External laryngotracheal trauma

External laryngotracheal trauma: a case series and an algorithmic management strategy

OBJECTIVES

External laryngotracheal trauma (ELT), blunt or penetrating, is a rare but potentially life-threatening injury. Immediate care in the emergency department can be challenging because it requires managing a potentially unstable airway and may have associated vascular injuries with massive bleeding. Here, we look at the details of injury, treatment measures, and outcomes in patients following ELT.

METHODS

We retrospectively analyzed 22 patients treated at our center for ELT from January 2005 up to December 2021 with varying grades of injury. We looked at their status at presentation, management strategy and functional status.

RESULTS

In our report, we include 18 men and 4 women having varying Schaefer injury grades. Eight patients had tracheostomy at presentation and eight had vocal fold immobility. Two patients were treated endoscopically, 12 had open surgery and 8 received no treatment. Of the patients undergoing open surgery, thyroid cartilage fracture was seen in 9 patients, thyroid plus cricoid fracture and cricotracheal separation were seen in 3 patients each. All patients were safely decannulated and spontaneous recovery of vocal cord palsy was seen in some patients.

CONCLUSION

The success of managing ELT relies on fast decision-making, correct patient evaluation, securing the airway and maintaining the hemodynamic stability. Early surgical intervention must be aimed at optimally treating the larygotracheal injuries to prevent long-term disastrous consequences.

Changes in occurrence and management of laryngeal fractures at the Helsinki University Hospital during 25 years

PURPOSE

Laryngeal fracture is a rare but potentially life-threatening trauma. Fractures vary from mild to dislocated and extensive with risk of severe complications. This study investigated the occurrence, clinical characteristics and management of laryngeal fractures in the last 15 years.

MATERIAL AND METHODS

A retrospective population-based cohort study reviewing all laryngeal fractures at the Helsinki University Hospital in 2005-2019. Patient records and imaging studies were systematically reviewed for mode of injury, fracture type, secondary complications, treatment modality, possible airway management, length of stay, and mortality. Results were compared with corresponding data from 1995 to 2004.

RESULTS

Overall 80 fracture patients were recorded (5.3/year); 79% were men and mean age was 42 years (range 18-78). Altogether 91% were closed and 9% open. While unintentional traumas were most common (54%), an increasing proportion were from intentional injury (10%) or Schaefer Gr IV in severity (35%). Altogether 46% had compromised airway and 21% needed airway intervention; airway narrowing was more common with cricoid (p = 0.042) and multiple fractures (p = 0.07) and correlated positively with amount of dislocation (p = 0.001) and number of fracture lines (p = 0.006). Surgery was performed for 33%, of which 46% were Schaefer Gr IV and 62% from intentional trauma. Mortality was 1.4%.

CONCLUSIONS

Deliberate and violence-related laryngeal fractures have increased. These often result in more extensive injuries predisposing to compromised airway and requiring surgical intervention and longer treatment. Most fractures are still treated conservatively with good long-term outcomes. An observation period of 24 h is recommended to detect any delayed complications. Mortality remains low.

Clinical, Radiologic, and Endolaryngeal Findings in Laryngeal Fractures: A 15-Year Case Series

Objective

Laryngeal fractures are rare injuries; recent data describing these injuries and associated examination findings are limited. This study aims to describe injury etiology and outcomes associated with laryngeal fractures.

Study Design

Retrospective case series.

Setting

Academic tertiary center.

Methods

Patients with laryngeal fractures from 2005 to 2020 were identified in a retrospective chart review. Patient demographics, injury mechanisms, management, and voice outcomes were examined. Fracture type, radiologic, and endolaryngeal examination findings were analyzed for associations between fracture etiology and examination characteristics.

Results

Laryngeal fractures most commonly occurred at the thyroid cartilage. Fractures were most commonly due to sport-related injuries. Mechanism of injury was not associated with specific radiologic or endolaryngeal findings. Mechanism of injury was additionally not significantly associated with the need for intubation, surgical intervention, or tracheotomy. Fracture location was significantly associated with intubation requirement (P = .015), with 40% of patients with concomitant thyroid and cricoid fractures requiring intubation. Mechanism of injury significantly correlated with dysphonia at follow-up (P = .033). Mechanism of injury, fracture location, and surgical management were not associated with increased vocal fold injury or dysphonia.

Conclusion

There are no significant correlations between injury mechanism and fracture location, characteristics, radiologic findings, or endolaryngeal findings. These features emphasize the importance of a thorough and comprehensive laryngeal examination.

Diagnosis, management and treatment of neck trauma

Trauma injuries to the neck account for 5-10% of all trauma injuries and carry a high rate of morbidity and mortality, as several vital structures can be damaged. Currently, there are several treatment approaches based on initial management by zones, initial management not based on zones and conservative management of selected patients. The objective of this systematic review is to describe the management of neck trauma.

Airway management changes associated with rising radiologic incidence of external laryngotracheal injury

BACKGROUND

Traumatic laryngeal injuries are uncommon life-threatening injuries that require prompt, rational management of a potentially precarious airway. It is unclear whether the current incidence of laryngotracheal injury is due to enhanced injury detection or increased occurrence. The objective of this study was to evaluate the relations between diagnostic imaging with both initial airway management and surgical treatment in patients with external laryngotracheal injuries (ELTIs) in Alberta.

METHODS

In this large-scale population-based analysis, we used regional health databases containing inpatient admissions, emergency department visits and trauma service activations employing International Classification of Diseases diagnostic codes to identify all ELTIs diagnosed from Apr. 1, 1995, to Dec. 31, 2011, in adults (age ≥ 16 yr). We evaluated health records and diagnostic imaging for injury features, airway management, operative interventions and hospital length of stay (LOS).

RESULTS

Eighty-nine patients met the inclusion criteria. The incidence of ELTIs increased over time, paralleling a rise in detection during the period incorporating greater computed tomography (CT) use (p = 0.002). Endotracheal tube intubation was performed in 8/30 cases (27%) in the pre-CT era, compared to 38/59 cases (64%) in the post-CT era (p = 0.001); the use of surgical intervention remained consistent. The largest contributors to increased endotracheal tube placements were the emergency department and emergency medical services. No change in survival was detected, but mean LOS among patients admitted for minor, isolated ELTIs increased by 2.3 (95% confidence interval 0.14-4.8) days (p = 0.06), mostly for patients admitted under critical care for mechanical ventilation.

CONCLUSION

Management of ELTIs shifted from predominantly conservative airway monitoring to endotracheal tube intubation over the study period in spite of no clinically significant change in injury severity or operative intervention frequency. The location of endotracheal tube placement suggests less comfort with ELTI among first-responder and emergency personnel.

Maxillofacial Fractures Associated With Laryngeal Injury: A Craniofacial Surgeon Should be Alert

OBJECTIVE

Maxillofacial fractures with concomitant laryngeal injuries put both the quality and maintenance of life in jeopardy. Because of its low incidence, it is often overlooked in the clinical setting. The purpose of this study is to review the incidence, clinical presentations, managements, and outcomes of these patients.

METHODS

A retrospective analysis of medical records from 2008 to 2015 was conducted at a single institute. A case series (n = 12, which contributed 22.2% of laryngeal injuries in our institute) of these patients was presented, and propensity score matching was applied for further statistical analysis.

RESULTS

When comparing patients who sustained maxillofacial fractures with concomitant laryngeal injuries with patients with only maxillofacial fractures and no laryngeal injuries, subcutaneous emphysema (83.3% vs 4.2%, P < 0.001), neck pain (75.0% vs 6.3%, P < 0.001), dyspnea (75.0% vs 0%, P < 0.001), hoarseness (41.7% vs 0%, P < 0.001), neck swelling (66.7% vs 4.2%, P = 0.012), stridor (16.7% vs 0%, P = 0.037), hemoptysis (16.7% vs 0%, P = 0.037), and thoracic trauma (58.3% vs 10.4%, P = 0.001) all showed significant differences. The length of intensive care unit stay (7.42 days vs 3.21 days, P = 0.008), ventilator use (66.7% vs 18.8%, P = 0.002), and tracheostomy (58.3% vs 0%, P < 0.001) were also significantly different.

CONCLUSIONS

A significant portion of laryngeal injuries is concurrent with maxillofacial fractures. As a craniofacial surgeon, we should be alert to the signs of laryngeal injury. Diagnosis of laryngeal injuries should be established before definitive surgery for maxillofacial fractures.

Impact of deferred surgical intervention on the outcome of external laryngeal trauma

BACKGROUND

External laryngeal trauma (ELT) can be a fatal injury. Proper management of ELT significantly affects patient survival and quality of life. The optimal timing of surgical intervention is controversial. In this study, we review the incidence, management, and outcome of ELT and attempt to analyze the risk factors and prognosis of this injury.

METHODS

We conducted retrospective review using prospective data collection from patients with ELT in a level I trauma center from May 2008 to May 2013. We retrieved data regarding the severity of ELT, Injury Severity Score (ISS), New Injury Severity Score (NISS), Reverse Trauma Score (RTS), surgical timing, intensive care unit length of stay (ICU LOS), hospital length of stay (HLOS), long-term outcome, and mortality. We analyzed the risk of prolonged hospitalization, adverse outcome, and mortality.

RESULTS

The 48 patients in this cohort had a mean age of 40.8±19.6 years. Twenty-four patients underwent operation within 48 hours, 10 patients underwent operation after 48 hours, and the other 14 patients did not require surgical intervention. A high NISS and the necessity for operation prolonged the ICU LOS and the HLOS. A high ISS and a low RTS predicted mortality. Initial phonatory impairment and the necessity of surgical intervention increased adverse outcomes.

CONCLUSIONS

In conclusion, ELT leads to high mortality and morbidity. The mortality in our series was related to severe associated injuries and to initial physical decompensation. Proper resuscitation and aggressively physiologic compensation were more important in the initial phase. Deferred treatment was acceptable until the patients were ready for operation.