Laryngeal Fracture in the Multiple Trauma Patient Robert E. Whited, MD, Cincinnati, Ohio
Laryngeal fractures are an unusual occurrence; however, the incidence of this injury has been increasing for several years [I]. The most common cause is the automobile accident with multiple trauma. In these instances the anterior neck strikes the steering wheel or dashboard, with the larynx being violently compressed against the cervical spine [2]. The use of lap belts without a shoulder harness provides incomplete protection for the anterior neck as the body is thrown forward with the head hyperextended. Yet, the rarity of severe laryngeal injury is believed to be due to a protective function of the mandible, with flexion of the head and neck absorbing the major impact force [3]. An additional factor in the rarity of treated laryngeal fractures is believed to be the immediate complete airway obstruction causing death before resuscitation can be instituted. With the incidence of laryngeal fractures increasing and with the usual association of multiple serious injury, the trauma surgeon must be aware of the importance of early diagnosis. It has long been recognized that delayed diagnosis and repair of laryngeal fracture dramatically alters the reconstructive potential [4]. This delay in treatment remains one of the most common causes for chronic laryngeal stenosis with attendant voice, airway, and sphincteric dysfunctions [5]. The present report aims to increase awareness of the injury and to demonstrate the results obtainable with early repair. Material and Methods All patients admitted to the Cincinnati General Hospital with laryngeal trauma from January 1970 to January 1976 were reviewed. There were twenty-six such admissions, with twelve patients selected for inclusion on the following basis: (1) having multiple serious trauma; (2) having laryngeal injury severe enough to require open reduction; and (3) undergoing all treatment at this complex. The twelve patients consisted of eight males and four females. The age range was nineteen to fifty-six years (median, 24 years). Ten patients had blunt laryngeal From the Department of Otolaryngologyand Maxillofacial Surgery, Cincinnati General Hospital, University of Cincinnati Medical Center, Cincinnati, Ohio. Repeat requests should be addressed to Robert E. Whited, MD, Department of Otolaryngology and Maxillofacial Surgery, University of Cincinnati Medical Center, 6504 Medical Science Building, 231 Bethesda Avenue, Cincinnati, Ohio 45267.
354
trauma from automobile accidents and two had penetrating injuries from assaults. All patients had serious associated trauma of multiple sites. (Table I.) Emergency Management. In this series, all patients were admitted to the Emergency Unit in shock and with varying degrees of respiratory distress. Initial resuscitation required immediate tracheotomy in five patients. In this group great care was taken to stabilize the head and neck on the necessary assumption of an existing cervical spine fracture. In those patients with adequate air exchange for life support, a physician with a tracheotomy set was in attendance throughout the evaluation phase and until an orderly airway could be established. No attempt at laryngoscopy or intubation was made in this group because of the danger of precipitating complete airway obstruction. It is significant that no patient died of airway obstruction and that there were no tracheotomy complications even though the operations were done under the most difficult of circumstances. Within the Emergency Unit necessary support measures were instituted, specialty consultations were obtained, and laboratory work was completed. At that point, priorities of treatment and tentative schedules were established among the various specialties under the direction of the trauma surgeon. From the standpoint of the laryngeal fracture, frontal and lateral neck x-rays were obtained primarily to rule out associated cervical spine injuries. Other than showing air in the tissues, these routine films were not helpful in determining the severity of laryngeal injury. No special radiologic studies were done at this level because of the patients’ unstable conditions. Laryngeal Fracture Management. All twelve patients required major operative procedures on an emergency basis within hours after admission. A brief endoscopic evaluation by the Otolaryngology Service was done at initial surgery in every case. Thus, the diagnosis of laryngeal fracture was confirmed and the extent of injury determined within 24 hours of admission. Also, this information was obtained with no prolongation of the emergency phase of treatment and no unnecessary lengthening of emergency operative time. Only one patient had laryngeal repair at initial surgery. The remaining patients underwent repair from two to fourteen days after admission, depending on the overall patient condition as well as on the severity of the fracture itself. In these cases, additional radiologic studies of the larynx were done only if the patient’s condition permitted and were not considered mandatory. A more detailed endoscopic evaluation, however, was done at the time of, but immediately preceding, open repair. This abbreviated preoperative evaluation represents an often necessary The AmericanJournal of Surgery
Laryngeal Fracture
modification of laryngeal fracture management for the patient with multiple trauma. In the present series there were no major complications from this regional standpoint. No patient developed laryngeal stenosis and none required additional reconstructive surgery. All patients were decannulated without difficulty an average of twelve weeks post repair. The primary determinate of tracheotomy removal was the need for repeated general anesthesia for procedures related to other injuries. In terms of voice restoration, ten of the twelve patients had excellent results. In the remaining two there has been permanent cord mobility disturbance.
hoarseness
secondary
to vocal
TABLE I
Sites of Injury Asaoclated with Laryngeal Fractures No. of
Patients Skull fractures Closed head injury Mild to moderate Severe Cervical spine fracture Facial fracture Extrafacial fracture lntraabdominal injury Chest injury (other than isolated rib fracture) Major vessel injury l
2 8 2
8 9’ 6 6 2
Including 6 patients with open fractures.
Comments The signs and symptoms of laryngeal fractures include airway obstruction, subcutaneous emphysema, voice alteration, hemoptyses, aspiration, local pain with or without referred otologia, dysphagia, and palpable laryngeal cartilage abnormalities. The early diagnosis of this injury would appear to be straight-forward; however, difficulties are not uncommon, even for those most experienced in multiple trauma. The airway compromise may be relatively mild on admission with a subsequent deterioration that can be precipitous. An airway problem may be attributed solely to associated injuries, such as mandibular fractures or oropharyngeal lacerations, edema, and hematoma. Difficulty with intubation in such a situation will be attributed to this more obvious cause. Subcutaneous emphysema which accompanies laryngeal fractures may vary from subtle to massive. At times its appreciation is obscured by hematoma and edema. A false sense of security may prevail when tracheotomy halts progression and allows gradual resolution of this physical finding. At times the emphysema may be attributed to a lower airway tear without further evaluation of the laryngeal region. The voice disturbances accompanying laryngeal injury are not observable in the unconscious patient. In others, the voice problem may be falsely attributed to associated injury of the tongue, pharynx, or other supralaryngeal structures. In a similar manner, swallowing difficulties and aspiration problems can easily be attributed to associated injury sites. Compounding these specific problems, the external neck appearance is usually deceptively benign. Palpable thyroid cartilage abnormalities may also be obscured by edema and hematoma. All of these factors readily contribute to a delay in diagnosis. In the multiple trauma patient a tracheotomy once placed often remains for several weeks while various repairs and healing occur. During this silent phase the laryngeal injuries will heal with displacement and
Volume 136, September 1978
maximal scarring. Attention is then drawn to the larynx when a difficulty with decannulation arises. If this delay is excessive, chronic laryngeal stenosis will have developed which may require multiple operations and a guarded reconstructive prognosis. In contrast, the present series, for which only the most severely injured patients were selected, demonstrated the excellent results obtainable with early diagnosis and repair. The ideal time to make the diagnosis is at the emergency room level. It is therefore recommended that all trauma patients with upper airway problems be suspected of having laryngeal injury. In addition, this injury must be considered despite the presence of obvious supralaryngeal trauma which may mask the laryngeal fracture. If a tracheotomy is required for airway compromise or progressive subcutaneous emphysema, then the early definition of laryngeal status becomes even more crucial. This cautious approach will insure early diagnosis of this most easily overlooked but highly significant. injury.
The Cincinnati General Hospital experience with early diagnosis and repair of laryngeal fractures in the multiple trauma patient is presented. The results demonstrate the feasibility and value of early laryngeal diagnosis and repair in these severely traumatized patients. References 1. Fitz-Hugh GS, Wallenborn WM. McGovern F: Injuries of the larynx and cervical trachea. Ann Otolatyngol71: 419, 1962. 2. Butler RM. Moser FH.: The padded dash syndrome: blunt trauma to the larynx and trachea. Laryngoscope 78: 1172, 1968. 3. Nahum AM, Siegel AW: Biodynamics of injury to the larynx in automobile collisions. Ann Otolaryngol76: 781, 1967. 4. Harris HH. Ainsworth JZ: Immediate management of laryngeal and tracheal injuries. Laryngoscope 75: 1103, 1965. 5. Montgomery WW: Laryngeal stenosis, p 543. Surgery of the Upper Respiratory System, sect 8, vol 2. Philadelphia, Lea and Febiger. 1973.
355
Laryngeal fractures are an unusual occurrence; however, the incidence of this injury has been increasing for several years [I]. The most common cause is the automobile accident with multiple trauma. In these instances the anterior neck strikes the steering wheel or dashboard, with the larynx being violently compressed against the cervical spine [2]. The use of lap belts without a shoulder harness provides incomplete protection for the anterior neck as the body is thrown forward with the head hyperextended. Yet, the rarity of severe laryngeal injury is believed to be due to a protective function of the mandible, with flexion of the head and neck absorbing the major impact force [3]. An additional factor in the rarity of treated laryngeal fractures is believed to be the immediate complete airway obstruction causing death before resuscitation can be instituted. With the incidence of laryngeal fractures increasing and with the usual association of multiple serious injury, the trauma surgeon must be aware of the importance of early diagnosis. It has long been recognized that delayed diagnosis and repair of laryngeal fracture dramatically alters the reconstructive potential [4]. This delay in treatment remains one of the most common causes for chronic laryngeal stenosis with attendant voice, airway, and sphincteric dysfunctions [5]. The present report aims to increase awareness of the injury and to demonstrate the results obtainable with early repair. Material and Methods All patients admitted to the Cincinnati General Hospital with laryngeal trauma from January 1970 to January 1976 were reviewed. There were twenty-six such admissions, with twelve patients selected for inclusion on the following basis: (1) having multiple serious trauma; (2) having laryngeal injury severe enough to require open reduction; and (3) undergoing all treatment at this complex. The twelve patients consisted of eight males and four females. The age range was nineteen to fifty-six years (median, 24 years). Ten patients had blunt laryngeal From the Department of Otolaryngologyand Maxillofacial Surgery, Cincinnati General Hospital, University of Cincinnati Medical Center, Cincinnati, Ohio. Repeat requests should be addressed to Robert E. Whited, MD, Department of Otolaryngology and Maxillofacial Surgery, University of Cincinnati Medical Center, 6504 Medical Science Building, 231 Bethesda Avenue, Cincinnati, Ohio 45267.
354
trauma from automobile accidents and two had penetrating injuries from assaults. All patients had serious associated trauma of multiple sites. (Table I.) Emergency Management. In this series, all patients were admitted to the Emergency Unit in shock and with varying degrees of respiratory distress. Initial resuscitation required immediate tracheotomy in five patients. In this group great care was taken to stabilize the head and neck on the necessary assumption of an existing cervical spine fracture. In those patients with adequate air exchange for life support, a physician with a tracheotomy set was in attendance throughout the evaluation phase and until an orderly airway could be established. No attempt at laryngoscopy or intubation was made in this group because of the danger of precipitating complete airway obstruction. It is significant that no patient died of airway obstruction and that there were no tracheotomy complications even though the operations were done under the most difficult of circumstances. Within the Emergency Unit necessary support measures were instituted, specialty consultations were obtained, and laboratory work was completed. At that point, priorities of treatment and tentative schedules were established among the various specialties under the direction of the trauma surgeon. From the standpoint of the laryngeal fracture, frontal and lateral neck x-rays were obtained primarily to rule out associated cervical spine injuries. Other than showing air in the tissues, these routine films were not helpful in determining the severity of laryngeal injury. No special radiologic studies were done at this level because of the patients’ unstable conditions. Laryngeal Fracture Management. All twelve patients required major operative procedures on an emergency basis within hours after admission. A brief endoscopic evaluation by the Otolaryngology Service was done at initial surgery in every case. Thus, the diagnosis of laryngeal fracture was confirmed and the extent of injury determined within 24 hours of admission. Also, this information was obtained with no prolongation of the emergency phase of treatment and no unnecessary lengthening of emergency operative time. Only one patient had laryngeal repair at initial surgery. The remaining patients underwent repair from two to fourteen days after admission, depending on the overall patient condition as well as on the severity of the fracture itself. In these cases, additional radiologic studies of the larynx were done only if the patient’s condition permitted and were not considered mandatory. A more detailed endoscopic evaluation, however, was done at the time of, but immediately preceding, open repair. This abbreviated preoperative evaluation represents an often necessary The AmericanJournal of Surgery
Laryngeal Fracture
modification of laryngeal fracture management for the patient with multiple trauma. In the present series there were no major complications from this regional standpoint. No patient developed laryngeal stenosis and none required additional reconstructive surgery. All patients were decannulated without difficulty an average of twelve weeks post repair. The primary determinate of tracheotomy removal was the need for repeated general anesthesia for procedures related to other injuries. In terms of voice restoration, ten of the twelve patients had excellent results. In the remaining two there has been permanent cord mobility disturbance.
hoarseness
secondary
to vocal
TABLE I
Sites of Injury Asaoclated with Laryngeal Fractures No. of
Patients Skull fractures Closed head injury Mild to moderate Severe Cervical spine fracture Facial fracture Extrafacial fracture lntraabdominal injury Chest injury (other than isolated rib fracture) Major vessel injury l
2 8 2
8 9’ 6 6 2
Including 6 patients with open fractures.
Comments The signs and symptoms of laryngeal fractures include airway obstruction, subcutaneous emphysema, voice alteration, hemoptyses, aspiration, local pain with or without referred otologia, dysphagia, and palpable laryngeal cartilage abnormalities. The early diagnosis of this injury would appear to be straight-forward; however, difficulties are not uncommon, even for those most experienced in multiple trauma. The airway compromise may be relatively mild on admission with a subsequent deterioration that can be precipitous. An airway problem may be attributed solely to associated injuries, such as mandibular fractures or oropharyngeal lacerations, edema, and hematoma. Difficulty with intubation in such a situation will be attributed to this more obvious cause. Subcutaneous emphysema which accompanies laryngeal fractures may vary from subtle to massive. At times its appreciation is obscured by hematoma and edema. A false sense of security may prevail when tracheotomy halts progression and allows gradual resolution of this physical finding. At times the emphysema may be attributed to a lower airway tear without further evaluation of the laryngeal region. The voice disturbances accompanying laryngeal injury are not observable in the unconscious patient. In others, the voice problem may be falsely attributed to associated injury of the tongue, pharynx, or other supralaryngeal structures. In a similar manner, swallowing difficulties and aspiration problems can easily be attributed to associated injury sites. Compounding these specific problems, the external neck appearance is usually deceptively benign. Palpable thyroid cartilage abnormalities may also be obscured by edema and hematoma. All of these factors readily contribute to a delay in diagnosis. In the multiple trauma patient a tracheotomy once placed often remains for several weeks while various repairs and healing occur. During this silent phase the laryngeal injuries will heal with displacement and
Volume 136, September 1978
maximal scarring. Attention is then drawn to the larynx when a difficulty with decannulation arises. If this delay is excessive, chronic laryngeal stenosis will have developed which may require multiple operations and a guarded reconstructive prognosis. In contrast, the present series, for which only the most severely injured patients were selected, demonstrated the excellent results obtainable with early diagnosis and repair. The ideal time to make the diagnosis is at the emergency room level. It is therefore recommended that all trauma patients with upper airway problems be suspected of having laryngeal injury. In addition, this injury must be considered despite the presence of obvious supralaryngeal trauma which may mask the laryngeal fracture. If a tracheotomy is required for airway compromise or progressive subcutaneous emphysema, then the early definition of laryngeal status becomes even more crucial. This cautious approach will insure early diagnosis of this most easily overlooked but highly significant. injury.
The Cincinnati General Hospital experience with early diagnosis and repair of laryngeal fractures in the multiple trauma patient is presented. The results demonstrate the feasibility and value of early laryngeal diagnosis and repair in these severely traumatized patients. References 1. Fitz-Hugh GS, Wallenborn WM. McGovern F: Injuries of the larynx and cervical trachea. Ann Otolatyngol71: 419, 1962. 2. Butler RM. Moser FH.: The padded dash syndrome: blunt trauma to the larynx and trachea. Laryngoscope 78: 1172, 1968. 3. Nahum AM, Siegel AW: Biodynamics of injury to the larynx in automobile collisions. Ann Otolaryngol76: 781, 1967. 4. Harris HH. Ainsworth JZ: Immediate management of laryngeal and tracheal injuries. Laryngoscope 75: 1103, 1965. 5. Montgomery WW: Laryngeal stenosis, p 543. Surgery of the Upper Respiratory System, sect 8, vol 2. Philadelphia, Lea and Febiger. 1973.
355
