Laryngeal Trauma, Tracheostomy Flashcards
What is the key to avoiding vocal fold scarring when performing vocal fold surgery? List 3 ways
- Avoid operating on opposing sides simultaneously
- Avoid injury to the anterior commissure
- Limit dissection to mucosa and SLP to avoid damage to the vocal ligament and vocalis
Describe the Classification system of Laryngeal Trauma
Schaefer-Fuhrman Classification
- Type 1
- Minor endolaryngeal hematoma
- No edema, no mucosal laceration, no detectable fracture - Type 2
- Edema or hematoma WITH minor mucosal tear
- No exposed cartiilage
- Non-displaced fractures noted on CT scan
- Varying degrees of airway compromise - Type 3
- Massive edema, large mucosal lacerations, exposed cartiliage
- Displaced fractures noted on imaging
- Vocal fold immobility - Type 4
- Same as group 3, except more severe with:
- Severe mucosal disruption
- Disruption of anterior commissure
- Unstable fracture, 2 or more fracture lines - Type 5
- Complete laryngotracheal classification
Key differentiating features:
- Hematoma only with no mucosal laceration and no fracture is Group 1
- (1) Minor mucosal tear (without exposed cartilage) or (2) non-displaced fracture upgrades to Group 2
- (1) Exposed cartilage or (2) Displaced fracture or (3) Vocal fold iimmobility upgrades to Group 3
- (1) Severe mucosal disruption or (2) Unstable fracture or 2+ fracture lines, or (3) Anterior commissure involvement upgrades to Group 4
- Complete laryngotracheal separation = Group 5
Mnemonic for Group 3 features: VCD
- Vocal fold immobility
- Cartilage exposure
- Displaced cartilage
Mnemonic for Group 4 features: USA
- Unstable fracture
- Severe mucosal disruption
- Anterior commissural involvement
What classes of laryngeal injury require tracheostomy? What is the general management for laryngeal injuries based on Classification type, based on the AAO Resident manual for Trauma?
Type 3 and above generally require tracheostomy
AAO Resident Manual:
1. Type 1:
- FNL only, no operative intervention required
- Medical management required only (steroids, antibiotics, reflux therapy, humidification, voice rest)
2. Type 2:
- Direct laryngoscopy and esophagoscopy should be performed (as injuries may be more severe than expected after FNL)
- Serial examiination should be done
- Occasionally MAY require tracheostomy
- Medical adjuncts helpful (steroids, reflux medications, humidification, voice rest, antibiotics)
3. Type 3:
- Tracheostomy often required
- Exploration and surgical repair generally required
4. Type 4:
- Tracheostomy always required
- Surgical repair will require stent placement to maintain laryngeal integrity
5. Type 5:
- Tracheostomy always required (but more complex due to separation)
- Complex laryngotracheal repair required
What are symptoms and signs of laryngeal trauma? What are the most common?
Symptoms:
1. Dysphonia (80%)
2. Dysphagia (50%)
3. Pain (40%)
4. Dyspnea
5. Hemoptysis
6. Airway obstruction
Signs:
External Exam:
1. External neck injury
2. Hematoma
3. Distorted anatomy
4. Crepitus
5. Pain to palpation
Internal Exam:
1. Mucosal swelling, edema, laceration
2. Hematoma
3. Cartilage exposure
4. Vocal cord/arytenoid asymmetry/dysfunction
Describe the initial management of a suspected laryngeal fracture in detail.
ABCDE = Airway, Breathing, Circulation, Disability, Exposure (follow trauma protocol)
Airway: Stable or unstable?
- Impending airway obstruction = Tracheostomy, then CT
- Airway stable = FNL first
FNL Findings: Normal or Abnormal?
- FNL Normal: Medical management, serial examination
- FNL Abnormal: CT scan
CT Findings:
- Airway encroached: Tracheostomy/Surgery
- No airway encroachment (Type 1-2): Medical management and serial examination
Surgical Management:
- Direct laryngoscopy and esophagoscopy
- Tracheostomy if unstable airway, Schaefer 3 or above
- Schaefer Group 3 - ORIF, thyrotomy OR endoscopic repair
- Schaefer Group 4 - ORIF, thyrotomy, repair with endolaryngeal stent
- Schaefer Group 5 - Debridement and primary anastomosis
Kevan Page 37
Discuss conservative management strategies for laryngeal trauma. 10 things
- Admit for observation (minimal 24 hours)
- Serial endoscopic examination (e.g. daily)
- Steroids
- Antibiotics (especially if mucosal tear)
- PPI therapy
- Humidificatiion
- Voice rest
- Heliox at bedside
- Elevate HOB
- Racemic epinephrine PRN
List 7 indications for surgical management of laryngeal trauma
Schaefer III (VCD)
1. Vocal fold immobility
2. Cartilage exposure
3. Displaced fracture
Schaefer IV
1. Unstable fracture
2. Severe mucosal disruption
3. Anterior commissural involvement
Schaefer V
1. Complete laryngotracheal separation
What are 3 indications for stenting in laryngeal trauma? How long do you leave stent in places?
Stenting indicated in Schaefer Group IV injuries (USA):
U: unstable fracture/2+ fracture lines
S: Severe mucosal disruption
A: Anterior commissural involvement
Stents are usually left in place for 2 weeks and removed in the operating room via an endoscopic procedure
List 6 complications of laryngeal trauma
- Vocal fold immobility (paralysis or fixation)
- Laryngeal stenosis
- Anterior glottic web
- Dysphonia
- Dysphagia
- Aspiration
What are the indications for tracheostomy?
- Prolonged mechanical ventilation
- More than ~7 days in an adult
- More than 3 weeks in an infant/chiild
- Respiratory disease
- Neuromuscular disease
- Depressed mental status/inability to protect airway - Pulmonary toilet
- Protection from aspiration (inability to handle secretions)
- Assist with tracheal-bronchial suctioning (toileting) - Surgical access
- Head/neck ablative and reconstructive surgery (e.g. prophylaxis)
- Extensive maxillofacial fractures - Airway obstruction - either acute or chronic
- Epiglottis
- Head and neck tumor
- Bilateral vocal fold paralysis
- Neck or Laryngeal trauma (Schaefer 3-5)
- Cranial facial abnormalities
- Foreign body
- Bleeding
- Angioedema
What are 3 contraindications to a tracheostomy?
- Skin infection
- Tracheal tumor at the location of the incision
- Unrepaired tracheal trauma
What are 12 absolute contraindications to a percutaneous tracheostomy?
- Emergency airway
- Infection over tracheostomy site
- Unable to palpate landmarks
- Laryngeal mass/malignancy
- Midline neck mass
- Unsecured airway (ie. patient not already intubated)
- Unstable C-spine fracture
- Pediatric patient
- High riding innominate
- Unstable patient
- Obese patient/large neck
- Coagulopathy; Ideally platelet > 50, INR < 1.5 (contraindication if reverse)
- PEEP >15-20 cm H2O (greater risk of SC emphysema or pneumothorax)
List 23 complications of tracheostomy. Categorize them into intraoperative, early post-operative, and late.
Intra-operative:
1. Bleeding or Great vessel injury
2. Airway fire
3. Unable to cannulate airway or False passage
4. Esophageal injury (tracheoesophageal fistula)
5. Post-obstructive pulmonary edema
6. Pneumothorax
7. Pneumomediastinum
8. Thymus injury (in children)
9. Death
Early:
1. Inadvertent decannulation or tube displacement
2. Mucous plug / tube obstruction
3. Post-operative hemorrhage
4. Wound infection
5. Subcutaneous emphysema
6. Pulmonary edema (post-obstructive)
Late:
1. Granulation tissue
2. Tracheoinnominate fistula
3. Tracheal stenosis
4. Subglottic stenosis
5. Tracheomalacia
6. Depressed scar
7. Tracheocutaneous fistula
8. Tracheoesophageal fistula
What are 8 factors that increase the risk of a tracheo-innominate fistula?
What is the mortality of a TIF?
- High riding innominate artery
- Prolonged tracheostomy
- Low tracheostomy positioning
- High cuff pressures
- Stoma Infection
- Chronic irritation
- Excessively long or curved tube
- Movement of the tube
Mortality 75%
Regarding post-obstructive pulmonary edema post-tracheostomy, discuss:
1. What are the clinical signs? 4
2. What is the management? 3
SIGNS:
1. Pink frothy secretions
2. Hypoxemia
3. Bilateral end expiratory wheezing with rales
4. Radiographic findings (increased pulmonary markings and fluid overload)
TREATMENT:
1. Fluid restriction
2. Diuretics - lasix
3. Positive pressure ventilation (push fluid out) - Intubation or CPAP
