2. Larynx is a well protected structure in the
neck
Functions: airway ,tracheobronchial
protection & phonation
Skeletal framework : hyoid,thyroid,cricoid
Divided into supraglottis.glottis,subglottis
Supraglottis –soft tissue
Glottis-relies on external
support,cricoarytenoid jt mobility and
neuromuscular coordinaton
Subglottis - cricoid
6. ANTERIOR BLUNT
INJURIES: Mc in
motor vehicle
accidents
During deceleration
driver is thrust
forward with neck
hyperextended:
without the
protection of
mandible, larynx
can strike wheel/
dashboard :
7. Clothesline injury : rider of vehicle : motorcycle
or snowmobile: encounter a fixed horizontal
object at neck, clotheline at neck, there is large
amount of energy against small surface
causing separation of cricoid from larynx or
the trachea
Strangulation : initially abrasion of skin
12 - 24 hrs later edema of larynx leading to
airway compromise
8. Penetrating injuries : gunshot or knife injuries
Gunshots at close range impart intense
energy and are usually fatal
Long range : damage may be minimal
High velocity weapons : surrounding tissue
damage is significant, wide debridement
advisable
10. Penetrating injuries
Bounces the laryngeal skeleton
enters thyrohyoid membrane
bleeding of paraglottic space
Airway obstruction
Enters cricothyroid membrane
Air escapes into soft tissues
Surgical emphysema
11. Hyoid
May
Can
bone :
be fractured
cause mild discomfort or painful
swallowing
Rarely can lead to formation of bursa at the
fractured ends which can be treated by
excision
12. Thyroid cartilage & arytenoids
Commonly fractured due to the prominence
of the thyroid cartilage in the neck
This injury depends on degree of calcification
of the cartilage
Minimal injury – no fracture
If pushed backwards over cervical
spine,thyroid ala is splayed apart to a more
obtuse angle
13. This can lead to pre-epiglottic space bleeding
& posterior displacement of epiglottis
Calcified thyroid cartilage gets shattered
resulting in communited fracture
15. Cricoid cartilage
Invariably associated with thyroid fractures
Anterior part of the cricoid mostly fractured
Cricotracheal seperation
Final soft tissue injury,usually results in death
the roadside
Cricotracheal membrane is sheared off
Several tracheal rings may be damaged
Larynx pulled upwards & trachea is pushed to
retrosternal area
at
the
16. Inhalational injuries
Hot air/smoke/steam: glottis reflexely closes:
limits the amount of thermal injury by stopping
inhalation : injury supraglottic larynx.
Ass with burns in othr parts of the body
Initial erythema & blackish sputum
Marked oedema
Early airway management : marked edema of
injured mucosa with loss of airway : inability to
intubate
Ingestion injuries
Mucosal burns
Direct damage due to ingestion / regurgitation
Alkali worse than acids
18. Diagnosis
Symptoms : Change in voice ,Difficulty in
breathing,Dysphonia,Dyspaghia,Pain,Cough
Hemoptysis
Stridor : b/l vc palsy/ surpaglottic/
subglottic edema
Skin : contusions, abrasions
glottic /
open fractures
laryngocutaneous fistula
Palpation : Crepitance
tenderness : significant injury
Cervical spine should always be palpated
19.
20. EXAMINATION
Incases of cricotracheal separation the
airway may be maintained via a cutaneous
laceration tat connects the trachea: no
attempt should be made to cover or
compress or manipulate the wound : until
surgeon ready for airway establishment
Subtle form of laryngeal dysfunction is
aspiration: immobitly of vocal cords
21. Any penetrating injury should be examined for
entry and exit wounds
Open wounds should not be explored with
instruments, should not be probed
Endolaryngeal anatomy examined : fibreoptic in
case of non intubated pts, very careful
Look for hematomas, movement of arytenoids or
presence of any exposed cartilage
22. Plain x-ray of cervical spine :
To exclude hyoid bone fracture & concurrent
cervical spine fracture
Chest x-ray
To rule out mediastinal emphysema /
puenomothorax
23. CT SCAN
Mainly for pts who can do well without any
surgical intervention
Pts requiring a open surgical repair or with
exposed cartilage : does give much input
nonivasive
Spiral ct scan- mainstay of post traumatic
laryngeal injury
Quick (< 20secs)
Can produce two dimensional ,reconstructed
images
Detects mucosal oedema,fracture of
thyroid,disruption of cricoaryteniod/cricothyroid
joint,assessment of c-spine
24. CT reserved for for
patients in whom
laryngeal injury is
supected from either
history or physical
examination without any
indications for surgery.
Noninvasive
confirmation of laryngeal
injury without need for
GA or laryngoscopy.
Presence of massive
edema or hematoma :
direct laryngoscopy not
helpful: CT provides
input.
25. Direct laryngoscopy
Done under GA
Look for 1) large mucosal laceration 2)
exposed cartilage 3)laceration on the free
edge of the vocal cords 4)vocal cord
immobility 5)dislocated arytenoids 6)
displaced fractures 6) other neck injuries
26. Suspicion of
Laryngeal Trauma
L_
History of Neck Trauma,
Signs of Injury
Examine for Physical
•
Impending Airway
Obstruction
Tracheotomy
ryngoscopy
Airway Stable
•
Flexible Fiberoptic
Laryngoscopy
i
Direct La •
and Esophagoscopy • •
I.
Nondisplaced, Mucosa and Mild Normal lity
E x
Nonangulated Cartilage A bnorma ndolarn
i
Hematoma, Small Isolate
• •
and
Thyroid Cartilage Disrupted
d Fracture. Mucosa Fracture
Laceration, but Displaced or Angulated Cartilage CT Scan
Endolarynx Intact Thyroid Cartilage Disrupted
but Endolarynx Intact
Abnormal
•
Normal
!
Observation
•
Observation
Observation
•
Open Exploration
•
Tracheotomy
or Intubation
• yngoscopy
of Neck with Open
Reduction and Internal
Fixation of Fracture
without Thyrotomy
Direct L ar
and Esophagoscopy
•
Laryngeal Thyrotomy
•
Laryn eal
ORIF Fractures,
g Cartilage Laryngeal Cartilage
Stable, Anterior
Commissure Intact
•
ORIF Fractures, Repair
Mucosal Lacerations
Repair Mucosa! Lacerations
Unstable, Anterior
+
Endolaryngeal
Stent
•
Commissure Disrupted,
Massive
ries
Mu cosa! Inju
27. GROUP SYMPTOMS SIGNS MANAGEMENT
Group I Minor airway
symptoms
Minimal hematoma Observation
Small laceration Humidified air
No fractures Head end elevation
+/- Steroids
Group II Airway compromise Oedema/hematoma Direct laryngoscopy
Minor mucosal disruption Oesophagoscopy
No cartilage exposure +/- Tracheostomy
+/- steroids
Group III Airway compromise Oedema Tracheostomy
Mucosal tears Direct laryngoscopy
Exposed cartilage Oesophagoscopy
Vocal cord immobility Exploration/repair
No stent needed
Group IV Airway compromise Massive oedema Tracheostomy
Significant mucosal tear Direct laryngoscopy
Exposed cartilage Oesophagoscopy
Vocal cord immobility Exploration/repair
Stent required
28. Securing the airway-
Tracheostomy
Endotracheal intubation-indicated only when
mucosa is intact,minimal laryngeal fracture
Endotracheal intubation may further damage the
larynx
Paediatric pt –airway secured with rigid
bronchoscopy,tracheostomy performed over
bronchoscope
Follwing intubation/ trach : direct laryngoscopy to
assess the extent of damage: hematomas,
exposed cartilage, lacerations, movement of vocal
cords
29. Conservative management
Group I & II
Clinical observation for 48hrs
Head end elevation 30 degree
Voice rest –minimize edema
Humidified air-prevents crust
improves ciliary function
Corticosteroids
Antibiotics
Antireflux medication
formation &
30. Surgical management
All injuries involving the anterior commisure
Exposed cartilage
Multiple or displaced fracture of thyroid
cartilage
Multiple fractures of cricoid cartilage causing
1. Vocal fold paralysis
2. Airway compromise to require intubation or
trach
3. Injury to neck requiring exploration
31. Open surgical exploration & repair
Exploration within 24hrs –maximizes
& phonation results
Hemostasis
Evacuation of hematoma
airway
Reconstruction of the laryngeal framework
Coverage of de-epithelialized surfaces
Group II to IV required surgical intervention
32. Subplatysmal apron flap elevated till the
hyoid bone
Laryngeal skeleton is exposed from the
hyoid to sternal notch
Midline thyrotomy
◦ May use a vertical fracture (2 to 3mm of midline)
Nondisplaced fractures
◦ Suture outer perichondrium
◦ Primary closure with nonabsorbable suture / wires
Mucosal lacerations
◦ Meticulously repaired using fine absorbable sutures
◦ Knots outside the laryngeal lumen
granulation)
(prevent
33. Displace fractures of
the cartilages are
reduced
◦ Stabilized using stainless
steel wires,
nonabsorbable suture or
miniplates.
◦ Small fragments of
cartilage with no intact
perichondrium are
removed to prevent
perichondritis.
Anterior commissure-
suspend the anterior
true vocal cords to
the outer
perichondrium
34.
35. Anterior glottic injuries :
Seen in vertical thyroid cartilage #
Ass with vocal fold laceration
Endolarynx approached through midline
thyrotomy or thru thyroid #
Anterior
Mucosal
Anterior
commisure divided in midline
laceration closed
free edges of false and true vocal
cords sutured thru the anterior thyroid
perichondrium
Keel used to reconstruct the anterior comm
36. Endolaryngeal stenting (group IV )
◦
◦
◦
◦
Disruption of the anterior commissure
Massive mucosal injuries
Comminuted fractures of the laryngeal skeleton
Cases wher architecture of larynx not maintained
open fixation
by
Uses :
◦
◦
Stability and prevent endolaryngeal adhesions
Maintains the scaphoid shape of anterior
commissure,essential for vocalization
Support to laryngeal framework : movement :
phonation/ swallowing
◦
37. Types of stents
Endotracheal portex tube-
Most easily available
3.5cm long,upper end closed with sutures to
prevent aspiration
Smooth clamps are placed to approximate true &
false vocal cords
Finger cots filled with gelfoam /gauze
39. Stent should be placed such that it extends from
false vocal cords to first tracheal ring
Stent secured by monofilament sutures through the
laryngeal ventricle and cricothyroid membrane and
tied to skin buttons.
Removed in a period of 10 to 14 days to prevent
mucosal damage
40. Antibiotics – 5 to 7 days
Antireflux – proton pump inhibitors routinely used
to prevent reflux which can cause mucosal damage
& scarring.
Avoid nasogastric tubes as
it
mucosa
Head end elevation
Early ambulation
Tracheostomy care
Removal of stents in 2 weeks
decannulation
erodes the
postcricoid
followed by
Follow up-1yr for assessment of true vocal cord
function & to monitor development of subglottic
stenosis
41. Formation of profuse granulation tissue ; can be
debulked endoscopically
Vocal cord immobility due to
• RLN injury- unilateral paralysis wait & watch for 6
months.Medializtion procedure considered if no
voice return is noted
• Bilateral paralysis-arytenoidectomy / cordotomy
Subglottic /Tracheal stenois
42. Common in clothesline
injuries., ligamentous inj
Cricotracheal separation is
usually associated with
cricoid fractures and
avulsion of the mucosa
from the anterior surface
of the posterior cricoid
plate.
high chance of
asphyxiation and
mortality.
Cricotracheal separation
highly associated with
recurrent lar
injury.
is
44. Primary re-
anastamosis from
posterior to anterior
Intact cricoid :only the
mucous membrane
needs to be repaired.
If
◦
cricoid is fractured:
internal fixation of
the cricoid cartilage
done.
> 2cm of tracheal
If
loss : larynx mobilized
Complications-
granulations, laryngeal
and tracheal stenosis,
glottic web
45. Incidence : 4-13% : adults, 0.5 -61% in
neonates
Mc cause : prolonged intubation
46. • Endotracheal intubation
1. Laryngeal mucosa
2. Soft tissues
3. Perichondrium
4. Cartilage
injuries
most injuries : superficial
ulceration : heal quickly
irritation / minor
•
More severe injuries : edema, granulation
tissue / ulcerations
•
49. Minor epithelial erosion :
primary epithelialization
Extensive ulceration
secondary intention healing
with granulation tissue
Granuloma
Contracted scar tissue
50. Endotracheal tube
lies in the posterior
larynx :
Applies pressure on
3 sites
1. Arytenoids : vocal
process: medial
surface
2. Posterior glottic
mucosa in the
interarytenoid
51. Physical trauma :
difficult/ repeated
intubations
•
Mucociliray mechanism
reduced :
:
Presence of tube
Stasis of secretions
Trauma from
suctioning
Bacterial
contamination
1.
2.
3.
Duration
:
of inutbation
•
7 days : adults
Infants : longer
Neonates : weeks
State of larynx
1.
2.
3.
•
•
4.
Gastroesophageal reflux
chemical irritation :
increased local injury
Nasogastric tube
:
Movement of tube :
coughing, swallowing,
bucking during
anesthesia,
transmitted ventilator
movement
52. Patient factors
◦ Poor tissue
perfusion (i.e.
sepsis, organ
failure, etc)
Tube characteristics
Tube sizing
Max : 8 mm in
males and 7mm in
females : inner dia
Upto 8yrs :
uncuffed tube
Cuff pressure 8cm
of H2O2
◦
◦
◦
LPR
Abnormal larynx
Wound healing,
keloid
53. ENDOSCOPIC ASSESMENT
Nature of degree of trauma assessed by direct
laryngoscopy and endoscopy
Assesment : 7 days : adultys, children after
weeks, infants when attempted extubation
unsuccesful
Continued intubation
1. Edema in vocal cords
2. Surface mucosal ulceration
1 -2
3. Minor granulation tissue at
4. Absence of deep ulceration
vocal process
and perichondritis
Intubation injuries heal quickly without
treatment
54. Severe injuries : deep ulceration :
tracheostomy
Continued intubation > 7 days :
tracheostomy
55. Early non specific :
Hyperemia
Edema
Surface ulceration
Granulation
1.
2.
3.
4.
Edema
In the loose tissue of
1.
ventricle : protrusion
In vocal folds perists :
reinkes edema
Edematous swelling in the
submucosa of criccoid
cartilage
2.
3.
56. Granulation tissue: at
the sites of ulceration
by tube pressure on
mucosa,
perichondrium/
cartilage
Formed within 48hrs
Spontaneous resolution
: after tube removal
Incomplete resolution
intubation granuloma
:
nodules
interarytenoid
adhesions
57. Ulceration
Caused by pressure necrosis of the tube
Sites :
1. medial surface of aytenoids
2. Anterior surface of lamina of thyroid
cartilage
3. Cricoarytenoid joints
Superficial ulcerations : epithelialization
Deep : scar tissue formation : stenosis
58. Misc injuries
Laceration
Bleeding into vocal cords
Arytenoid dislocation
Perforation
Cricoid ulceration: sinus/ fistula : both NG
tube and ET tube presence
65. Establishing diagnosis
◦ Laryngeal stenosis
Noisy breathing
Stridor
Phases: inspiratory, expiratory, biphasic
Wheezing
Recurrent : precepitating factors and aggravating factors
Infection, exercise
History of emergency intubation
Suggest higher possibility of intubation trauma due to
repetition, stylet use and higher friction
Duration of mechanical ventilation (2-5/7: 0-2%, 5-10/7:
10%, >10/7: 12-14%)2,3, cuff pressure (laryngeal
5-
1
microcirculation critical P 30mmHg)
Tracheostomy (site, type of incision, tube biomechanics)4
Acute organophosphate poisoning: primary reason of
intubation contributes to laryngotracheal stenosis
Dysphagia, change in quality of voice
66. ◦ Infective (Tuberculosis of the larynx)
Prolonged history of fever, unintentional weight loss,
cough, hemoptysis, change in quality of voice, neck
swelling.
Contact with tuberculosis patients
Immune mediated (Sarcoidosis, Rheumatoid
arthritis, Pemphigus)
Onset and progression is usually gradual
Related symptoms: joint pain and deformity, skin
lesions,
Vocal fold immobility
Change in quality of voice
Aspiration symptoms
◦
◦
71. Cotton-Myer
◦ Based on relative
reduction
of subglottic cross-
sectional area
◦ Good for mature, firm,
circumferential lesions
◦ Does not take into
account
extension to other
subsites or
length of stenosis
73. Posterior glottic stenosis : Bogdasarian & olson
classification
Type I : interarytenoid adhesion
Type II : posterior commisure stenosis with
scarring in interarytenoid plane & post cricoid
lamina
Type III :posterior commisure stenosis with
unilateral cricoarytenoid ankylosis
Type IV : posterior commisure stenosis with
bilateral cricoarytenoid jt ankylosis
76. Timing of repair initial management and
airway establishment : evaluation of degree of
laryngeal injury
Acute stenosis : open repair within first two
weeks of injury
Chronic stenosis : repair elective
78. Endoscopic repair
Acute stenosis secondary to granulation
tissue after extubation
Mc used : CO2 laser
Adv of CO2 : delayed formation and
maturation of collagen : allows time for
reepithelialization before scar tissue
formation
Minimal deep tissue injury
Precise control of hemostasis : preservation
of mucosa
79. Goal : to establish satisfactory airway,phonation
glottis closure
Assessment of stenosis :location,vocal fold
impairement,degree of functional impairement
Management protocol :
Re-establishment of stuctural
support;grafts/cartilage
Preservation of mucosa
Judicious use of antibiotics,stents,skin
&
grafts,cartilage & bone grafts to reduce
formation & scarring
granuloma
80. For repair : cartilage / bone grafts
Acute injuries : stabilization of fractures
Chronic : for structural
augmentation
Grafts :
1. Rib : mc used
support, luminal
2. Iliac crest
3. Hyoid
4. Epiglottis
5. Thyroid
6. Auricular
: mc used
7. Septal cartilage
81. Uses : to
approximate
epidermal grafts
and immobilize it
Support for
1-3 wks : mucosal
healing
6-8 wks : to
maintain laryngeal
skeleton in position
Upto 14months :
cartilagenous
framework
deficient,
maturation of scar
cartilage
grafts
Separate
surfaces
Maintain
and bone
opposing
lumen in a
recontructed area
83. Made of Silicon
Long central lumen & smaller lumen
projecting from side at 90 degree/75 degree
Used in laryngotracheal
stenosis
reconstruction in
Can be left in place for > 12months
Advantage : pt can speak with T –tube
Disadvantage : more prone for crusting ( can
be prevented by blocking the side lumen&
proper suctioning)
85. Inert material used
Prevent adhesion
formation
Holds open the anterior
commissure and the
posterior commissure as
reqd
Extend from cricoid
membrane to 2-3 mm
above posterior
commissure
Placed endoscopically or
through mini-
cricothyroidotomy
•
•
•
•
•
•
86. Supraglottic stenosis
Adhesions of epiglotttis to the
hypopharyngeal walls : division of adhesion
along long axis; submucosal excision of scar
and primary mucosal closure
Horizontal web : vertical incision : scar
excised
87. External laryngeal trauma : thyroid cartilage #
and mucosal disruption
Endolaryngeal truama : intubation or surgical
removal of mucosa : anterior edges : two
opposing raw edges heal together : web
Management : endoscopic resection / MLS
excision with laser
Keel placed
88. Keel :
Should be inert material
Length should be sufficient to extend from the
cricothyroid membrane atleast 2-3mm above
the anterior comissure
Anterior edge of keel should make 120 degree
angle
The posterior wing should lie at the vocal
processes and should not touch the posterior
commisure
Removed after 2-4weeks
89. External approach
If extends > 5mm
Ass with laryngeal
:
into subglottis
inlet stenosis
Endoscopic approach failed
90. Et intubation/ cricothyroid joint arthritis
Endoscopic repair : type
division of web + finger
weeks/ with laser
With arytenoid fixation :
if b/l arytenoid fixation
I and II : simple
cot stents for 2
external approach
: removal of least
mobile arytenoid, denuded surfaces covered
with mucosal flaps , skin and mucosal grafts
Stenting for 2-3 weeks
Type IV : endoscopic laser arytenoidectomy
91.
92. 95% of cases of SGS
90% due to long-term or prior intubation
◦
◦
◦
◦
◦
◦
Duration of intubation
ETT size
Number of intubations
Traumatic intubations
Movement of the ETT
Infection
93. Cartilaginous Stenosis
Cricoid cartilage
deformity
Soft-Tissue
Stenosis
Submucosal
fibrosis
Submucosal
gland hyperplasia
Granulation
tissue
◦ Normal shape
Small for infant's size
Abnormal shape
◦
Large anterior lamina
Oval (elliptic shape)
Large posterior lamina
Generalized thickening
Submucous (occult) cleft
Other congenital cricoid
stenosis
◦ Trapped first
ring
eal
94. I. Endoscopic
◦ Dilation
◦ Laser
II. Open procedure
◦ Expansion procedure
LTR)
Laryngotracheoplasty
(with trach and stent or SS-
Laryngotracheal reconstruction
98. Described in 1980 as an alternative to
tracheotomy in the management of acquired
SGS in premature infants
Safe and effective (67-70% extubation rate)
◦
◦
If stenosis isolated & moderate grade
No other anatomic abnormalities prohibiting
decannulation
Pulmonary reserve must be adequate
◦
101. Indications
◦ Anterior SGS
◦ Anterior collapse
Graft
◦
◦
Elliptical
Larger and thicker
than posterior grafts
Large external flange
Perichondrium faces
luminal surface
Knots are external
Vicryl suture
◦
◦
◦
◦
102. Indications
◦ Posterior SGS
◦ Glottic extension
Try to avoid
complete
laryngofissure
Graft
◦
◦
Elliptical
Thinner than anterior
graft
Width
.05 to 1.00 mm/yr of
age up to 1 cm
(Cotton, 1999)
◦
103. Pts with possible perforation : gastrograffin
swallow/ barium swallow
Best detected by combination of
esophagoscopy and esophagram in
symptomatic patients.
Close wounds in watertight 2 layer
fashion.
After mucosal repair, muscle flap may be
interposed, minimises the risk of TE Fistula
Small pharyngeal lesions above arytenoids
104. Missed tears represent most of delayed
injuries : mediastinits
Neck exploration for patients who have air in
soft tissues of neck
During neck exploration. NG tube can be
pulled up to the level of the neck and
methyelene blue infused to localise.
105. caused by severe hyperextension during
acceleration/deceleration motor injuries.
Signs: Hemiplegia, quadriplegia, CN deficits,
change of sensorium, Horner’s syndrome
(disturbance of stellate ganglion), neurogenic
shock
Evaluation: clinical examination and imaging –
AP and lateral cervical radiography plain films
and CT scan.
Management: Neurosurgery should be consulted
for any surgical intervention. From the ENT
standpoint, stability of cervical spine to be
established.
