Chien-Hung Liao, MD, FICS,* Jen-Fu Huang, MD,* Shao-Wei Chen, MD, Chih-Yuan Fu, MD, FICS, Li-Ang Lee, MD, FICS, Chun-Hsiang Ouyang, MD, Shang-Yu Wang, MD, FICS, I-Ming Kuo, MD, Kuo-Chin Yuan, MD, and Yu-Pao Hsu, MD Departments of Traumatology and Emergency Surgery, Cardiovascular Surgery, and Otorhinolaryngology, Head, and Neck Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan

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.

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has been the subject of debate. Many authors have proposed that early reconstruction of ELT provides a better prognosis for phonation and recannulation [1, 6]. Because of the complexity of the neck, most patients with ELT have multiorgan injuries, which makes a clinical judgment difficult. Surgical intervention in the larynx sometimes has to be delayed if patients present with unstable hemodynamic status. Some authors report that delayed treatment can provide comparable results to early treatment of patients with ELT [7, 8]. The clinical experience of the authors has provided the basis for these recommendations; however, the optimal timing of surgical intervention for ELT is not conclusively known. In the present study, we review the details of the incidence, management, and outcomes of ELT at a level I trauma center and attempt to identify the impact of deferred surgical management on the outcome of this lifethreatening injury.

xternal laryngeal trauma (ELT) is a rare but potentially fatal injury that accounts for approximately 1 patient in 14,000 to 30,000 emergency visits [1, 2]. The larynx plays an important role in respiration and phonation. The larynx is supported by the mandible superiorly, the sternum and clavicle inferiorly, and the cervical spine posteriorly [3]. ELT is uncommon because the barrier of the neck protects the larynx. Once violated, it can rapidly become a tight space, leading to airway compromise and collapse [4]. ELT threatens both the quality and maintenance of life. Therefore, management of ELT greatly affects the immediate probability of the patient’s survival and long-term quality of life. Restoration of its skeletal framework, ligaments, muscle, and epithelial covering is essential to the protection of respiration and to the phonation function of the larynx [5]. Despite a relative congruency regarding the treatment of laryngeal injuries, the timing of surgical intervention Accepted for publication April 15, 2014. *Chien-Hung Liao and Jen-Fu Huang contributed equally to this work. Address correspondence to Dr Fu, Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, 5 Fu-Hsing St, Kwei-Shan Shiang, Taoyuan, Taiwan; e-mail: [email protected]

Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc

(Ann Thorac Surg 2014;98:477–83) Ó 2014 by The Society of Thoracic Surgeons

Material and Methods We compiled a prospective trauma computerized data registry at the Chang Gung memorial hospital (CGMH), Linkou, Taiwan, which is a level I trauma center. We performed a retrospective review of all patients who had 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.04.079

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Impact of Deferred Surgical Intervention on the Outcome of External Laryngeal Trauma

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ELT from May 2008 to May 2013. The cases were retrieved by filtering them using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD9-CM) codes (807.5, 807.6, 874.00, 874.01, 874.10, and 874.11). The data set was further limited by age to include patients older than 17 years and younger than 80 years. The study was approved by the Internal Review Board of CGMH. During the period of the study, we had an established protocol for treating ELT at CGMH. The trauma team managed all trauma patients from arrival at the emergency department (ED) until discharge. Once the diagnosis of ELT was suspected, we performed flexible laryngoscopy to assess the grading of the injury and the status of the airway. Reconstructive computed tomography (CT) was performed to evaluate the framework of cartilage, ligaments, and muscle. The ELT was graded using the Schaefer-Fuhrman classification [1, 9]. (1,9) Group I includes minor laryngeal edema or lacerations. Group II includes demonstrable edema or hematomas without exposed cartilage. Group III includes massive edema or mucosal lacerations with exposed cartilage or displaced cartilaginous fractures or vocal fold immobility. Group IV includes the destabilization of the laryngeal structure, including the disruption of the anterior commissure, more than 1 unstable displaced fracture, or severe mucosal injury. Group V includes complete laryngotracheal separation. If the patient had mucosal edema without a compromised airway, we used nonsurgical management. For patients with a compromised airway, we performed a tracheostomy or fiberoptically guided intubation to secure the airway. For patients who presented with destruction of the architecture or disruption of the mucosal covering of the larynx, surgical intervention was

Fig 1. CONSORT diagram describing cohort identification. (ICD-9-CM, International Classification of Diseases, Ninth Division, Clinical Modification.)

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performed as soon as possible. However, for patients with severe associated injuries or those who were hemodynamically unstable, operation was deferred until the patient’s condition improved. We divided the patients into 2 groups based on the operative timing. Patients who underwent operation within 48 hours were included in the early group, and patients who underwent operation after 48 hours were included in the deferred group. We retrieved the demographic data, clinical symptoms and signs, associated injuries, laryngeal trauma grade, Revised Trauma Score (RTS), Injury Severity Score (ISS), New Injury Severity Score (NISS), intensive care unit length of stay (ICU LOS), hospital length of stay (HLOS), and mortality. All the patients were followed in the outpatient department, and adverse outcomes were collected. Adverse outcomes included airway stenosis, phonatory defects, and deglutitive dysfunction. We defined airway stenosis as the need for tracheal dilatation, degranulation, or a tracheal stent. A defect of phonation was defined as hoarseness, dysphonia, and aphonia. Dysfunction of deglutition was defined as consistent abnormalities in swallowing with any food or abnormalities with a barium swallow or endoscopic evaluation. Patients were followed from the date of arrival at the ED until December 31, 2013. In this study, we excluded patients who had undergone previous oropharyngolaryngeal operations and patients who were lost to follow-up at our institution. The patients with laryngeal trauma resulting from caustic ingestion, intubation, or other iatrogenic insults were also excluded (Fig 1).

Statistical Analysis Pearson’s c2 test and Fisher’s exact test were used, as appropriate, to compare categorical variables. Quantitative variables were compared with the Student’s t test and

an analysis of variance. Univariate and multivariate analyses were calculated by logistic regression in the case of qualitative variables and linear regression in the case of quantitative variables. Statistical analysis was performed with PASW Statistics, version 20.0 for Macintosh (SPSS Inc, Chicago, IL). A p value of less than 0.05 was considered statistically significant.

Results There were a total of 148,765 patients admitted to the trauma bay of CGMH during this period. The study cohort consisted of 48 patients: 41 men and 7 women. The incidence of ELT was 0.032%. The demographic data regarding ELT are presented in Table 1. The mean patient age was 40.8  19.6 years, and the median age was 41.0 years. There were 35 patients with blunt trauma and 13 patients with penetrating injuries. Patients with ELT frequently had multiple organ injuries (n ¼ 35 [72.9%]). The most common associated injuries were craniofacial fractures followed by intracranial hemorrhage, cervical spine injury, esophageal injury, and carotid artery injury. The mean ISS was 18.8  11.0, the mean NISS was 21.3  10.8, and the mean RTS was 6.59  1.88. The ICU LOS was 6.5  5.2 days, and the HLOS was 18.0  12.8 days. By Schaefer-Fuhrman classification, there were 5, 15, 13, 10, and 5 patients with laryngeal injury in groups 1, 2, 3, 4, and 5, respectively. Thirty-three patients needed emergency airways, including 10 tracheostomies and 23 fiberoptic-guided intubations. The other 15 patients did not need emergency airways. Thirty-four patients required surgical intervention. Five patients underwent tracheostomy and debridement, 12 patients had mucosal repair, 3 patients had cartilage reduction without fixation, 7 patients had reduction with fixation, 4 patients had laryngeal reconstruction without stenting, and 3 patients had laryngeal reconstruction with stenting. The other 14 patients did not require surgical intervention for ELT. High ISS, high NISS, the necessity of operation, and deferred operation were all risk factors for a prolonged ICU LOS. After a multivariate analysis, the necessity of surgical intervention and NISS were the independent factors predicting ICU LOS. High ISS, high NISS, high laryngeal trauma grade, the necessity of surgical intervention, and deferred operation were all risk factors for a prolonged HLOS. After a multivariate analysis, NISS and the necessity of surgical intervention were found to prolong the HOLS (Table 2). There were 4 patients who died after ELT, and the mortality rate was 8.3%. Significant predictors of mortality were ISS (p ¼ 0.003), NISS (p ¼ 0.034), and RTS (p < 0.001). Nevertheless, a multivariate analysis identified ISS (p ¼ 0.040) and RTS (p ¼ 0.022) as independent predictors of mortality (Table 2). The demographic data and prognosis of early and deferred groups are summarized in Table 3, separated by surgical timing. In total, 24 patients underwent operation within 48 hours and 10 patients had deferred surgical intervention. The severity grade of the laryngeal injury in both groups was comparable (p ¼ 0.054). The ISS was higher

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Table 1. The Characteristics of Patients With External Laryngeal Trauma Characteristics Patients, No. Age (y, mean  SD) (median, interquartile range) Sex (n, %) Male Mechanism (n, %) Blunt Penetrating Symptoms Hoarseness Neck pain Dyspnea Signs Subcutaneous emphysema Hemoptysis Ecchymosis Associated injury (n, %) Craniofacial bone Intracranial hemorrhage Cervical spine Esophagus Carotid artery Laryngeal trauma groupa (n, %) I II III IV V Emergency airway requirement Unnecessary (n, %) Tracheostomy (n, %) Intubation (n, %) Operation (n, %) Early group (n, %) Deferred group (n, %) ISS (mean  SD) NISS (mean  SD) RTS (mean  SD) ICU LOS (d, mean  SD) HLOS (d, mean  SD) Follow-up (mo, mean  SD) Long-term adverse outcomes (n, %) Airway stenosis (n, %) Phonatory impairment (n, %) Deglutitive impairment (n, %) Mortality (n, %) a

Values 48 40.8  19.6 41.0, 22.3–56.5 41, 85.4% 35, 72.9% 13, 27.1% 35, 72.9% 33, 70.8% 21, 43.8% 31, 5, 5, 35, 31, 9, 6, 6, 5,

64.6% 14.7% 14.7% 72.9% 64.6% 18.7% 12.5% 12.5% 10.4%

6, 8, 7, 8, 5,

17.6% 23.5% 20.6% 23.5% 14.7%

15, 44.1% 10, 20.8% 23, 47.9% 34, 70.8% 24, 50.0% 10, 20.8% 18.8  11.0 21.3  10.8 6.59  1.88 6.5  5.2 16.3  9.1 36.4  11.6 19, 39.6% 7, 14.6% 13, 27.1% 8, 16.7% 4, 8.3%

Schaefer-Fuhrman classification.

ICU LOS ¼ intensive care unit length of stay; ISS ¼ injury severity; score; HLOS ¼ hospital length of stay; NISS ¼ new injury severity score; RTS ¼ revised trauma score; SD ¼ standard deviation.

in the deferred group, 22.8  5.5, than in the early group, 17.9  7.8 (p ¼ 0.047). The deferred group had a longer ICU LOS than did the early group (11.7  5.3 versus 6.4  4.5;

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Table 2. Factors That Affect Hospital-Related Outcome ICU LOS

HLOS

Mortality

Variable

p Value

Multivariate Analysis

p Value

Multivariate Analysis

p Value

Multivariate Analysis

Laryngeal trauma groupa Necessity of Deferred operation RTS ISS NISS

0.054

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

External laryngeal trauma (ELT) can be a fatal injury. Proper management of ELT significantly affects patient survival and quality of life. The optima...
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