The management of laryngeal fractures using internal fixation

Penetrating Neck Injury: Double Jeopardy of a Complex Aerodigestive Dilemma

The neck is a critical region containing many essential structures. Before surgical intervention, it is crucial to assess the adequacy of the airway and circulation, as well as the presence of any skeletal or neurological damage. Here, we present a case of a 33-year-old male with a background of amphetamine abuse who presented to our emergency department with a penetrating neck injury just below the mandible at the hypopharynx level, resulting in an upper zone II neck injury with complete separation of the airway. The patient was taken immediately to the operating room for exploration. Airways were managed by direct intubation, hemostasis was maintained, and the open laryngeal injury was repaired. After the surgery, this patient was transferred to the intensive care unit for two days and discharged after a satisfactory full recovery. Penetrating neck injuries are rare but often fatal. Advanced trauma life support guidelines emphasize the importance of managing the airway as the first action. Providing multidisciplinary care before, during, and after trauma can help prevent and treat such incidents.

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.

External penetrating laryngeal trauma caused by a metal fragment: A Case Report

BACKGROUND

Although external penetrating laryngeal trauma is rare in the clinic, such cases often result in a high mortality rate. The early recognition of injury, protection of the airway, one-stage laryngeal reconstruction with miniplates and interdisciplinary cooperation are important in the treatment of such patients.

CASE SUMMARY

A 58-year-old male worker sustained a penetrating injury in the left neck. After computed tomography scanning at a local hospital, he was transferred to our hospital, where he underwent tracheotomy, neck exploration, extraction of the foreign object, debridement and repair of the thyroid cartilage using titanium miniplates. An endo laryngeal stent was inserted, which was removed 12 days later. The patient recovered well and his voice rapidly improved after surgery.

CONCLUSION

Penetrating laryngeal trauma is uncommon. We successfully treated a patient with early laryngeal reconstruction and management by interdisciplinary cooperation.

Combined Pharyngeal Laceration and Laryngeal Fracture Secondary to Dog Bite: A Case Report

Dog bites are the most common animal bites, typically occurring in the head and neck region or extremities. The majority of dog bite-related injuries are superficial and require minimal medical intervention. Less commonly, dog bite injuries can be very serious when involving the airway, major blood vessels, or extensive tissue loss. To this day, there are very few case reports in the medical literature that describe severe dog bites and outline their management. We present a case of successfully treating an extensive pharyngeal laceration with a laryngeal cartilage fracture produced by an unvaccinated dog bite.

Management of Post-Traumatic Subglottic Stenosis and Pharyngosubglottic Fistula

Injury to the aerodigestive tract following external laryngeal trauma is rare. Reports of acquired laryngopharyngeal fistula are very few. We report a very rare presentation of penetrating neck trauma presenting with fracture of the cricoid cartilage, subglottic stenosis and pharyngosubglottic fistula. The term 'pharyngosubglottic fistula' is used here for the first time to describe a communication tract between hypopharynx and subglottis. The successful surgical management of this case is discussed.

Repair of displaced thyroid cartilage fracture using miniplate osteosynthesis

Acute laryngeal trauma is estimated to occur in approximately one patient per 14 500 to 42 500 emergency room admissions. If the larynx is injured, its vital functions are affected and can be threatened in case of severe injury. Soft cartilage offers no protective advantage, which is the reason why young as well as older individuals are at risk of thyroid cartilage fracture. Experimentation on cadaver larynx has demonstrated that virtually all laryngeal fractures are longitudinally oriented. Furthermore, muscular pull can contribute to a misalignment of the fractures. As stated by Bent and Porubsky, a fracture is considered severely rather than moderately displaced, if it is freely mobile on physical examination, has more than two fracture lines or demonstrates a displacement greater than the width of the thyroid cartilage on CT imaging. We present two cases of severely displaced thyroid cartilage fracture treated in our department by open reduction and internal fixation using miniplates. Functional and radiological outcomes were excellent.

Traumatic Airway Injuries: Role of Imaging

Airway Injuries are rare but often immediately life threatening. Incidence ranges from 0.5-2 % in blunt and 1-6 % in penetrating trauma. Upper airway injuries (UAI) are often clinically apparent and get shunted during the primary survey in the emergency department. Few UAI and majority of lower airway injuries (LAI) are occult on primary survey and need a high suspicion index. Clinically, the diagnosis of tracheobronchial injury is delayed in many patients because the airway column is maintained by the peribronchial tissue. Imaging in the form of MDCT, in conjunction with endoscopy, plays a role in delineating the exact site and extent of injury and ruling out associated vascular and esophageal injuries for definitive management of UAI. Chest radiographs and ultrasonography help raise suspicion of LAI by detection of pneumomediastinum, persistent pneumothorax and/or subcutaneous emphysema and should be followed up with multidetector computed tomography (MDCT) which is the mainstay of diagnosis. However, it requires careful evaluation of the airway tract and a thorough knowledge about the mechanism of trauma for detection of subtle injuries. Reconstructions in multiple planes and use of various post-processing techniques including minimum intensity projection (MinIP) images enhance the detection rate. The specific signs of LAI on CT include discontinuity in the tracheobronchial tree, focal intimal flap projecting in the lumen, focal soft tissue attached to the tracheal/bronchial wall, complete cut off of the bronchus/trachea and the fallen lung sign. We, hereby, illustrate the imaging spectrum of traumatic airway injuries in detail and discuss their management implications.

Laryngeal fractures treated with titanium mesh fixation

The larynx plays a vital role in respiration, swallowing, and vocal function. Thus, laryngeal fractures that are not appropriately managed may lead to permanent dyspnea, dysphagia, and voice disorders. In cases of laryngeal fractures, surgical repair by internal fixation has been performed with materials such as thread, steel wire, and titanium miniplates. However, thyroid and cricoid cartilage have a complicated morphology, and ossification at each site in the cartilage is not uniform; thus, in some cases it is difficult to perform internal fixation with conventional methods. In this case report, we describe two patients who underwent successful fixation of fractures in their laryngeal cartilage after trauma by using titanium mesh with thread and screws. Since optimal reduction and fixation of fractured laryngeal cartilage cannot be performed with conventional methods in patients with unossified cartilage, titanium mesh may be considered a safe and reliable alternative.

Tissue-Engineered Larynx: Future Applications in Laryngeal Cancer

Purpose of Review

This article reviews the latest developments in tissue engineering for the larynx with a specific focus on the treatment of laryngeal cancer.

Recent Findings

Challenges in tissue engineering a total larynx can be divided into scaffold design, methods of re-mucosalization, and how to restore laryngeal function. The literature described a range of methods to deliver a laryngeal scaffold including examples of synthetic, biomimetic, and biological scaffolds. Methods to regenerate laryngeal mucosa can be divided into examples that use a biological dressing and those that engineer a new mucosal layer de novo. Studies aiming to restore laryngeal function have been reported, but to date, the optimum method for achieving this as part of a total laryngeal transplant is yet to be determined.

Summary

There is great potential for tissue engineering to improve the treatments available for laryngeal cancer within the next 10 years. A number of challenges exist however and advances in restoring function must keep pace with developments in scaffold design.

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.

Management of laryngeal fractures--a 10-year experience

OBJECTIVES

Laryngeal fracture patients can present with a spectrum of clinical findings ranging from normal to airway collapse and death. We will therefore examine and emphasize clinical presentation, an algorithm for appropriate diagnosis and acute airway management, and radiological or physical examination findings and demonstrate the appropriate surgical approach for optimum clinical outcome in cases of blunt and penetrating laryngeal injury. Herein, we present one of the largest series of management of laryngeal and tracheal fractures from a tertiary care level I trauma center.

STUDY DESIGN

A retrospective chart review from 1998 to 2008.

METHODS

A retrospective chart analysis on patients presenting to the head and neck trauma service. Institutional review board approval was obtained before the start of the research.

RESULTS

Our series consisted of 11 men and one woman with a mean age of 41.8 years presenting with laryngeal fractures caused by blunt (n=10) or penetrating (n=2) trauma. One patient presented with complete laryngotracheal separation, which was successfully managed by immediate tracheotomy and early surgical intervention. The other 11 patients had a combination of conservative (n=6) and surgical (n=5) management. All patients who required a tracheotomy (n=7) were decannulated.

CONCLUSIONS

Early suspicion and diagnosis of acute laryngeal and tracheal injuries are crucial. The airway must be secured via tracheotomy when possible. Computed tomography scans play a central role in diagnosis. Proper restoration of the laryngeal framework with appropriately timed open reduction and internal fixation is critical for optimal recovery of the airway, voice, and swallowing.

Upper airway injury and its management

Injuries to the upper airways are rare, but carry a significant morbidity and mortality. The degree of injury and presentation varies; thus recognition often requires a high index of suspicion based on mechanism. Effective management of laryngotracheal injuries begins with immediate control of the airway whether by orotracheal and surgical route. Definitive management of upper airway injuries relies on an understanding of the anatomy of the larynx, trachea and surrounding structures. Associated injuries are common and must be addressed concomitantly. Postoperative complications are frequent, requiring perioperative vigilance and long-term follow-up to ensure best outcome.

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.

Acute External Laryngotracheal Trauma: Diagnosis and Management

Laryngotracheal trauma may result in lifelong complications or even death if diagnosis or treatment is delayed. Emergency room physicians, trauma surgeons, anesthesiologists, and especially otolaryngologists should maintain a high level of awareness of and suspicion for laryngotracheal trauma whenever a patient presents with multiple trauma in general or with cervical trauma in particular. Although there is some controversy regarding care, treatment in experienced hands will usually result in a favorable outcome. In this article, we review and update the diagnosis and management of acute external laryngotracheal trauma.

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.

Post traumatic laryngeal incompetence

Self-inflicted laryngeal injuries are rare. This is a case of attempted suicide with a knife. The patient was brought into A&E and initial attempts at repair of the laryngo-skeletal structures were performed Later it became evident that the patient had an insensate hypofunctioning larynx. We present a technique aimed at rehabilitating the poorly functioning, incompetent larynx without the necessity for a permanent tracheostomy or laryngectomy. A single surgical procedure combining a cricopharyngeal myotomy, an anterior hyoid suspension and vocal fold angmentations was performed in an attempt to avoid a laryngectomy in non-malignant pathology. The long-term results of this surgery would need to be subjected to further evaluation.