The Journal of Laryngology and Otology April 1992, Vol. 106, pp. 372-373
The dangers of minor blunt laryngeal trauma L. J. O'KEEFFE, F.R.C.S.I.,* A. R. MAW, M.S., F.R.C.S.** (Bristol)
Abstract Since the introduction of seat belts, laryngotracheal trauma has become a rare injury, comprising less than one per cent of blunt trauma cases seen at major trauma centres. However, a wide range of damage to the soft tissue and cartilaginous framework of the larynx may result from such injuries but signs of injury are easily overlooked leading to potentially serious consequences for the patient. We report a case of isolated blunt laryngeal trauma from a relatively minor injury which illustrates some of the problems resulting in these cases and review the treatment of blunt laryngeal trauma.
cords. It was planned to divide these adhesions a month later when all infection had settled, inserting a silastic stent at the same time. However, at subsequent laryngoscopy there was only a pinhole airway visible posteriorly. The cords were foreshortened and thickened, with the left cord lying at a lower level than the right. The precise nature of the injury to the laryngeal cartilages was not identifiable at laryngoscopy. A laryngeal reconstruction was carried out via a laryngofissure and a silastic keel was inserted. The keel was removed six months later. Repeat microlaryngoscopy was carried out on three occasions post-operatively. On one of these afibrousadhesion was vapourized with a CO2 laser. The tracheostomy tube was finally removed approximately 18 months after her initial injury. The patient has been followed in clinic for a further year and is making good progress. Her voice, while rough and gravelly in nature, is sufficiently powerful that she is easily understood across a classroom. She continues to attend for speech therapy.
Introduction Blunt laryngeal injuries are rare and are rarely seen in isolation, usually being associated with multiple trauma. These cases now comprise less than one per cent of blunt trauma cases seen at major trauma centres (Gussack et al., 1986). Myers and Iko (1987) have found that such patients may appear deceptively normal when seeking medical attention, possibly for several hours after the injury occurred. This increases the risks of missed diagnosis or possible mismanagement which could lead to serious airway problems and impaired voice production. We report a case of isolated mild blunt laryngeal trauma which illustrates the potential problems. Case report A 7-year-old girl slipped in the bathroom striking the anterior aspect of her neck against the toilet seat. Initially well, she sought attention some hours later complaining of dysphagia and a minor haemoptysis. Examination at that time revealed mild inspiratory stridor without any further evidence of injury. Indirect laryngoscopy showed an overhanging epiglottis with no supraglottic swelling. A soft tissue radiograph of the neck at the time was said to show hypopharyngeal oedema without any evidence of surgical emphysema. She was observed in hospital for four days. When allowed home the patient had slight dysphonia and slight dysphagia but no respiratory symptoms. Ten days later she was readmitted with hoarseness and increasing biphasic stridor. She was not distressed on examination. Indirect laryngoscopy confirmed an overhanging epiglottis but it was not possible to visualize the vocal cords. A soft tissue radiograph of the neck appeared to show subglottic narrowing with possible arytenoid dislocation. She was admitted and laryngoscopy was arranged for the next routine operating list. She appeared to settle on conservative management but three nights later she developed sudden severe stridor while sleeping. The stridor was biphasic but the patient was acyanotic despite having evident tracheal tug and sternal recession. Direct laryngoscopy under general anaesthetic revealed gross, irregular, haemorrhagic oedema of the vocal cords. The false cords were also inflamed and swollen and pus was visible in the larynx and upper trachea. A tracheostomy was fashioned and the patient also continued treatment with a combination of intravenous corticosteroids, antibiotics and humidified air. At direct laryngoscopy one month later, there were fibrous adhesions visible involving the anterior two-thirds of the vocal
Discussion This case illustrates the major, potentially fatal, consequences which may follow even apparently minor blunt laryngeal injury. The interesting features of the case are the 14 day period which elapsed before serious problems arose, the severe fibrosis which resulted and the ensuing late sequelae. Infection appeared to play a major role in this case. Pus was visible in the larynx and trachea together with inflamed oedematous laryngeal tissues when direct laryngoscopy was performed at the time of airway obstruction. Submucosal haemorrhage or haematoma, particularly if infected, was almost certainly a further contributory factor. Indeed, Maran et al. (1981) have stated that the larynx is particularly prone to stenosis from submucosal bleeding because of the large number of potential spaces into which bleeding may occur. The proximity of the larynx to the oropharynx facilitates easy contamination and resulting infection of traumatized laryngeal tissues. We believe that infection and submucosal haemorrhage combined with the original injury to induce gross laryngeal fibrosis and stenosis. Because of its rarity, few people have any great experience of management of blunt laryngeal trauma. Specialist opinion should therefore be sought early. Important symptoms include dyspnoea or stridor, hoarseness, neck pain, cough, haemoptysis and dysphagia. External evidence of injury may be absent but loss of the normal neck contour, subcutaneous emphysema and
*Department of Otolaryngology, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL. **Department of Otolaryngology, Bristol Royal Infirmary, Upper Maudlin Street, Bristol BS2 8HW. Accepted for publication: 12 December 1991. 372
373
CLINICAL RECORDS
laryngeal tenderness or crepitus should not be overlooked. Patients exhibiting any of these clinical features may warrant hospital admission. Diagnosis is more difficult and may consequently be delayed in cases of multiple injuries which may overshadow coexistent laryngotracheal trauma. However, several authors remind us that we should be aware of the possibility of laryngotracheal trauma in multiple trauma patients, particularly in those with injuries to the chest and neck (Angood et al., 1986; Myers and Iko, 1987). While all agree on the importance of early diagnosis, the subsequent management of laryngotracheal trauma is quite controversial. Topics at issue include the appropriate use of CT scanning, endotracheal intubation versus tracheostomy and the timing of surgery. In recent years a number of management protocols have been advanced in a bid to resolve conflict and improve patient prognosis (Gussack et al., 1986; Schaeffer and Close, 1989; Fuhrman et al., 1990). Fuhrman and colleagues (1990) advise that indirect laryngoscopy or flexible fibreoptic nasendoscopy should be performed to view the mucosa of the upper aerodigestive tract. This allows direct assessment of vocal cord mobility and mucosal integrity without endangering the cervical spine which may be a consideration in these patients. Direct laryngoscopy involves a general anaesthetic and may be misleading. Maran and Stell (1970) have noted that a dislocated epiglottis may be missed on direct laryngoscopy because the instrument lifts the epiglottis forwards out of sight. Direct laryngoscopy may also exacerbate mucosal tears. Radiographs of the chest and neck should always be obtained. The existence of an abnormal tracheal outline, a pneumothorax, a pneumomediastinum or cervical emphysema are important indicators of a possible breach of laryngotracheal integrity. CT scanning is widely available and Stanley (1984) has shown it to be valuable in assessing the laryngeal framework. Schaeffer and Close (1989) believe that CT scanning is not indicated in cases of severe laryngeal disruption where surgery is absolutely indicated, reserving it instead for cases where the results may influence the likely treatment. Angood et al. (1986) would argue that CT scanning should be used selectively and is of particular value in cases of blunt laryngeal trauma. Gussack and Jurkovich (1988) and Fuhrman et al. (1990) agree with this view. Provision of an adequate airway is of principal importance but the method of doing so is controversial. Gussack et al. (1986, 1988) feel that endotracheal intubation is safe and effective. Fuhrman et al. (1990) and Schaeffer and Close (1989) disagree, preferring instead to perform a tracheostomy. Orotracheal intubation may exacerbate laryngeal injuries and may even result in the loss of a compromised airway (Schaeffer and Close, 1989), and we therefore support the use of tracheostomy as the principal means of securing an airway. Cricothyroidomy carries a high risk of exacerbating laryngeal injuries and is not advised in this setting (Gussack et al., 1986). Prophylactic antibiotics may be prescribed to avoid contamination from the oropharynx. Corticosteroids are often given to reduce glottic oedema and subsequent scarring of the larynx. Humidification of inspired gases help to avoid crusting of the airway and thus aids respiration. Operative intervention is necessary in some cases of blunt laryngeal trauma but the timing of surgery is controversial. Nahum (1969) recommended that a three tofiveday period elapses before undertaking surgery to allow oedema and inflammation to subside. Olson and Miles (1971) concur with this
Key words: Laryngeal trauma.
viewpoint. Most recent papers disagree, urging early surgery because it allows accurate assessment of laryngeal injuries, primary repair of mucosal lacerations, and accurate early reduction of fractured cartilages with a reduced incidence of complications (Gussack and Jurkovich, 1988; Schaeffer and Close, 1989; Fuhrman et al., 1990). Leopold (1983) reviewed the results of over 200 cases reported in the literature over a 20 year period and concluded that those who underwent necessary surgery within 24 hours of injury had a better outcome in terms of phonation and of airway function. Conclusion Blunt trauma results in great disruptions to the larynx, probably because greater force is required than in cases of penetrating trauma. Unfortunately, the consequences of blunt laryngeal trauma may be quite disproportionate to the patient's initial appearance and it is therefore important that such patients are not taken lightly. While there are controversial issues in the management of blunt laryngeal trauma, the weight of published evidence stresses that early diagnosis and early operative intervention when required are the keys to a successful outcome. References Angood, P. B., Attia, E. L., Brown, R. A., Mulder, D. S. (1986) Extrinsic civilian trauma to the larynx and cervical trachea. Journal of Trauma, 26(10): 869-873. Fuhrman, G. M., Stieg, F. H., Buerk, C. A. (1990) Blunt laryngeal trauma: classification and management protocol. Journal of Trauma, 30(1): 87-92. Gussack, G. S., Jurkovich, G. J. (1988) Treatment dilemmas in laryngotracheal trauma. Journal of Trauma, 28: 1439-1444. Gussack, G. S., Jurkovich, G. J., Luterman, A. (1986) Laryngotracheal trauma: a protocol approach to a rare injury. Laryngoscope, 96(6): 660-665. Leopold, D. A. (1983) Laryngeal trauma. A historical comparison of treatment methods. Archives of Otolaryngology, 109(2): 106-112. Maran, A. G. D., Murray, J. A. M., Stell, P. M., Tucker, A. (1981) Early management of laryngeal injuries. Journal of the Royal Society of Medicine, 74(9): 656-660. Maran, A. G. D., Stell, P. M. (1970) Acute laryngeal trauma. Lancet, 2: 1107-1110. Myers, E. M., Iko, B. O. (1987) The management of acute laryngeal trauma. Journal of Trauma, 27 (4): 448^52. Nahum, A. M. (1969) Immediate care of acute blunt laryngeal trauma. Journal of Trauma, 9: 112-125. Olson, N. R., Miles, W. K. (1971) Treatment of acute blunt laryngeal injuries. Annals of Otology, Rhinology and Laryngology, 80: 704-709. Schaeffer, S. D., Close, L. G. (1989) Acute management of laryngeal trauma. Update. Annals of Otology, Rhinology and Laryngology, 98 (2): 98-104. Stanley, R. B. (1984) Value of computed tomography in management of acute laryngeal injury. Journal of Trauma, 24 (4): 359-362. Address for correspondence: L. O'Keeffe, F.R.C.S.I., Department of Otolaryngology, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL.
The dangers of minor blunt laryngeal trauma L. J. O'KEEFFE, F.R.C.S.I.,* A. R. MAW, M.S., F.R.C.S.** (Bristol)
Abstract Since the introduction of seat belts, laryngotracheal trauma has become a rare injury, comprising less than one per cent of blunt trauma cases seen at major trauma centres. However, a wide range of damage to the soft tissue and cartilaginous framework of the larynx may result from such injuries but signs of injury are easily overlooked leading to potentially serious consequences for the patient. We report a case of isolated blunt laryngeal trauma from a relatively minor injury which illustrates some of the problems resulting in these cases and review the treatment of blunt laryngeal trauma.
cords. It was planned to divide these adhesions a month later when all infection had settled, inserting a silastic stent at the same time. However, at subsequent laryngoscopy there was only a pinhole airway visible posteriorly. The cords were foreshortened and thickened, with the left cord lying at a lower level than the right. The precise nature of the injury to the laryngeal cartilages was not identifiable at laryngoscopy. A laryngeal reconstruction was carried out via a laryngofissure and a silastic keel was inserted. The keel was removed six months later. Repeat microlaryngoscopy was carried out on three occasions post-operatively. On one of these afibrousadhesion was vapourized with a CO2 laser. The tracheostomy tube was finally removed approximately 18 months after her initial injury. The patient has been followed in clinic for a further year and is making good progress. Her voice, while rough and gravelly in nature, is sufficiently powerful that she is easily understood across a classroom. She continues to attend for speech therapy.
Introduction Blunt laryngeal injuries are rare and are rarely seen in isolation, usually being associated with multiple trauma. These cases now comprise less than one per cent of blunt trauma cases seen at major trauma centres (Gussack et al., 1986). Myers and Iko (1987) have found that such patients may appear deceptively normal when seeking medical attention, possibly for several hours after the injury occurred. This increases the risks of missed diagnosis or possible mismanagement which could lead to serious airway problems and impaired voice production. We report a case of isolated mild blunt laryngeal trauma which illustrates the potential problems. Case report A 7-year-old girl slipped in the bathroom striking the anterior aspect of her neck against the toilet seat. Initially well, she sought attention some hours later complaining of dysphagia and a minor haemoptysis. Examination at that time revealed mild inspiratory stridor without any further evidence of injury. Indirect laryngoscopy showed an overhanging epiglottis with no supraglottic swelling. A soft tissue radiograph of the neck at the time was said to show hypopharyngeal oedema without any evidence of surgical emphysema. She was observed in hospital for four days. When allowed home the patient had slight dysphonia and slight dysphagia but no respiratory symptoms. Ten days later she was readmitted with hoarseness and increasing biphasic stridor. She was not distressed on examination. Indirect laryngoscopy confirmed an overhanging epiglottis but it was not possible to visualize the vocal cords. A soft tissue radiograph of the neck appeared to show subglottic narrowing with possible arytenoid dislocation. She was admitted and laryngoscopy was arranged for the next routine operating list. She appeared to settle on conservative management but three nights later she developed sudden severe stridor while sleeping. The stridor was biphasic but the patient was acyanotic despite having evident tracheal tug and sternal recession. Direct laryngoscopy under general anaesthetic revealed gross, irregular, haemorrhagic oedema of the vocal cords. The false cords were also inflamed and swollen and pus was visible in the larynx and upper trachea. A tracheostomy was fashioned and the patient also continued treatment with a combination of intravenous corticosteroids, antibiotics and humidified air. At direct laryngoscopy one month later, there were fibrous adhesions visible involving the anterior two-thirds of the vocal
Discussion This case illustrates the major, potentially fatal, consequences which may follow even apparently minor blunt laryngeal injury. The interesting features of the case are the 14 day period which elapsed before serious problems arose, the severe fibrosis which resulted and the ensuing late sequelae. Infection appeared to play a major role in this case. Pus was visible in the larynx and trachea together with inflamed oedematous laryngeal tissues when direct laryngoscopy was performed at the time of airway obstruction. Submucosal haemorrhage or haematoma, particularly if infected, was almost certainly a further contributory factor. Indeed, Maran et al. (1981) have stated that the larynx is particularly prone to stenosis from submucosal bleeding because of the large number of potential spaces into which bleeding may occur. The proximity of the larynx to the oropharynx facilitates easy contamination and resulting infection of traumatized laryngeal tissues. We believe that infection and submucosal haemorrhage combined with the original injury to induce gross laryngeal fibrosis and stenosis. Because of its rarity, few people have any great experience of management of blunt laryngeal trauma. Specialist opinion should therefore be sought early. Important symptoms include dyspnoea or stridor, hoarseness, neck pain, cough, haemoptysis and dysphagia. External evidence of injury may be absent but loss of the normal neck contour, subcutaneous emphysema and
*Department of Otolaryngology, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL. **Department of Otolaryngology, Bristol Royal Infirmary, Upper Maudlin Street, Bristol BS2 8HW. Accepted for publication: 12 December 1991. 372
373
CLINICAL RECORDS
laryngeal tenderness or crepitus should not be overlooked. Patients exhibiting any of these clinical features may warrant hospital admission. Diagnosis is more difficult and may consequently be delayed in cases of multiple injuries which may overshadow coexistent laryngotracheal trauma. However, several authors remind us that we should be aware of the possibility of laryngotracheal trauma in multiple trauma patients, particularly in those with injuries to the chest and neck (Angood et al., 1986; Myers and Iko, 1987). While all agree on the importance of early diagnosis, the subsequent management of laryngotracheal trauma is quite controversial. Topics at issue include the appropriate use of CT scanning, endotracheal intubation versus tracheostomy and the timing of surgery. In recent years a number of management protocols have been advanced in a bid to resolve conflict and improve patient prognosis (Gussack et al., 1986; Schaeffer and Close, 1989; Fuhrman et al., 1990). Fuhrman and colleagues (1990) advise that indirect laryngoscopy or flexible fibreoptic nasendoscopy should be performed to view the mucosa of the upper aerodigestive tract. This allows direct assessment of vocal cord mobility and mucosal integrity without endangering the cervical spine which may be a consideration in these patients. Direct laryngoscopy involves a general anaesthetic and may be misleading. Maran and Stell (1970) have noted that a dislocated epiglottis may be missed on direct laryngoscopy because the instrument lifts the epiglottis forwards out of sight. Direct laryngoscopy may also exacerbate mucosal tears. Radiographs of the chest and neck should always be obtained. The existence of an abnormal tracheal outline, a pneumothorax, a pneumomediastinum or cervical emphysema are important indicators of a possible breach of laryngotracheal integrity. CT scanning is widely available and Stanley (1984) has shown it to be valuable in assessing the laryngeal framework. Schaeffer and Close (1989) believe that CT scanning is not indicated in cases of severe laryngeal disruption where surgery is absolutely indicated, reserving it instead for cases where the results may influence the likely treatment. Angood et al. (1986) would argue that CT scanning should be used selectively and is of particular value in cases of blunt laryngeal trauma. Gussack and Jurkovich (1988) and Fuhrman et al. (1990) agree with this view. Provision of an adequate airway is of principal importance but the method of doing so is controversial. Gussack et al. (1986, 1988) feel that endotracheal intubation is safe and effective. Fuhrman et al. (1990) and Schaeffer and Close (1989) disagree, preferring instead to perform a tracheostomy. Orotracheal intubation may exacerbate laryngeal injuries and may even result in the loss of a compromised airway (Schaeffer and Close, 1989), and we therefore support the use of tracheostomy as the principal means of securing an airway. Cricothyroidomy carries a high risk of exacerbating laryngeal injuries and is not advised in this setting (Gussack et al., 1986). Prophylactic antibiotics may be prescribed to avoid contamination from the oropharynx. Corticosteroids are often given to reduce glottic oedema and subsequent scarring of the larynx. Humidification of inspired gases help to avoid crusting of the airway and thus aids respiration. Operative intervention is necessary in some cases of blunt laryngeal trauma but the timing of surgery is controversial. Nahum (1969) recommended that a three tofiveday period elapses before undertaking surgery to allow oedema and inflammation to subside. Olson and Miles (1971) concur with this
Key words: Laryngeal trauma.
viewpoint. Most recent papers disagree, urging early surgery because it allows accurate assessment of laryngeal injuries, primary repair of mucosal lacerations, and accurate early reduction of fractured cartilages with a reduced incidence of complications (Gussack and Jurkovich, 1988; Schaeffer and Close, 1989; Fuhrman et al., 1990). Leopold (1983) reviewed the results of over 200 cases reported in the literature over a 20 year period and concluded that those who underwent necessary surgery within 24 hours of injury had a better outcome in terms of phonation and of airway function. Conclusion Blunt trauma results in great disruptions to the larynx, probably because greater force is required than in cases of penetrating trauma. Unfortunately, the consequences of blunt laryngeal trauma may be quite disproportionate to the patient's initial appearance and it is therefore important that such patients are not taken lightly. While there are controversial issues in the management of blunt laryngeal trauma, the weight of published evidence stresses that early diagnosis and early operative intervention when required are the keys to a successful outcome. References Angood, P. B., Attia, E. L., Brown, R. A., Mulder, D. S. (1986) Extrinsic civilian trauma to the larynx and cervical trachea. Journal of Trauma, 26(10): 869-873. Fuhrman, G. M., Stieg, F. H., Buerk, C. A. (1990) Blunt laryngeal trauma: classification and management protocol. Journal of Trauma, 30(1): 87-92. Gussack, G. S., Jurkovich, G. J. (1988) Treatment dilemmas in laryngotracheal trauma. Journal of Trauma, 28: 1439-1444. Gussack, G. S., Jurkovich, G. J., Luterman, A. (1986) Laryngotracheal trauma: a protocol approach to a rare injury. Laryngoscope, 96(6): 660-665. Leopold, D. A. (1983) Laryngeal trauma. A historical comparison of treatment methods. Archives of Otolaryngology, 109(2): 106-112. Maran, A. G. D., Murray, J. A. M., Stell, P. M., Tucker, A. (1981) Early management of laryngeal injuries. Journal of the Royal Society of Medicine, 74(9): 656-660. Maran, A. G. D., Stell, P. M. (1970) Acute laryngeal trauma. Lancet, 2: 1107-1110. Myers, E. M., Iko, B. O. (1987) The management of acute laryngeal trauma. Journal of Trauma, 27 (4): 448^52. Nahum, A. M. (1969) Immediate care of acute blunt laryngeal trauma. Journal of Trauma, 9: 112-125. Olson, N. R., Miles, W. K. (1971) Treatment of acute blunt laryngeal injuries. Annals of Otology, Rhinology and Laryngology, 80: 704-709. Schaeffer, S. D., Close, L. G. (1989) Acute management of laryngeal trauma. Update. Annals of Otology, Rhinology and Laryngology, 98 (2): 98-104. Stanley, R. B. (1984) Value of computed tomography in management of acute laryngeal injury. Journal of Trauma, 24 (4): 359-362. Address for correspondence: L. O'Keeffe, F.R.C.S.I., Department of Otolaryngology, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL.
