Larynx - Laryngeal Trauma

Front 1

what reflex protects the larynx from trauma?

Back 1

startle reflex brings the chin down. in general, airway is protected by mandible and sternum.

Front 2

clothesline injury can result in?

Back 2

cricotracheal separation

Front 3

what is different about the pediatric age group?

Back 3

higher larynx is protective. softer cartilage less likely to fracture

small anatomy means higher risk of obstruction

Front 4

keys to diagnosis in airway trauma?

Back 4

Hoarseness, neck pain, crepitus, loss of normal midline neck landmarks.

W/u is endoscopic airway evaluation (NP scope) and CT scan

Front 5

penetrating neck trauma: what is is the risk of multiple structures being injured

Back 5

30% of cases

Front 6

what part of the history correlates with the degree of injury

Back 6

mass and velocity of the instrument

Front 7

when worried about intubation injury, what is the risk of injury with prolonged intubation? when should you convert to trach?

Back 7

4-19%

5-7 days

Front 8

what are the benefits of tracheostomy in prolonged intubation patient?

Back 8

(1) decrease dead space
(2) improve pulmonary toilet
(3) increase comfort and decrease the need for sedation
(4) ease the process of weaning
(5) lessen the risk of long-term complications.

Front 9

what factors of intubation increase the risk of injury?

how do you minimize the risk?

Back 9

large-diameter endotracheal tubes
excessive patient movement
repeated self-extubation
overinflated endotracheal tube cuffs
prolonged intubation
reflux and infection

minimize the above factors, use PPI

Front 10

how can arytenoid dislocation occur?

Back 10

trauma with intubation or with inflated cuff with extubation

Front 11

when you first encounter the patient with laryngeal trauma, what are your goals

Back 11

(1) securing the airway
(2) obtaining hemodynamic stability while controlling the bleeding
(3) immobilizing the cervical spine.

Front 12

Pt presents with history of neck trauma. what are your first moves?

Back 12

listen for voice and breathing

evaluate for crepitus, stridor and hemoptysis

look for expanding hematoma, bruit, pulse deficit (vascular injury)

Front 13

you grab your NP scope. what do you need to look for

Back 13

mucosal tears, exposed cartilage, cartilage step offs, VC mobility, evaluate upper tracheal if patient tolerates it

Front 14

what films do you get next?

Back 14

if the patient is stable Xray can be helpful to look for free air.

CT should be ordered if the patient is stable and warrants surgical intervention, might be helpful for surgical planning.

If not stable, go straight to OR. If not seriously injured and looks good, can observe.

Front 15

how to do you evaluate the esophagus?

Back 15

gastrograffin, then barium swallow (rule out big esophageal perf, then use barium for mucosal detail)...used with rigid esophagoscopy.

Front 16

how do you evaluate the vessels? which neck zones are harder to control surgically?

Back 16

angiography is gold standard and allows for IR embolization if needed

CTA and MRA have lower cost and risk

zones I due to proximity to chest/great vessels
zone II due to proximity to the skull base

zone II can be explore surgically when needed.

asymptomatic patients can be monitored.

Front 17

is it ok to intubate this patient? what else would you do? how about in kids?

Back 17

only if you have a good view of a normal larynx and can use a smallest possible tube. Need to be set up for emergent trach if you lose the airway.

However, an awake trach may be more prudent

In kids who cannot tolerate awake trach, then rigid bronch intubation with spontaneous respiration is best.

Front 18

Describe the groups for laryngeal injuries. How does this help dictate treatment?

Note: need for trach is based solely on airway compromise.

Back 18

Group 1 - minor endolaryngeal lacs or hematomas
- medical managment.

Group 2 - more significant soft tissue injury and single non displaced fractured cartilage
- trach, DL/B with closed reduction of arytenoid dislocation

Group 3 - massive edema, mucosal tears with exposed cartilage, displaced fractures, or vocal cord immobility
Group 4 - unstable larynx with comminuted fractures
Group 5 - complete laryngotracheal separation

Group 3-5 - need operative repair, likely stent placement

Front 19

What is the medical management for Group 1 injuries

Back 19

humidified air, head of bed elevation, and voice rest

PPI and abx if mucosa injury

steroids are controversial but may be needed for swelling

repeat NP scope in 48 hrs.

Front 20

when is surgery indicated? are outcomes better when you operate early or late?

Back 20

(1) lacerations involving the anterior commissure, injury to the free edge of the true vocal fold, or the finding of exposed cartilage; (2) displaced or comminuted fractures; (3) vocal fold immobility; or (4) arytenoid dislocation.

operate 48 hrs for better outcome

Front 21

what materials do you use for reduction of cartilage? for closure of mucosal lacs?

Back 21

stainless-steel wires or absorbable sutures. Miniplates (titanium or absorbable)

lacs can be reapproximated or use local flaps to cover cartilage and reduce changes of perichondritis, granulation, scarring

stent if needed, remove < 1-2 weeks

Front 22

what are the zones in the neck?

Back 22

(1) Zone I extends from the sternal notch to the cricoid;
(2) Zone II extends from the cricoid to the angle of the mandible;
(3) Zone III extends cranially from the mandible to the skull base.

Front 23

mucosal lacerations in what areas can be expectantly managed? which areas require surgical exploration and closure?

Back 23

lacs above the level of the arytenoids can be expectantly managed.

lacs lower hypopharynx and esophagus require surgical exploration and closure

Front 24

how do you differentiate glottic stenosis from VC paralysis?

Back 24

manual assessment of arytenoid mobility or by the use of laryngeal electromyography

Front 25

in cases of tracheal stenosis, how many rings can be removed for a complete resection reanastamosis?

Back 25

4-5 rings

Front 26

how do you treat scarring in the larynx/trachea? what are your options

Back 26

dilation, laser, steroid injection, resection

Front 27

what finding suggests arytenoid dislocation?

Back 27

uneven vocal cord level seen on laryngoscopy

Front 28

what is the fatality rate of penetrating neck trauma

Back 28

3-6%

Front 29

what injuries typically have unfavorable functional outcomes from laryngeal trauma?

Back 29

displaced cricoid cartilage, arytenoid subluxation, or recurrent laryngeal nerve injury