Laryngo-Tracheal Trauma (A Retrospective Study)

SATISH MEHTA, ASHOK VERMA, S. B.S. MANN Et Y. N. MEHRA

T h i r t y f i ve cases o f l a r yngo t rachea l t r a u m a in t h e age g roup o f 1 - -72 years are be ing repo r ted in t h i s s tudy . Un i la te ra l voca l cord palsy was no ted in 20 cases and lef t side was i n vo l ved more c o m m o n l y t h a n t he r igh t . The e x t e n t o f t he in ju r ies var ied f r o m s imp le haematoma in t h e v e n t r i c l e t o a c o m p l e t e l y sha t te red l a r y n x and avu ls ion o f t he t rachea. A l l neck w o u n d s w e r e exp lo red and debr ided under general anaesthesia. Surg ica l e x p l o r a t i o n o f l a r yngo t rachea l in ju r ies w a s d i r ec ted t o w a r d s an open reduct ion and s tab i l i za t i on in pos i t i on o f f u n c t i o n . C o m p l i c a t i o n s l ike la ryngea l stenosis and permanent t r a c h e o s t o m y can be best avo ided, i f managed at t he ear l iest .

Out of the thirty five cases, injury due to accident was seen in 19 cases, 15 patients had injury due to homicidal attempt, one patient had self inflicted (suicidal) injury. Three patients reported with the history of road traffic accident. Penetrating and blunt injuries were seen in 20 and 15 patients respec- tively.

The details of the nature and the type of injury are shown in Table I £t II respectively.

Table III reveals the age and sex distribution and duration of injury at the time of first presenta- tion.

S y m p t o m s Er S igns •

A detailed historyof each patient was taken and then subjected to general physical and systemic exa- mination. A thorough Ear, Nose

Throat check-up including exa- mination of neck was carried out. Where ever required fibreoptic exa-

Satish Mehta, Junior Resident AshokVerma, Senior Resident S. B. S. Mann, Associate Professor Y. N. Mehra, Professor ~ Head

Department of E.N.T., Post graduate Institute of Medical Education Et Research, Chandigarh.

mination of larynx was done. Bro- nchoscopy and oesophagoscopy were also performed. X-rays of chest and cervical spine were done in every case. Contrast study of oesophagus was done in suspec- ted cases of oesophageal per- foration.

Fig. 1. Shows the fragmented thyroid cartilage after laryngotracheal trauma marked as '1" and the stent in situ after exploring the wound via laryngo-fissure approach, marked as 'll'.

Hoarseness of voice was present in 20 patients (57%) and was noted to be the most common presenting symptom. 12 patients (34%) had diff iculty in breathing, which was progressive in 10 patients. Haemoptysis was present in 5 patients only. Five patients presented in the Outpatient Depart- ment with tracheostomy tube in situ. The vital signs were main- tained in all these patients and none had the signs of circulatory collapse.

The commonest presenting sign was surgical emphysema or cervi- cal crepitation. This was noted in 26 patients (74%).

Restricted vocal cord mobil i ty was seen in 21 patients (60%). Left vocal cord was more com- monly involved than the right.

Haematoma of larynx was seen in 7 patients (20%). Five patients had moderate degree of laryngeal oedema while laryngeal cartilages were ,lying .exposed in 3 'patients.

Fig. 2. Shows postoperative case of laryngotracheal trauma wth stent in situ marked as "a"

Table IV shows the distribution of symptoms ~ signs.

Table V reveals the f indings in the larynx and local examination of the neck.

S i te o f In ju ry : The upper tracheal injuries were

more common than the laryngeal

64 Indian Journal of Otolaryngology, Volume 39, No. 2, June, 1987

LARYNGO-TRACHEAL TRAUMA (A RETROSPECTIVE STUDY)--MEHTA et al

injuries. Amongst the laryngeal injuries, involvement of subglott ic region was not seen in any patient and the glottic and supraglottic region were involved in equal number of cases.

The details of the site of injury are shown in Table VI.

T r e a t m e n t : All the patients were managed as

emergency except the five patients who reported 3 months after the injury with tracheostomy tube al- ready in situ. Tracheostomy was required in 33 out of 35 cases and it was preferred to make a fresh tracheostome rather than putting the tube through fractured site. The indications of tracheostomy in our series were surgical em- physema, fracture of laryngeal car- tilage and air way obstruction.

Primary tracheal repair was done in 6 cases and in one of these cases a large segment of trachea was shattered, which was repaired by laryngeal drop and tracheal pul l-up technique.

Table VII depicts the treatment given to these patients.

The patients who required medi- cal trestment only had minimal pathology in the larynx like hae- meatoma/oedema of larynx.

Laryngo-fissure was performed in 5 patients and internal splints were used in these patients to stabilise the mucosal flaps and fractured fragments in place. Splints were kept for 6 weeks. Infection occurred in 3 of these patients in whom the stent had to be removed within 10 days.

Tracheo-oesophageal fistula was present in one case, and was repaired.

Laryngectomy was required in one case in whom the whole larynx was scarred serving no more the function of voice box.

Nasogastric feeding or intrave- nous alimentation was utilized for atleast the first 7 days to allow healing of any laceration of pharynx Oral feeding was a matter of surgi- cal judgement in each individual case. Antibiotics were used almost in every type of wound.

TABLE l

Nature of injury No. of cases % age

Accident 19 54.28

Homicidal 15 42.86

Suicidal 01 02.86

Total 35 1 00.00

TABLE II

Type of injury No. of cases % age

Penetrating 20 57

Blunt 15 43

Total 35 100

TABLE III

Total number of patients 35

Age group 01-72 years (Mean 36 years)

Sex : Ma~e 28 (80%) Female 07 (20%)

Time of reporting 24 hours 30 (85%)

03 months 05 (15%)

TABLE IV

Symptoms No. of patients % age

Hoarseness of voice 20 57

Respiratory obstruction 12 34

Pain neck 08 20

Haemoptysis 05 14

Aspiration 03 08

R e s u l t s •

In our series of the thirty five patients, thirty patients reported within 24 hours and 5 patients patients presented 3 months after the injury.

Out of 30, twenty six patients were decannulated successfully after the primary repair.

In nineteen patients the voice remained hoarse due to the in- volvement of the recurrent laryn- seal nerve.

One patient, in whom there was more than six cms loss of trachea, primary tracheal repair remained unsuccessful and patient had to bear permanent tracheal tube.

Three patients who had exten- sive injury to the larynx and trachea had aspirated blood before coming to the hospital and could not be saved inspite of best possi- ble treatment.

Five patients who reported 3 months after injury could not be

Indian Journal of Otolaryngology, Volume 39, No. 2, June, 1987 65

LARYNGO-TRACHEAL T R A U M A (A RETROSPECTIVE S T U D Y ) - - M E H T A et a l

decannulated inspite of the repeat- ed surgical interventions to treat the larynseal stenosis. These patients were given the valved tracheostomy tube for the speech purpose.

Amongst blunt trauma, garot- t ing injury was seen commonly al though skin of neck was not traumatised in these cases but laryngeal and tracheal injuries were very severe. Road traffic accidents were seen only in 3 patients which is the first causative group in western countries.

Table VIII depicts the complica- t ions and sequalae in these patients

TABLE V

Sign No. of patients % age

Surgical emphysema Restricted vocal cord mobility Haematoma of larynx Oedema of larynx Loss of laryngeal prominence Exposed cartilage

26 74 21 60 07 20 05 14 06 18 03 08

TABLE Vl

Site of injury No. of patients % age

Tracheal (isolated) 17 48.5 Glottic (isolated) 02 5.7 Supraglottic (isolated) 02 5.7 Subglottic (isolated) 00 0.0 Glottic ~ supraglottic 04 11.4 Glottic a Subglottic 04 11.4 Subglottic Et Tracheal 06 17.3

C o n c l u s i o n s :

. Laryngotracheal trauma in the present s tudy was noted to be four t imes more common in males as compared to females.

. Amongst the accident group, road traff ic accidents as a cause is seen only in 3 patients. This is in contrast to the reports of the Western Literature where it is mention- ed as the common cause of laryngo-tracheal trauma.

3 . Incidence of associated recur- rent laryngeal nerve injury is very high i.e. 60% (20 patients) and involvement of left R.L.N. is twice common than right.

. Prognosis in patients report- ing late is bad as seen in 5 patients in our series.

. Primary repair should be done as early as possible to achieve better results.

. Unfortunate cause of the death in isolated laryngotra- cheal trauma is aspiration of blood, as seen in 3 patients in our series.

TABLE VII

Treatment No. of patients % age

(A) Medical 2 5 (B) Surgical 33 96

(Surgical Procedures) (i) Tracheostomy (alone) 21 63 (ii) Tracheostomy Et primary

tracheal repair 6 18 (iii) Laryngofissure 5 16 (iv) Total iaryngectomy 1 3

TABLE VIIi

Complications Et Sequalae No. of Patients

Hoarseness of voice 19 Laryngeal stenosis 05 Permanent tracheostomy 06 Tracheo-oesophagal fistula 01 Aspiration ~ Death 03

References

1. Bryce, D. P. : The surgicalmanage- 5. ment of L.T. injury. Journaj of Laryngology ~ Otology, 86: 547-

587, 1972.

2. Chon, A. and Laeson, D.: Laryn- 6. geal injury Archive of Oto/aryn- go/ogy, 102 : 166-170, 1976.

3. Harris, H. H. and Ainsworth, J.Z.: Immediate management of lary- ngeal and tracheal injuries. Lary- ngoscope, 75 : 1103-1115, 1965.

7. 4. Harris, H. H.: Management of in-

juries to tthe larynx and traches. Laryngoscope: 82 : 1924-1929, 1972.

Maran, A. G. D. and Stell, P. M.: Acute laryngeal trauma. Lancet:2, 1107-1110, 1970.

Ogura, J.: Management of trauma- tic injuries of the larynx and trachea including stenosis. Journal of Laryngology [t Otology 85:1259-1261 1971.

Ogura, J. H. and Biller, H. F.: Reconstruction of the larynx follow- ing blunt trauma. Annals of Otolo[ty Rhinology [t Laryngology 80: 492 : 506, 1971.

66 Indian Journal of Otolaryngology, Volume 39, No. 2, June, 1987