ggg e f e d LL JoquJnN cj ouJnlOA q~IA~ osoq7 dIIe!aodso p u e 'sln!~:)!A etune~t~. [[~ q3.t~ Ole.tado~tdde s! sV soartToe,~2 Ie~.~Aao3 pme!~osse peq suo!1~osuea~ [eoq~eal aq~ 3o 3 F H '(~ °[qe,L) Uommoa ~sotu oao~ (luoaan~oa) saAaou [eo~uEae t pue 'snB~qdoso 'xo[dmo~ [e~.a~jo!ueaa oql jo osoq/L s a u n f m pole~aosse aaoA~ oaoq~ 'soaumsu! tie ~sotu F u I e m n e a ~ ~unIq moa~ oao~ sa[an[ut BuDelsvha p lsotu oql '[eaouo~ u I sao~uossed leos luoa3 ao saoA.up ,~q pa~o33ns oao~As o u n [ -u! osoq~ 's~uopta~e o[!qommne But -Ato~u! sose~ tie u I (~ a t q e i ) soan~a~a3 snou!~elDaea snoj pue suo_~laosuea~ xts 'suo!Teaaae[ [erluoBue7 oA.U 'suo.t1 -eaojaod q~no;[q~-pue-q~noaq~ lqB!o oaom poutelsns so.unfu! 3o sod£~ oq& "(I otq~L) punoA~ o3!u~[ e ouo pue s p u n o ~ ~oqsunB3o Mns -oa oq~ OaOA~,[nod 'sotan[u! Bu!u!emoa oql ao3 pmunoaae so!an!u! Bu!~ea~ouod •s ~ u a p ! ~ e o[!qomo~ne u.t pou~e~sns oao~ it e pue suo!~aosuea~ ieaqaea7 o~oidmoo aao~ osaq~ 3o x!s po~eo,~ OaOA~ so.tin.[u! [eoL[aea 1 UOAO[[~[ "Bu!qqe~s O~ ooaq~ pu~ spunoA~ ~oqs -un~ ol oIqmnq_u~e oaoA~ oA.~3 ' s a u n f -ul ~q~!o Bu!u.mmoa oq7 30 "Bu.~eoq moa3 poMnsoa ouo '.s~uop!~e ot!qomo ~ -ne u! pou.~e~sns oaoA~ osoq~ 3° oo~q& e m n e a ~ ~untq o~ ~{avpuooos O~OA~ s o u n r u ! ano d "emnea~ [eo~u£~e[ qT!A~ po3uosaad sluo!3ed aAtO~J, "0~ 3° abe O~elOAt~ UI~ I.[~.IAX's,leoz{ 9~' O~ 9I tuoag abe ut But~uea uomoA~ ano3 pue uom 6[ '~[on~uo~I 'otI!As.moq 't~7!dso H t~,~ouao eII!As!noq eq~ ~e OgIAIOSteo!B
-,ms LauoBaomo oq~ o~ poll.ttupe OaOA~ £an[ut. [eoqa~a~oBuXae[ ao[eua 3o sosea g~ '£L61 o~ 996I po.uod oq7 Bu!an(I £N=qN=IOVNVIN " I V I I l N I QNV NOIIV£N=IS~]I=Id I N 3 1 1 V d [e~.~dsoH I~aouoD oII!As!noq oq~ 7~ sleo_£ u o 3. aoAo Kin.Cut [eoqae.t 7 -oBu£ae[ Io[eta ~o sosea 8~ pOA~O!AOI OA~-Xq.t[tq~s.~po[qtssod pue soanpoaoad [ea!~Ins l u a n b o s q n s jo so!aos e o7 7uo!7 -ed oql Butumopuoa '~[nsoa £etu uo.t~ -3nalsqo £eA~:tI~ 9!uoaqo "uo!le.tx£qd -s~ ol Bu!pvo[ e!xod£q OAtSsolBo/d jo luamdo[aAop It.m:~odXetu X~tn.fu!stql 'po~aotopun uaqAk "uo.ta.tdsns 30 xoput qB!q e saamboa 'xaidmoa [eoqaealo~ -uXae[ aq:~ 30 uo.qona~sop OAlSSem st aaaql uoqA~ UOAO'etunea~ ~uniq 'aOAO -A~OH ~an[ut ,(eA~am aoddn 3o ,{~ti.tq.~s
-I v
9L61- JOqLUOAON d ~ r ~ £]:[;~L sesu~ l 'OSI~[~ 09IO~ II V O[[I.AOq~..,{[~I '[E~I(:[
-soil XVSI-I 'DIAl '~IVSYI '£VIAI '(/IAI 'ap '%~oqmeq "~ uuolo ;sTuuda.~.to3 sTsonba~[ '9L6I ~;ei~ 'e.IUI~A[I{SULIOcI'e!qd[opeI.tqd m 9u!~oaua soo!^~aS [ea~poIAI £~uo~aotux aoj uo!~p -ossv X~.~S.tOA.m~[enuue oq~ 7e po'~uaso~td '£~I~n~ua~I'OlltASmoq '~a~uoo saouotoS q~leaH 'au~ot.polA[ jo [ooq3S a[i.tA -s~noq jo £~.SaOA!Ui-1 '~ao~anS 3o ~uotu~aed -o(i '£So[o~u£auio~o jo uo.ts.tA.~(Ioq~ uaoa~i -sod oq] o~ uo.t~uo71e ~[Iva X[~uonboa3 'uoDeao [ s).t 2o osneaoq '~[aou oql 30 emnea7 BuDea~ouod -oauolo!A ue![!~ -ta pu~ IOAeXt oI!qotuo~.ne poods q~!q 3o osne~oq Bu!seoa~ut ~[~uoaedde s.t 1! 'u~ou~Iun s~ e u l n ~ s l Ieoqoe.~oBu~ae[ 3o oauop~.au! o n a l o q l q B n o q M v NOIlOnOOt:llNI
•leaqoeljo~u.4Jel 'euJne,Ll ;~ufle,qaued pue ,lunlq 'ee!Jn[u! leeqoeJ~oBu,,£ml "9L61- JaqtuaAON 'L88-888:£ dgOVP q.ueuJeSe -uetu pue uo!:l.!UfiOOeJ :euJneJ~. leeqoe.qo6uAJeq :/E) ,4J~nlhlOlhl '3E) :lJeqLue-I •~oIIO J a.mdoa X a n m u d p u v uo!~ -UOA.IO:[II!OnI1tW.Iodo~dmoa d "Xmo]soaqoeJ~ Xq p o ~ o i i o ~ u o ! ] e q n ] u ! ao Xmo~ .sooq:ma~ ~ a u o ~ a o m o ~ q pOAo!qov st Xe~:tm oq] Jo [oa~uo 0 "s!souffe!p oq~ m a u u o o p i n o q s so.tpn]s o.tqdmtBo!p¢a p u e X d o o s o p u o o ] e u d o a d d V "Xan.fu! [uoqom[]o~uXavl j o s ~ u ! p u ! j OA!]dumsoad o:m ' p u n o ~ ~ u p [ o n s v 'so!anf -u! B u . q v ~ o u o d u ! ' p u ~ 's~iaeuIpuv I o l q e d i v d j o s s o I ' u o ! ] o n a ] s q o Xv~at~ j o s u ~ ! s 's!sX~domo q ' v ! u o q d s X p ao e ! u o q d u ' e m o s X q d m o s n o o u e ~ n o q n S •so!an[u! Bu.t~mqouod u v q ] OaOAOS oaom o:to~ so!an[u! ] u n I q 'ieaouo~ u I •s ! s o u o ] s a!]~ol~qns aoj u o ! ] e a o d o aoq~.mj p e q ~uot.~ud o u O "s!sXimmd OAa0U ]uoaanooa .to spaoo oq~ o] X:m.fu! ~ooa!p o~ olqv~nq!a]~e s s o u o s . m o q s ¢ ~ uo!~ -ea!idmo:~ X.m.fu!~sod u o m m o o ~ s o m oq& "X:m.fu! X u ~ a ! v oq~ o] oiqv]nq!a~ -~e XI~Ooa!p SeA~ q~uop OUO "pOAgAanS 6! ' p o ! a o d auoX-uo] v ffu!anp lm!d -so H i v a o u o o O[[IAS!nO,-I oq~t~tu e m n v a ] [ v o q a v a ] o J ] u X a v I q]!A~ s ~ u o p v d gg uI
•~)lon~ua)l 'alllas!no'l GIN '/uJnltVOlN "1 uopJoo OM/ 'J/" "#JequJe7 "9 UUalO
],uauJa6eue pue uo!],!u6ooet::l :eLuneJ1 leaqoeJ],ofiuAJe-I
J
SNOIIV~IFIOIENO0 GNV 'SIN.gNOdl4100 'SldgONO0
c o n t a m i n a t e d by oropharyngeal flora. The hope was to reduce the possibility of s u b s e q u e n t infection, which, by in. fluencing wound healing, may con]. promise a n y functional g a i n achieved by operative interven-tion_
Table 1 INCIDENCE OF LARYNGOTRACHEAL T R A U M A No. of Patients
Cause
Site oflnjury
Trachea Blunt trauma Gunshot wound Stab wound Larynx Blunt trauma Gunshot wound Stab wound
4 5 3
TOTAL
23
Table 2 TYPE OF LARYNGOTRACHEAL T R A U M A Type of Injury
No. of Patients
Through-and-through perforation Disruption Fracture Tangential laceration Slash injury
8 6 4 3 2
TOTAL
23
Table 3 INJURIES ASSOCIATED WITH LARYNGOTRACHEAL /TRAUMA Associated Injuries
No.
Recurrent laryngeal nerve
6
Pharyngeal or esophageal laceration
5
Closed head injury
5
Cervical fracture
4
Table 4 CLINICAL FINDINGS IN LARYNGOTRACHEAL INJURIES Findings
Subcutaneous emphysema 21 Hemoptysis
18
Airway obstruction
13 10
Chest trauma
4
Aphonia or hoarseness Loss of palpable landmarks
Thyroid laceration
3
Sucking wounds
Abdominal trauma Long bone fracture
2 1
neck injuries, securing an adequate airway is the prime consideration. In the cases reviewed, i m m e d i a t e control of the airway was obtained in all patients with obvious or i m p e n d i n g airway obstruction. Seventeen patients were m a n a g e d successfully with endotracheal intubation, including three with complete tracheal disruption. One p a t i e n t with complete transection was i n t u b a t e d at the accident scene by one of our residents, who happened by and stopped to render
Page 884 Volume 5 Number 11
No.
7 6
aid. Six p a t i e n t s required emergency tracheostomy for airway control. After a i r w a y control was gained, fluid resuscitation was b e g u n with a balanced salt solution, u s u a l l y Ringer's lactate. Blood was typed, crossmatched, and transfused as needed. In addition to r o u t i n e resuscitative efforts, in all i n s t a n c e s of suspected laryngotracheal t r a u m a , broad spect r u m antibiotics were a d m i n i s t e r e d because these wounds generally are
P e n e t r a t i n g injuries to the laryn. gotracheal complex are seldom dif. ficult to detect b u t the diagnosis of b l u n t t r a u m a to the upper airway can be a problem. Because t h e r e may be little e x t e r n a l evidence of major in. j u r y , a h i g h i n d e x of s u s p i c i o n is necessary to make the diagnosis. To f u r t h e r complicate the problem, as seen in four cases described below, even extensive injuries m a y present quite s u b t l y with little i n i t i a l evi. dence of airway obstruction, only to produce severe airway compromise as wound edema progresses. Symptoms and signs m a y vary with the extent of injury. Nevertheless, as d e m o n s t r a t e d i n our series, certain physical findings are reliable predictors of major airway injuries (Table 4). Subcutaneous e m p h y s e m a was almost universal_ Hemoptysis was a common finding i n d i c a t i n g mucosal laceration. Some degree of a i r w a y obstruction was present i n over 50% of patients, r a n g i n g from mild stridor to complete o b s t r u c t i o n . T h e t i m e of o n s e t of o b s t r u c t i o n Varied g r e a t l y and, in some instances, a p p e a r e d t w o to three hours after injury. Loss of palpable l a n d m a r k s over the thyroid cartilage proved diagnostic of l a r y n g e a l fracture. Aphonia or dysphonia as a result of direct vocal cord damage or recurr e n t nerve i n j u r y occurred in one half of the p a t i e n t s in this series. Sucking wounds in pene.trating t r a u m a of the neck were almost always associated with upper airway perforation. After the airway was assured, soft tissue films of the neck were routinely obtained to d e t e r m i n e the presence of subcutaneous air or deformity of the air column. Although soft tissue films added little to the diagnosis of airway injury t h a t physical e x a m i n a t i o n had not shown, they were i m p o r t a n t to rule out concomitant cervical spine inj u r i e s . C h e s t r o e n t g e n o g r a m s were obtained to e v a l u a t e possible pleural or p u l m o n a r y p a r e n c h y m a l injury. C o n t r a s t s t u d i e s of t h e l a r y n x or esophagus were performed only i~ equivocal cases.
November 1976 J ~ P
Direct laryngoscopy was performed pre-operatively to evaluate the extent of i n j u r y a n d p o s t o p e r a t i v e l y to evaluate the adequacy of the repair. Indirect l a r y n g o s c o p y , a l t h o u g h a simple technique, was a very difficult procedure i n the u n c o o p e r a t i v e injared patient, and its use was limited. Findings typical of significant airway injury were obvious distortion of cartilaginous structures, extensive raucosal lacerations, and vocal cord paralysis. Bronchoscopy and esophagoscopy frequently were used to rule. out associated injuries of the major bronchi and esophageal lacerations.
CASE REPORTS Four cases i n this series illustrate the potential difficulties of the recognition and i n i t i a l m a n a g e m e n t of blunt t r a u m a to the laryngotracheal apparatus. Case N u m b e r One. A 41-year-old woman was a d m i t t e d to the emergency d e p a r t m e n t after a n auto accident i n which she had been a front seat passenger. She had obvious facial f r a c t u r e s , r i b f r a c t u r e s , a n d p n e u m o t h o r a x . S u b c u t a n e o u s emphysema was present in the neck region b u t was believed to be a result of her chest injuries. After insertion of c h e s t t u b e s , h e r c o n d i t i o n appeared to stabilize. D u r i n g the next hour, however, she experienced increasing dyspnea and her condition d e t e r i o r a t e d . L a r y n g o s c o p y confirmed a fractured larynx. Case N u m b e r T w o A 20-year-old woman was seen i n the emergency department after b e i n g b e a t e n and choked. I n i t i a l e x a m i n a t i o n focused on her o b v i o u s f a c i a l l a c e r a t i o n s . Approximately three hours later she began to d e m o n s t r a t e signs of upper airway obstruction. Direct laryngoscopy showed a l a r y n g e a l fracture, An open reduction was achieved_ Case N u m b e r T h r e e . A 19-year01d m a n sustained multiple injuries when the car he was driving struck an e m b a n k m e n t . \ I n i t i a l e v a l u a t i o n performed a t a n o t h e r h o s p i t a l showed a closed head injury. He was semiconscious and a significant Upper airway injury was o v e r l o o k e d . On arrival at General Hospital the Patient was i n obvious r e s p i r a t o r y distress. He was i n t u b a t e d a n d at exploration found to have a crushed
J ~
November 1976
l a r y n x , w h i c h was r e p a i r e d w i t h open r e d u c t i o n . After six m o n t h s , marked hoarseness persists. C a s e N u m b e r F o u r . A 39-yearold m a n presented at a n o t h e r hospit a l a f t e r t h e car he w a s d r i v i n g s t r u c k a n e m b a n k m e n t . He had a closed head i n j u r y and was quite intoxicated. On t r a n s f e r to Louisville General, he was in severe respiratory distress. The p a t i e n t was successfully i n t u b a t e d a n d his c o n d i t i o n stabilized. At operation he was found to have complete l a r y n g o t r a c h e a l disr u p t i o n , w h i c h was r e p a i r e d w i t h an end-to-end anastomosis. Because of r e c u r r e n t l a r y n g e a l nerve injury, the patient remains moderately hoarse. After complete assessment, all pat i e n t s d e e m e d to h a v e s i g n i f i c a n t a i r w a y i n j u r y were s u r g i c a l l y e x - ' plored. Almost uniformly, operative approach was t h r o u g h a t r a n s v e r s e anterior incision. Simple lacerations a n d t h r o u g h - a n d - t h r o u g h perforations were t r e a t e d with simple closure. The more complex l a r y n g e a l injuries and tracheal transections were treated by careful mucosal closure and end-to-end anastomosis in instances of laryngotracheal disrupt i o n , or c a r e f u l r e d u c t i o n of cartilaginous fracture w h e n the l a r y n x was found to be crushed. Concomit a n t p h a r y n g e a l or esophageal lacerations were carefully repaired. Soft i n t r a l u m i n a l stents were used in the presence of severe mucosal damage or d i s r u p t i o n of c a r t i l a g i n o u s framework.
RESULTS Delayed or staged repair of major t r a u m a to the l a r y n x or trachea m a y be c o m p l i c a t e d by d e v e l o p m e n t of fibrous scar tissue in the wound leading to contracture and distortion. As t h i s m a y seriously i m p a i r the funct i o n a l r e s u l t , we b e l i e v e t h a t immediate p r i m a r y repair provides the o p t i m a l o p p o r t u n i t y for c a r e f u l anatomic repair, thereby i n s u r i n g a n adequate voice, a p a t e n t airway, and a satisfactory swallowing mechanism. In 19 patients, p r i m a r y repair with s e p a r a t e t r a c h e o s t o m y was performed. In one case, definitive repair was c a r r i e d o u t t h r e e d a y s a f t e r tracheostomy. Three patients had
Table 5 COMPLICATIONS OF LARYNGOTRACHEAL INJURY Complications Among Survivors Hoarseness
No. 9
Tracheal stenosis
2
Tracheoesophageal fistula
1
Web formation
1
Horner's syndrome
1
tracheostomy only. In one, the site of injury was used as the tracheostomy. I n two others, p r i m a r y repair was deferred because of the patients' critical conditions. Four hospital deaths occurred a m o n g t h e 23 p a t i e n t s . O n l y one d e a t h w a s d i r e c t l y r e l a t e d to t h e airway i n j u r y - - a w o m a n who had suffered massive b l u n t t r a u m a pres e n t e d w i t h signs of upper a i r w a y obstruction which was not relieved by tracheostomy. Immediate thoract o m y was p e r f o r m e d b u t she died from a t r a n s e c t e d trachea j u s t above the c a r i n a . Two p a t i e n t s who had t r a c h e a l t r a n s e c t i o n s and concomit a n t cervical fractures with quadriplegia died from p u l m o n a r y infections l a t e r i n t h e i r hospitalization. One diabetic p a t i e n t died as a result of acute hypoglycemia a week after s u c c e s s f u l r e p a i r of a l a c e r a t e d thyroid cartilage. The most common p o s t t r a u m a t i c complication found i n nine patients (Table 5) was hoarseness. In two patients this completely resolved; two were lost to follow-up, and five rem a i n e d hoarse. One p a t i e n t required a second o p e r a t i o n for a tracheoesophageal fistula following penetrati n g i n j u r y . Two p a t i e n t s w i t h tracheal t r a n s e c t i o n had subglottic stenosis after operative repair. One required s u b s e q u e n t resection of the stenotic area and reanastomosis. One p a t i e n t with moderate stenosis refused further surgical intervention. A n o t h e r p a t i e n t developed a web of t h e a n t e r i o r c o m m i s s u r e of the vocal cords but also refused furt h e r o p e r a t i o n _ T h e r e were no wound infections.
DISCUSSION Although injuries to the laryngo-
Volume 5 Number 11 Page 885
tracheal a p p a r a t u s are u n c o m m o n , the true incidence is difficult to assess because m a n y of these injuries r e s u l t i n d e a t h before t h e v i c t i m reaches a hospital. Most scientific d a t a r e g a r d i n g traffic accidents do n o t reflect t h e i n c i d e n c e of u p p e r airway injuries. 1 The n u m b e r of recent series 2-~ provides indirect evidence that the incidence is increasing_ The relative r a r i t y of p e n e t r a t i n g laryngotracheal i n j u r y is related to the protective a n a t o m y of the cervical area. s The majority of b l u n t injuries are secondary to motor vehicle accidents. The most susceptible indiv i d u a l is the front seat passenger, followed by t h e d r i v e r . I n f r o n t impact automobile accidents, the p a s s e n g e r ' s h e a d a n d t r u n k are thrown forward and the anterior craniofacial complex may strike the w i n d s h i e l d . This h y p e r e x t e n d s the neck, placing the n o r m a l l y protected, delicate l a r y n g o t r a c h e a l complex at risk on the f u l c r u m of the cervical v e r t e b r a e . The a n t e r i o r neck t h e n strikes the edge of the dashboard or the steering column r e s u l t i n g in cart i l a g i n o u s f r a c t u r e a n d separation. The waist-type seatbelt m a y actually contribute to the injury by allowing only the upper body and head to be thrown forward. Butler and Moser s have labeled this p a r t i c u l a r sequence of e v e n t s and i n j u r i e s '~the padded dash s y n d r o m e . " The h i g h k i n e t i c e n e r g y t h a t develops e v e n i n low speed collisions is dissipated over a small area - - the anterior neck and dashboard2 This explains why even at slow speeds massive i n j u r y can result. This fact was confirmed i n a cadaver l a r y n x model by T r a v i s et al. ~° N a h u m 2 , s a n d B u t l e r a n d Moser s have made recommendations for vehicular design to p r e v e n t these injuries. The single most i m p o r t a n t r e c o m m e n d a t i o n was the cross-chest and waist seat belt combination. Trailbikes, snowmobiles, a n d m i n i bikes are also c o n t r i b u t i n g to this injury i n instances of collision with wires and cables2 z Some controversy is found in the l i t e r a t u r e r e g a r d i n g a t t e m p t e d endotracheal i n t u b a t i o n versus emergency tracheostomy in m a n a g i n g these i n j u r i e s . Some authorsS, 11-1~ prefer emergency tracheostomy, others 6 with extensive experience
Page 886 Volume 5 Number 11
r e c o m m e n d c a r e f u l i n t u b a t i o n . In our series, 17 p a t i e n t s were successfully i n t u b a t e d , a m o n g these were three p a t i e n t s with complete disruption. E n d o t r a c h e a l i n t u b a t i o n has much to r e c o m m e n d it. A t r a c h e o s t o m y performed over a n endotracheal tube is preferable to a h u r r i e d tracheostomy in less t h a n satisfactory surr o u n d i n g s . S u b s t a n t i a l d a n g e r of p r e c i p i t a t i n g total airway occlusion accompanies vigorous attempts at int u b a t i o n , b u t p r o v i s i o n s for imm e d i a t e t r a c h e o s t o m y should be available when i n t u b a t i o n is attempted. However, cervical spine injuries m a y be worsened by i n t u b a t i o n attempts. In addition to efficient transportat i o n of the i n j u r e d to h e a l t h care facilities and better resuscitative t e c h n i q u e s , t h e r e a s o n for t h e m a r k e d reduction i n both m o r t a l i t y and s u b s e q u e n t morbidity in injuries of the trachea and l a r y n x d u r i n g the last decade has been prompt airway control and i m m e d i a t e p r i m a r y repair.l,4-G,9,12,13 Delayed r e p a i r carries s i g n i f i c a n t m o r b i d i t y and m a y condemn the p a t i e n t to a prolonged convalescence and m u l t i p l e surgical procedures.a, ~4 All patients with severe mucosal lacerations, subcutaneous e m p h y s e m a , cartilage fracture, or increasing airway obstruction are candidates for open exploration.S, 12 If, after complete evaluation, uncert a i n t y r e m a i n s as to the extent of injury, operation is indicated. Repair of simple l a c e r a t i o n s a n d t h r o u g h - a n d - t h r o u g h perforation are seldom technically challenging.iS, 1~ The major c r u s h i n g i n j u r i e s of the l a r y n x and l a r y n g o t r a c h e a l disruptions, by contrast, can severely tax the s u r g e o n ' s i n g e n u i t y to i n s u r e both a n adequate airway and the ret u r n of a c c e p t a b l e vocal a b i l i t y . Careful mucosal closure, reapproxim a t i o n of t i s s u e s w i t h o u t t e n s i o n , a n d a n a t o m i c r e d u c t i o n of c a r t i l a ginous fractures should significantly reduce postoperative morbidity. In a n effort to influence scar formation a n d p r e v e n t s t e n o s i s , m a n y authors'a,zs, '7 use i n t r a l u m i n a l stents of soft plastic or rubber. If there is e x t e n s i v e m u c o s a l d e n u d a t i o n , the s t e n t is w r a p p e d i n a s p l i t t h i c k ness skin graft.
M e n t i o n should be made of conser, vative .treatment of laryngotracheal injuries. In those patients in whom no evidence of Cartilaginous fracture or m a j o r m u c o s a l l a c e r a t i o n s is found, a w a t c h - a n d : w a i t attitude should be adopted. As o u t l i n e d by N a h u m , 9 this type of t r e a t m e n t consists of humidified oxygen, voice rest, restricted diet, and antibiotics. Careful o b s e r v a t i o n a n d d a i l y indirect laryngoscopy m u s t be performed. The use of steroids i~ controversial, but most o t o l a r y n g o l o g i s t s recommend t h e m in a short course. This form of m a n a g e m e n t can be u n d e r t a k e n only after e x t e n s i v e efforts t o rule out major injury. If there is any doubt, o p e n e x p l o r a t i o n is a d v i s e d . The closed reduction of c e r t a i n cartilage displacements is described i n the literature, s b u t we have had no experience with this_ Close, p r o l o n g e d f o l l o w - u p is necessary in all patients with massive l a r y n g o t r a c h e a l t r a u m a . Significant stenosis m a y appear months after i n i t i a l injury. P e r s i s t e n t recurr e n t l a r y n g e a l nerve paralysis may r e q u i r e a r y t e n o i d o p e x y a n d cord lateralizations. ~s
REFERENCES 1. Downey WL, Owen RC, Ward PH: Traumatic laryngeal injury - - Its management and sequelae. South Med J 60:756-761, 1967. 2. Nahum AM, Siegel AW: Biodynamics of injury to the larynx in automobile collisions. A n n Otol Rhinol Laryngol 76:781-785, 1967. 3. Curtin JW, Holinger PH, Greeley PW: Blunt trauma to 'the larynx and upper trachea: immediate treatment, complications and late reconstructive procedures. J Trauma 6:493-502, 1966. 4_ Harris HH, Tobin HA: Acute injuries of the larynx and trachea in 49 patients. (Observations over a 15-year period.) Laryngoscope 80:1376-1384, 1970. 5. Pennington CL: External trauma of the larynx and trachea: immediate treatment and management. Ann Otol Rhinol Laryngol 81:546-554, 1972. 6. Sheely CH II, Mattox KL, Beall AC Jr: Management of acute cervical tracheal trauma A m J Surg 128:805-808, 1974. 7. Shumrick DA: Trauma of the larynX. Arch Otolaryngol 86:691-696, 1967. 8. Butler RM, Moser FH: The padded dash syndrome: b l u n t t r a u m a to the larynx and trachea. Laryngoscope 78:1172-1182, 1968.
November 1976 J ~ P
9. N a h u m AM: Immediate care of acute blunt l a r y n g e a l t r a u m a . J Trauma 9:112-125, 1969.
12. Alonso WA, P r a t t LL, Zollinger WK, et al: Complications of l a r y n g o t r a c h e a l disruption. Laryngoscope 84:1276-1290, 1974.
10. Travis LW, Olson NR, Melvin JW, et al: Static and dynamic impact t r a u m a of the h u m a n larynx. Trans Am Acad Ophthalmol Otolaryngol 80:382-390, 1975.
13. Harris HH, Ainsworth JZ: Immediate m a n a g e m e n t of laryngeal and tracheal injuries. Laryngoscope 75:1103-1115, 1965.
11. Alonso WA, Caruso VG, Roncace EA: ~inibikes: a new factor in laryngotracheal t r a u m a . Ann Otol Rhinol Laryn~ol 82:800-804, 1973.
14. Ogura JH, Powers WE: Functional r e s t i t u t i o n of t r a u m a t i c stenosis of the l a r y n x a n d p h a r y n x . Laryngoscope 74:1081-1110, 1964.
15. Boyles JH: Lacerations of the larynx.
Arch Otolaryngol 87:422-424, 1968. 16. LeMay SR: P e n e t r a t i n g wounds of the l a r y n x a n d cervical t r a c h e a . Arch Otolaryngol 94:558-565, 1971. 17. S h a i a FT, Cassady CL: L a r y n g e a l t r a u m a . Arch Otolaryngol 95:104-108, 1972. 18. Florman LD, Weiner I_J: Laryngotracheal trauma. J Ky Med Assoc 73:30-32, 1975.
Correction: Unfortunately, several errors appeared in "Nerve Blocks of the Foot," (JACEP, September, 1976, pp 689-702) by Locke and Locke. In the following, the italicized words were incorrect in the original. 1. On page 699, concerning the length of action of bupivacaine hydrochloride: "When pain is anticipated following instrumentation, debridement, or other emergency procedure, a longer acting anesthetic such as bupivacaine hydrochloride that can provide anesthesia up to seven hours 11 is desirable." 2. On page 702: "In one of the authors' (RKL) experience, while the hyperemia . . . . " 3. On page 702, the last sentence of the article: "One of the authors (RKL) though not using epinephrine in digital surgery has utilized this vasoconstrictor in nerve blocks (in strengths of 1:200,000 or 1:300,000) without any untoward effects in over 2,000 procedures (unpublished data). The article was inadvertently left out of the Table of Contents where it should have appeared under the category Emergency Methods and Techniques. On page 698, Raymond t~. Locke, DPM was mistakenly listed as being from Belmont, Massachusetts. Dr. Locke lives in Englewood, New Jersey.
~]~)
November 1976
Volume 5 Number 11 Page 887
-,ms LauoBaomo oq~ o~ poll.ttupe OaOA~ £an[ut. [eoqa~a~oBuXae[ ao[eua 3o sosea g~ '£L61 o~ 996I po.uod oq7 Bu!an(I £N=qN=IOVNVIN " I V I I l N I QNV NOIIV£N=IS~]I=Id I N 3 1 1 V d [e~.~dsoH I~aouoD oII!As!noq oq~ 7~ sleo_£ u o 3. aoAo Kin.Cut [eoqae.t 7 -oBu£ae[ Io[eta ~o sosea 8~ pOA~O!AOI OA~-Xq.t[tq~s.~po[qtssod pue soanpoaoad [ea!~Ins l u a n b o s q n s jo so!aos e o7 7uo!7 -ed oql Butumopuoa '~[nsoa £etu uo.t~ -3nalsqo £eA~:tI~ 9!uoaqo "uo!le.tx£qd -s~ ol Bu!pvo[ e!xod£q OAtSsolBo/d jo luamdo[aAop It.m:~odXetu X~tn.fu!stql 'po~aotopun uaqAk "uo.ta.tdsns 30 xoput qB!q e saamboa 'xaidmoa [eoqaealo~ -uXae[ aq:~ 30 uo.qona~sop OAlSSem st aaaql uoqA~ UOAO'etunea~ ~uniq 'aOAO -A~OH ~an[ut ,(eA~am aoddn 3o ,{~ti.tq.~s
-I v
9L61- JOqLUOAON d ~ r ~ £]:[;~L sesu~ l 'OSI~[~ 09IO~ II V O[[I.AOq~..,{[~I '[E~I(:[
-soil XVSI-I 'DIAl '~IVSYI '£VIAI '(/IAI 'ap '%~oqmeq "~ uuolo ;sTuuda.~.to3 sTsonba~[ '9L6I ~;ei~ 'e.IUI~A[I{SULIOcI'e!qd[opeI.tqd m 9u!~oaua soo!^~aS [ea~poIAI £~uo~aotux aoj uo!~p -ossv X~.~S.tOA.m~[enuue oq~ 7e po'~uaso~td '£~I~n~ua~I'OlltASmoq '~a~uoo saouotoS q~leaH 'au~ot.polA[ jo [ooq3S a[i.tA -s~noq jo £~.SaOA!Ui-1 '~ao~anS 3o ~uotu~aed -o(i '£So[o~u£auio~o jo uo.ts.tA.~(Ioq~ uaoa~i -sod oq] o~ uo.t~uo71e ~[Iva X[~uonboa3 'uoDeao [ s).t 2o osneaoq '~[aou oql 30 emnea7 BuDea~ouod -oauolo!A ue![!~ -ta pu~ IOAeXt oI!qotuo~.ne poods q~!q 3o osne~oq Bu!seoa~ut ~[~uoaedde s.t 1! 'u~ou~Iun s~ e u l n ~ s l Ieoqoe.~oBu~ae[ 3o oauop~.au! o n a l o q l q B n o q M v NOIlOnOOt:llNI
•leaqoeljo~u.4Jel 'euJne,Ll ;~ufle,qaued pue ,lunlq 'ee!Jn[u! leeqoeJ~oBu,,£ml "9L61- JaqtuaAON 'L88-888:£ dgOVP q.ueuJeSe -uetu pue uo!:l.!UfiOOeJ :euJneJ~. leeqoe.qo6uAJeq :/E) ,4J~nlhlOlhl '3E) :lJeqLue-I •~oIIO J a.mdoa X a n m u d p u v uo!~ -UOA.IO:[II!OnI1tW.Iodo~dmoa d "Xmo]soaqoeJ~ Xq p o ~ o i i o ~ u o ! ] e q n ] u ! ao Xmo~ .sooq:ma~ ~ a u o ~ a o m o ~ q pOAo!qov st Xe~:tm oq] Jo [oa~uo 0 "s!souffe!p oq~ m a u u o o p i n o q s so.tpn]s o.tqdmtBo!p¢a p u e X d o o s o p u o o ] e u d o a d d V "Xan.fu! [uoqom[]o~uXavl j o s ~ u ! p u ! j OA!]dumsoad o:m ' p u n o ~ ~ u p [ o n s v 'so!anf -u! B u . q v ~ o u o d u ! ' p u ~ 's~iaeuIpuv I o l q e d i v d j o s s o I ' u o ! ] o n a ] s q o Xv~at~ j o s u ~ ! s 's!sX~domo q ' v ! u o q d s X p ao e ! u o q d u ' e m o s X q d m o s n o o u e ~ n o q n S •so!an[u! Bu.t~mqouod u v q ] OaOAOS oaom o:to~ so!an[u! ] u n I q 'ieaouo~ u I •s ! s o u o ] s a!]~ol~qns aoj u o ! ] e a o d o aoq~.mj p e q ~uot.~ud o u O "s!sXimmd OAa0U ]uoaanooa .to spaoo oq~ o] X:m.fu! ~ooa!p o~ olqv~nq!a]~e s s o u o s . m o q s ¢ ~ uo!~ -ea!idmo:~ X.m.fu!~sod u o m m o o ~ s o m oq& "X:m.fu! X u ~ a ! v oq~ o] oiqv]nq!a~ -~e XI~Ooa!p SeA~ q~uop OUO "pOAgAanS 6! ' p o ! a o d auoX-uo] v ffu!anp lm!d -so H i v a o u o o O[[IAS!nO,-I oq~t~tu e m n v a ] [ v o q a v a ] o J ] u X a v I q]!A~ s ~ u o p v d gg uI
•~)lon~ua)l 'alllas!no'l GIN '/uJnltVOlN "1 uopJoo OM/ 'J/" "#JequJe7 "9 UUalO
],uauJa6eue pue uo!],!u6ooet::l :eLuneJ1 leaqoeJ],ofiuAJe-I
J
SNOIIV~IFIOIENO0 GNV 'SIN.gNOdl4100 'SldgONO0
c o n t a m i n a t e d by oropharyngeal flora. The hope was to reduce the possibility of s u b s e q u e n t infection, which, by in. fluencing wound healing, may con]. promise a n y functional g a i n achieved by operative interven-tion_
Table 1 INCIDENCE OF LARYNGOTRACHEAL T R A U M A No. of Patients
Cause
Site oflnjury
Trachea Blunt trauma Gunshot wound Stab wound Larynx Blunt trauma Gunshot wound Stab wound
4 5 3
TOTAL
23
Table 2 TYPE OF LARYNGOTRACHEAL T R A U M A Type of Injury
No. of Patients
Through-and-through perforation Disruption Fracture Tangential laceration Slash injury
8 6 4 3 2
TOTAL
23
Table 3 INJURIES ASSOCIATED WITH LARYNGOTRACHEAL /TRAUMA Associated Injuries
No.
Recurrent laryngeal nerve
6
Pharyngeal or esophageal laceration
5
Closed head injury
5
Cervical fracture
4
Table 4 CLINICAL FINDINGS IN LARYNGOTRACHEAL INJURIES Findings
Subcutaneous emphysema 21 Hemoptysis
18
Airway obstruction
13 10
Chest trauma
4
Aphonia or hoarseness Loss of palpable landmarks
Thyroid laceration
3
Sucking wounds
Abdominal trauma Long bone fracture
2 1
neck injuries, securing an adequate airway is the prime consideration. In the cases reviewed, i m m e d i a t e control of the airway was obtained in all patients with obvious or i m p e n d i n g airway obstruction. Seventeen patients were m a n a g e d successfully with endotracheal intubation, including three with complete tracheal disruption. One p a t i e n t with complete transection was i n t u b a t e d at the accident scene by one of our residents, who happened by and stopped to render
Page 884 Volume 5 Number 11
No.
7 6
aid. Six p a t i e n t s required emergency tracheostomy for airway control. After a i r w a y control was gained, fluid resuscitation was b e g u n with a balanced salt solution, u s u a l l y Ringer's lactate. Blood was typed, crossmatched, and transfused as needed. In addition to r o u t i n e resuscitative efforts, in all i n s t a n c e s of suspected laryngotracheal t r a u m a , broad spect r u m antibiotics were a d m i n i s t e r e d because these wounds generally are
P e n e t r a t i n g injuries to the laryn. gotracheal complex are seldom dif. ficult to detect b u t the diagnosis of b l u n t t r a u m a to the upper airway can be a problem. Because t h e r e may be little e x t e r n a l evidence of major in. j u r y , a h i g h i n d e x of s u s p i c i o n is necessary to make the diagnosis. To f u r t h e r complicate the problem, as seen in four cases described below, even extensive injuries m a y present quite s u b t l y with little i n i t i a l evi. dence of airway obstruction, only to produce severe airway compromise as wound edema progresses. Symptoms and signs m a y vary with the extent of injury. Nevertheless, as d e m o n s t r a t e d i n our series, certain physical findings are reliable predictors of major airway injuries (Table 4). Subcutaneous e m p h y s e m a was almost universal_ Hemoptysis was a common finding i n d i c a t i n g mucosal laceration. Some degree of a i r w a y obstruction was present i n over 50% of patients, r a n g i n g from mild stridor to complete o b s t r u c t i o n . T h e t i m e of o n s e t of o b s t r u c t i o n Varied g r e a t l y and, in some instances, a p p e a r e d t w o to three hours after injury. Loss of palpable l a n d m a r k s over the thyroid cartilage proved diagnostic of l a r y n g e a l fracture. Aphonia or dysphonia as a result of direct vocal cord damage or recurr e n t nerve i n j u r y occurred in one half of the p a t i e n t s in this series. Sucking wounds in pene.trating t r a u m a of the neck were almost always associated with upper airway perforation. After the airway was assured, soft tissue films of the neck were routinely obtained to d e t e r m i n e the presence of subcutaneous air or deformity of the air column. Although soft tissue films added little to the diagnosis of airway injury t h a t physical e x a m i n a t i o n had not shown, they were i m p o r t a n t to rule out concomitant cervical spine inj u r i e s . C h e s t r o e n t g e n o g r a m s were obtained to e v a l u a t e possible pleural or p u l m o n a r y p a r e n c h y m a l injury. C o n t r a s t s t u d i e s of t h e l a r y n x or esophagus were performed only i~ equivocal cases.
November 1976 J ~ P
Direct laryngoscopy was performed pre-operatively to evaluate the extent of i n j u r y a n d p o s t o p e r a t i v e l y to evaluate the adequacy of the repair. Indirect l a r y n g o s c o p y , a l t h o u g h a simple technique, was a very difficult procedure i n the u n c o o p e r a t i v e injared patient, and its use was limited. Findings typical of significant airway injury were obvious distortion of cartilaginous structures, extensive raucosal lacerations, and vocal cord paralysis. Bronchoscopy and esophagoscopy frequently were used to rule. out associated injuries of the major bronchi and esophageal lacerations.
CASE REPORTS Four cases i n this series illustrate the potential difficulties of the recognition and i n i t i a l m a n a g e m e n t of blunt t r a u m a to the laryngotracheal apparatus. Case N u m b e r One. A 41-year-old woman was a d m i t t e d to the emergency d e p a r t m e n t after a n auto accident i n which she had been a front seat passenger. She had obvious facial f r a c t u r e s , r i b f r a c t u r e s , a n d p n e u m o t h o r a x . S u b c u t a n e o u s emphysema was present in the neck region b u t was believed to be a result of her chest injuries. After insertion of c h e s t t u b e s , h e r c o n d i t i o n appeared to stabilize. D u r i n g the next hour, however, she experienced increasing dyspnea and her condition d e t e r i o r a t e d . L a r y n g o s c o p y confirmed a fractured larynx. Case N u m b e r T w o A 20-year-old woman was seen i n the emergency department after b e i n g b e a t e n and choked. I n i t i a l e x a m i n a t i o n focused on her o b v i o u s f a c i a l l a c e r a t i o n s . Approximately three hours later she began to d e m o n s t r a t e signs of upper airway obstruction. Direct laryngoscopy showed a l a r y n g e a l fracture, An open reduction was achieved_ Case N u m b e r T h r e e . A 19-year01d m a n sustained multiple injuries when the car he was driving struck an e m b a n k m e n t . \ I n i t i a l e v a l u a t i o n performed a t a n o t h e r h o s p i t a l showed a closed head injury. He was semiconscious and a significant Upper airway injury was o v e r l o o k e d . On arrival at General Hospital the Patient was i n obvious r e s p i r a t o r y distress. He was i n t u b a t e d a n d at exploration found to have a crushed
J ~
November 1976
l a r y n x , w h i c h was r e p a i r e d w i t h open r e d u c t i o n . After six m o n t h s , marked hoarseness persists. C a s e N u m b e r F o u r . A 39-yearold m a n presented at a n o t h e r hospit a l a f t e r t h e car he w a s d r i v i n g s t r u c k a n e m b a n k m e n t . He had a closed head i n j u r y and was quite intoxicated. On t r a n s f e r to Louisville General, he was in severe respiratory distress. The p a t i e n t was successfully i n t u b a t e d a n d his c o n d i t i o n stabilized. At operation he was found to have complete l a r y n g o t r a c h e a l disr u p t i o n , w h i c h was r e p a i r e d w i t h an end-to-end anastomosis. Because of r e c u r r e n t l a r y n g e a l nerve injury, the patient remains moderately hoarse. After complete assessment, all pat i e n t s d e e m e d to h a v e s i g n i f i c a n t a i r w a y i n j u r y were s u r g i c a l l y e x - ' plored. Almost uniformly, operative approach was t h r o u g h a t r a n s v e r s e anterior incision. Simple lacerations a n d t h r o u g h - a n d - t h r o u g h perforations were t r e a t e d with simple closure. The more complex l a r y n g e a l injuries and tracheal transections were treated by careful mucosal closure and end-to-end anastomosis in instances of laryngotracheal disrupt i o n , or c a r e f u l r e d u c t i o n of cartilaginous fracture w h e n the l a r y n x was found to be crushed. Concomit a n t p h a r y n g e a l or esophageal lacerations were carefully repaired. Soft i n t r a l u m i n a l stents were used in the presence of severe mucosal damage or d i s r u p t i o n of c a r t i l a g i n o u s framework.
RESULTS Delayed or staged repair of major t r a u m a to the l a r y n x or trachea m a y be c o m p l i c a t e d by d e v e l o p m e n t of fibrous scar tissue in the wound leading to contracture and distortion. As t h i s m a y seriously i m p a i r the funct i o n a l r e s u l t , we b e l i e v e t h a t immediate p r i m a r y repair provides the o p t i m a l o p p o r t u n i t y for c a r e f u l anatomic repair, thereby i n s u r i n g a n adequate voice, a p a t e n t airway, and a satisfactory swallowing mechanism. In 19 patients, p r i m a r y repair with s e p a r a t e t r a c h e o s t o m y was performed. In one case, definitive repair was c a r r i e d o u t t h r e e d a y s a f t e r tracheostomy. Three patients had
Table 5 COMPLICATIONS OF LARYNGOTRACHEAL INJURY Complications Among Survivors Hoarseness
No. 9
Tracheal stenosis
2
Tracheoesophageal fistula
1
Web formation
1
Horner's syndrome
1
tracheostomy only. In one, the site of injury was used as the tracheostomy. I n two others, p r i m a r y repair was deferred because of the patients' critical conditions. Four hospital deaths occurred a m o n g t h e 23 p a t i e n t s . O n l y one d e a t h w a s d i r e c t l y r e l a t e d to t h e airway i n j u r y - - a w o m a n who had suffered massive b l u n t t r a u m a pres e n t e d w i t h signs of upper a i r w a y obstruction which was not relieved by tracheostomy. Immediate thoract o m y was p e r f o r m e d b u t she died from a t r a n s e c t e d trachea j u s t above the c a r i n a . Two p a t i e n t s who had t r a c h e a l t r a n s e c t i o n s and concomit a n t cervical fractures with quadriplegia died from p u l m o n a r y infections l a t e r i n t h e i r hospitalization. One diabetic p a t i e n t died as a result of acute hypoglycemia a week after s u c c e s s f u l r e p a i r of a l a c e r a t e d thyroid cartilage. The most common p o s t t r a u m a t i c complication found i n nine patients (Table 5) was hoarseness. In two patients this completely resolved; two were lost to follow-up, and five rem a i n e d hoarse. One p a t i e n t required a second o p e r a t i o n for a tracheoesophageal fistula following penetrati n g i n j u r y . Two p a t i e n t s w i t h tracheal t r a n s e c t i o n had subglottic stenosis after operative repair. One required s u b s e q u e n t resection of the stenotic area and reanastomosis. One p a t i e n t with moderate stenosis refused further surgical intervention. A n o t h e r p a t i e n t developed a web of t h e a n t e r i o r c o m m i s s u r e of the vocal cords but also refused furt h e r o p e r a t i o n _ T h e r e were no wound infections.
DISCUSSION Although injuries to the laryngo-
Volume 5 Number 11 Page 885
tracheal a p p a r a t u s are u n c o m m o n , the true incidence is difficult to assess because m a n y of these injuries r e s u l t i n d e a t h before t h e v i c t i m reaches a hospital. Most scientific d a t a r e g a r d i n g traffic accidents do n o t reflect t h e i n c i d e n c e of u p p e r airway injuries. 1 The n u m b e r of recent series 2-~ provides indirect evidence that the incidence is increasing_ The relative r a r i t y of p e n e t r a t i n g laryngotracheal i n j u r y is related to the protective a n a t o m y of the cervical area. s The majority of b l u n t injuries are secondary to motor vehicle accidents. The most susceptible indiv i d u a l is the front seat passenger, followed by t h e d r i v e r . I n f r o n t impact automobile accidents, the p a s s e n g e r ' s h e a d a n d t r u n k are thrown forward and the anterior craniofacial complex may strike the w i n d s h i e l d . This h y p e r e x t e n d s the neck, placing the n o r m a l l y protected, delicate l a r y n g o t r a c h e a l complex at risk on the f u l c r u m of the cervical v e r t e b r a e . The a n t e r i o r neck t h e n strikes the edge of the dashboard or the steering column r e s u l t i n g in cart i l a g i n o u s f r a c t u r e a n d separation. The waist-type seatbelt m a y actually contribute to the injury by allowing only the upper body and head to be thrown forward. Butler and Moser s have labeled this p a r t i c u l a r sequence of e v e n t s and i n j u r i e s '~the padded dash s y n d r o m e . " The h i g h k i n e t i c e n e r g y t h a t develops e v e n i n low speed collisions is dissipated over a small area - - the anterior neck and dashboard2 This explains why even at slow speeds massive i n j u r y can result. This fact was confirmed i n a cadaver l a r y n x model by T r a v i s et al. ~° N a h u m 2 , s a n d B u t l e r a n d Moser s have made recommendations for vehicular design to p r e v e n t these injuries. The single most i m p o r t a n t r e c o m m e n d a t i o n was the cross-chest and waist seat belt combination. Trailbikes, snowmobiles, a n d m i n i bikes are also c o n t r i b u t i n g to this injury i n instances of collision with wires and cables2 z Some controversy is found in the l i t e r a t u r e r e g a r d i n g a t t e m p t e d endotracheal i n t u b a t i o n versus emergency tracheostomy in m a n a g i n g these i n j u r i e s . Some authorsS, 11-1~ prefer emergency tracheostomy, others 6 with extensive experience
Page 886 Volume 5 Number 11
r e c o m m e n d c a r e f u l i n t u b a t i o n . In our series, 17 p a t i e n t s were successfully i n t u b a t e d , a m o n g these were three p a t i e n t s with complete disruption. E n d o t r a c h e a l i n t u b a t i o n has much to r e c o m m e n d it. A t r a c h e o s t o m y performed over a n endotracheal tube is preferable to a h u r r i e d tracheostomy in less t h a n satisfactory surr o u n d i n g s . S u b s t a n t i a l d a n g e r of p r e c i p i t a t i n g total airway occlusion accompanies vigorous attempts at int u b a t i o n , b u t p r o v i s i o n s for imm e d i a t e t r a c h e o s t o m y should be available when i n t u b a t i o n is attempted. However, cervical spine injuries m a y be worsened by i n t u b a t i o n attempts. In addition to efficient transportat i o n of the i n j u r e d to h e a l t h care facilities and better resuscitative t e c h n i q u e s , t h e r e a s o n for t h e m a r k e d reduction i n both m o r t a l i t y and s u b s e q u e n t morbidity in injuries of the trachea and l a r y n x d u r i n g the last decade has been prompt airway control and i m m e d i a t e p r i m a r y repair.l,4-G,9,12,13 Delayed r e p a i r carries s i g n i f i c a n t m o r b i d i t y and m a y condemn the p a t i e n t to a prolonged convalescence and m u l t i p l e surgical procedures.a, ~4 All patients with severe mucosal lacerations, subcutaneous e m p h y s e m a , cartilage fracture, or increasing airway obstruction are candidates for open exploration.S, 12 If, after complete evaluation, uncert a i n t y r e m a i n s as to the extent of injury, operation is indicated. Repair of simple l a c e r a t i o n s a n d t h r o u g h - a n d - t h r o u g h perforation are seldom technically challenging.iS, 1~ The major c r u s h i n g i n j u r i e s of the l a r y n x and l a r y n g o t r a c h e a l disruptions, by contrast, can severely tax the s u r g e o n ' s i n g e n u i t y to i n s u r e both a n adequate airway and the ret u r n of a c c e p t a b l e vocal a b i l i t y . Careful mucosal closure, reapproxim a t i o n of t i s s u e s w i t h o u t t e n s i o n , a n d a n a t o m i c r e d u c t i o n of c a r t i l a ginous fractures should significantly reduce postoperative morbidity. In a n effort to influence scar formation a n d p r e v e n t s t e n o s i s , m a n y authors'a,zs, '7 use i n t r a l u m i n a l stents of soft plastic or rubber. If there is e x t e n s i v e m u c o s a l d e n u d a t i o n , the s t e n t is w r a p p e d i n a s p l i t t h i c k ness skin graft.
M e n t i o n should be made of conser, vative .treatment of laryngotracheal injuries. In those patients in whom no evidence of Cartilaginous fracture or m a j o r m u c o s a l l a c e r a t i o n s is found, a w a t c h - a n d : w a i t attitude should be adopted. As o u t l i n e d by N a h u m , 9 this type of t r e a t m e n t consists of humidified oxygen, voice rest, restricted diet, and antibiotics. Careful o b s e r v a t i o n a n d d a i l y indirect laryngoscopy m u s t be performed. The use of steroids i~ controversial, but most o t o l a r y n g o l o g i s t s recommend t h e m in a short course. This form of m a n a g e m e n t can be u n d e r t a k e n only after e x t e n s i v e efforts t o rule out major injury. If there is any doubt, o p e n e x p l o r a t i o n is a d v i s e d . The closed reduction of c e r t a i n cartilage displacements is described i n the literature, s b u t we have had no experience with this_ Close, p r o l o n g e d f o l l o w - u p is necessary in all patients with massive l a r y n g o t r a c h e a l t r a u m a . Significant stenosis m a y appear months after i n i t i a l injury. P e r s i s t e n t recurr e n t l a r y n g e a l nerve paralysis may r e q u i r e a r y t e n o i d o p e x y a n d cord lateralizations. ~s
REFERENCES 1. Downey WL, Owen RC, Ward PH: Traumatic laryngeal injury - - Its management and sequelae. South Med J 60:756-761, 1967. 2. Nahum AM, Siegel AW: Biodynamics of injury to the larynx in automobile collisions. A n n Otol Rhinol Laryngol 76:781-785, 1967. 3. Curtin JW, Holinger PH, Greeley PW: Blunt trauma to 'the larynx and upper trachea: immediate treatment, complications and late reconstructive procedures. J Trauma 6:493-502, 1966. 4_ Harris HH, Tobin HA: Acute injuries of the larynx and trachea in 49 patients. (Observations over a 15-year period.) Laryngoscope 80:1376-1384, 1970. 5. Pennington CL: External trauma of the larynx and trachea: immediate treatment and management. Ann Otol Rhinol Laryngol 81:546-554, 1972. 6. Sheely CH II, Mattox KL, Beall AC Jr: Management of acute cervical tracheal trauma A m J Surg 128:805-808, 1974. 7. Shumrick DA: Trauma of the larynX. Arch Otolaryngol 86:691-696, 1967. 8. Butler RM, Moser FH: The padded dash syndrome: b l u n t t r a u m a to the larynx and trachea. Laryngoscope 78:1172-1182, 1968.
November 1976 J ~ P
9. N a h u m AM: Immediate care of acute blunt l a r y n g e a l t r a u m a . J Trauma 9:112-125, 1969.
12. Alonso WA, P r a t t LL, Zollinger WK, et al: Complications of l a r y n g o t r a c h e a l disruption. Laryngoscope 84:1276-1290, 1974.
10. Travis LW, Olson NR, Melvin JW, et al: Static and dynamic impact t r a u m a of the h u m a n larynx. Trans Am Acad Ophthalmol Otolaryngol 80:382-390, 1975.
13. Harris HH, Ainsworth JZ: Immediate m a n a g e m e n t of laryngeal and tracheal injuries. Laryngoscope 75:1103-1115, 1965.
11. Alonso WA, Caruso VG, Roncace EA: ~inibikes: a new factor in laryngotracheal t r a u m a . Ann Otol Rhinol Laryn~ol 82:800-804, 1973.
14. Ogura JH, Powers WE: Functional r e s t i t u t i o n of t r a u m a t i c stenosis of the l a r y n x a n d p h a r y n x . Laryngoscope 74:1081-1110, 1964.
15. Boyles JH: Lacerations of the larynx.
Arch Otolaryngol 87:422-424, 1968. 16. LeMay SR: P e n e t r a t i n g wounds of the l a r y n x a n d cervical t r a c h e a . Arch Otolaryngol 94:558-565, 1971. 17. S h a i a FT, Cassady CL: L a r y n g e a l t r a u m a . Arch Otolaryngol 95:104-108, 1972. 18. Florman LD, Weiner I_J: Laryngotracheal trauma. J Ky Med Assoc 73:30-32, 1975.
Correction: Unfortunately, several errors appeared in "Nerve Blocks of the Foot," (JACEP, September, 1976, pp 689-702) by Locke and Locke. In the following, the italicized words were incorrect in the original. 1. On page 699, concerning the length of action of bupivacaine hydrochloride: "When pain is anticipated following instrumentation, debridement, or other emergency procedure, a longer acting anesthetic such as bupivacaine hydrochloride that can provide anesthesia up to seven hours 11 is desirable." 2. On page 702: "In one of the authors' (RKL) experience, while the hyperemia . . . . " 3. On page 702, the last sentence of the article: "One of the authors (RKL) though not using epinephrine in digital surgery has utilized this vasoconstrictor in nerve blocks (in strengths of 1:200,000 or 1:300,000) without any untoward effects in over 2,000 procedures (unpublished data). The article was inadvertently left out of the Table of Contents where it should have appeared under the category Emergency Methods and Techniques. On page 698, Raymond t~. Locke, DPM was mistakenly listed as being from Belmont, Massachusetts. Dr. Locke lives in Englewood, New Jersey.
~]~)
November 1976
Volume 5 Number 11 Page 887
