Pathology of laryngeal trauma (laryngeal injury)
Management of laryngeal trauma (laryngeal injury) is complex, prolonged, and prone to recurrence. Especially difficult when accompanied by tracheal trauma.
Larynx anatomy and physiology - Diagnosisbook supporting video
Laryngeal trauma (laryngeal injury) is common in ear, nose, throat, head, and neck injuries. Some features should be noted in diagnosis and management to avoid functional sequelae that affect much life and living.
Laryngeal injuries are classified by:
- Injuries outside the larynx due to causes such as falling, hitting, cutting... hurt the larynx from outside.
- Injuries in the larynx are mainly caused by endotracheal intubation, laryngoscopy, treatment of tumors, and damage in the larynx.
Laryngeal trauma (laryngeal injury)
Injury outside the larynx
It is possible to have a mere injury to the larynx. But it is also often to have an injury to the adjacent parts such as the trachea, lower throat, general trauma to the neck, facial jaw...
Injury outside the larynx includes:
An open injury occurs when the injury travels from the outside (skin, muscle, cartilage) into the larynx.
Closed injury when the lesion of the larynx is not exposed.
The open injury is usually caused by hard objects such as cutting, stabbing with a knife, scissors, sharp hard objects, by fire like bullets ...
The closed injury is often caused by soft objects such as choking, strangling, or imprisonment objects such as walking sticks, stabbing, falling into hard objects, imprisonment...
The open injury is often easier because the symptoms are obvious, present immediately. Sometimes it can be ignored due to the emergency condition of the victim such as fainting, traumatic shock combined with other important parts. And it is more prominent such as traumatic brain injury, rupture, fracture of the jaw...
Neck wound is not always properly diagnosed, it is easy to except for neck wound caused by cutting. Lateral neck injuries caused by knives and bullets are difficult to determine if there are laryngeal injuries due to the neck position when injured. On the other hand, due to the loose organization of the neck, it is easy to change direction and quickly swell.
Pronunciation: hoarse, lethargic, unable to speak, or difficulty speaking.
Respiratory disorders: coughing and difficulty breathing, sometimes breathing heavily or choking, breathing out with blood bubbles.
Subcutaneous pneumothorax can spread throughout the ribs, into the mediastinum.
There are also signs of gas or blood-stained with blood, which follows the exhalation, coughing, or trying to speak. Most attention should be paid in case of cut or puncture.
Neck examination is only valid if done in the first hours after injury. If late, the neck area will be swollen, the swelling is difficult to determine.
The closed injuries are often confirmed the diagnosis more difficult, symptoms may appear slowly.
Difficulty breathing: especially laryngeal dyspnea, in closed laryngeal trauma, dyspnea can come late after a few hours to many hours.
Hoarseness: This is an important suggestive sign, but may not be seen if the lesion is only localized above or below the glottis.
Swallowing pain: is also a valuable sign due to crushing, misalignment of the pharyngeal and funnel cartilage, but also when the lesion is only in the lower throat.
Cough: changeable cough, sputum with blood should be noted, may appear late.
Laryngoscopy: valuable for diagnosis especially in cases of unclear symptoms, closed trauma.
Laryngoscopy aims to identify:
Morphology and anatomy of the laryngeal organs.
Laryngeal activity: paralysis, restriction, or abnormal movement.
X-ray: Leaning posture, straight neck, tomography can help determine the damage, but because the neck area is often swollen and swollen a lot, it does not give accurate pictures.
Complications and sequelae
Asphyxiation: Due to many causes special attention should be paid
- Increased bleeding into the trachea and stagnation of sputum secretions.
- Foreign objects obstructing the airways.
- Shock requires emergency tracheostomy.
Bleeding: Due to trauma to the vessel and a change in the position of the neck, it causes a blood clot in the traumatic vessel. Therefore, it is necessary to stop bleeding immediately.
The neck is loose, inflamed quite quickly, especially when there is airflow under the skin, causing inflammation, spreading necrosis in the neck, face, chest.
Inflammation can spread down causing mediastinal inflammation. It is often accompanied by trauma to the lower throat, larynx.
Speaking: disorders of speech, voice changes are quite common after trauma to the vocal cords, funnel cartilage, inverted nerve, may appear late, difficult to recover.
Breathing: dyspnea, depending on the damage status, location, morphology of the scar tissue.
Difficulty breathing is most difficult to breathe in, threatening respiratory failure, must open the trachea before other surgery, pay attention to open the wound lower, suck fluid, give oxygen.
Anti-shock and bleeding treatment prevent blood from flowing into the lungs.
After the emergency
Antibiotic at high dose, broad-spectrum, long term.
SAT injection (against tetanus).
Surgery: do not sew the wound tightly, drain with a rubber bar, withdraw after 48 hours.
For pain relievers, sedatives.
Systemic corticosteroids and topical nebulizers.
Feeding through the stomach for 8-10 days.
Closed laryngeal injury
In addition to the rare chemical cause of laryngeal burns, a trauma in the larynx is mainly caused by physicians. With the expansion of the indication for endotracheal intubation, trauma to the larynx is also increasing.
Endotracheal intubation is the main cause. In addition to anesthesia endotracheal intubation, special attention should be paid to emergency endotracheal intubation, resuscitation due to urgent requirements, so that the tube is prolonged, so the rate of injury in the larynx is quite large.
Vocal cord function surgery such as removing polyps, fibroids, fibrous particles ... if not careful, they can cause injury in the larynx.
Potential: re-inquiring, identifying laryngeal interventions is very necessary because symptoms often appear late, considered a sequel to trauma.
Depending on the severity and location of the injury that we can encounter:
Pronunciation changes: from mild, causing hoarseness, lasting to severe, causing loss of sound, difficult to pronounce and speak.
Shortness of breath: may be mild, shortness of breath at times, when exertion, also severe, frequent, pronounced shortness of breath requires open trachea.
Laryngoscopy to determine lesions: If conditions permit, hysteroscopy or laryngoscopy should be performed for a more complete assessment. Common lesions:
Laryngeal narrowing: can be a fibrous membrane or scarring causing narrowing more or less of the glottis, above or below the glottis.
Ring-funnel joint stiffness: see that the funnel cartilage is limited or fixed, has an abnormal position.
Laryngeal paralysis: complete or limited, unilateral or both.
Management of laryngeal trauma is complex, prolonged, and prone to recurrence. Especially difficult when accompanied by tracheal trauma.
Performed through the removal of membranes, fibrosis-scarring, orthodontic larynx, catheter placement.
Atopic and local treatment with corticosteroids, anti-scarring.
The larynx is a very sensitive and vulnerable organ.
When intubation must clearly see the larynx, insert the tube through the glottis gently.
Choose a catheter that matches the size of the larynx.
Endotracheal intubation is only a means of emergency, need aggressive treatment of the cause to be able to withdraw the tube early.