PAEDIATRIC
LARYNGOTRACHEAL
TRAUMA
DR ANURAG SRIVASTAVA
CONSULTANT ENT
INDORE
THE UNIQUENESS …..
• Paediatric blunt laryngeal trauma is
infrequently encountered
• However, it can have fatal consequences if
managed inappropriately.
Unique situation : High index – Low threshold
situation
• Due to behavioural factors as well as anatomic differences
between these two groups.
• patients - very little signs and symptoms on initial presentation
as well as the significant risk of concomitant injury
• high index of suspicion and a low threshold for investigation and
intervention are required
THE 2 ADVANTAGES !
• BEHAVIOURAL
• ANATOMICAL
• superior position of the paediatric larynx in the cervical
region
• short neck allows the mandibular arch to shield the larynx
to some extent
• greater pliability of cartilage decreases the likelihood of
fractures, which in turn decreases the severity of injury
THE DISADVANTAGES
• narrow lumen of the paediatric airway
• increased risk of substantial oedema and haematoma
formation due to the loose adherence of the submucosal
tissue
CLINICAL FEATURES
• Respiratory distress.
• Hoarseness of voice or aphonia.
• Painful swallowing.
• Aspiration of food.
• Local pain in the larynx
• Marked on speaking
• Swallowing.
• Haemoptysis
• Tears in laryngeal or tracheal mucosa.
EXTERNAL SIGNS
• Bruises or abrasions over the skin.
• Tenderness
• Subcutaneous emphysema due to mucosal tears
• Flattening of thyroid prominence
• Loss of contour of anterior cervical region.
• Fracture displacements of thyroid or cricoid
• Fracture of hyoid bone.
• Gap may be felt between the fractured fragments.
• Bony crepitus
• Separation of cricoid cartilage from larynx or trachea.
INITIAL MANAGEMENT !
• Depends on the stability of the patient's airway-
• Endothracheal tube (ETT) placement Vs Tracheotomy
• ETT - exacerbate mucosal lacerations,
Further disrupt already displaced structures
laryngotracheal separation
creation of a false passage.
• Use of a rigid bronchoscope to secure the airway under
direct visualization
• Once the airway is secured, a surgical tracheotomy can then
be performed over the bronchoscope
INITIAL EVALUATION Tracheotomy versus intubation
• Air way endanger: frank
stridor, significant subcutaneous
emphysema, exposed
cartilage
Intubation hazardous
• Further tear or cricotracheal
separation
• Respiratory distress:
tracheotomy
Avoid cricothyroidotomy
If no acute breathing difficulty
• Detailed history and careful
physical examination
IMAGING ROLE ….
• Cervical spine X-rays, lateral soft tissue neck films
oesophagogram with water-soluble contrast
• chest X-ray : whether subcutaneous emphysema or a
pneumomediastinum
• Computed tomography (CT) provides the most valuable
information regarding cartilage fractures
TYPES
• Chemical
• Thermal
• Physical
AETIOLOGY
• Automobile accidents
• Blow or kick on the neck.
• Striking against a stretched wire or cable.
• Strangulation.
• Penetrating injuries with
• Sharp instruments
• gunshot wounds
PATHOLOGY – BIOMECHANICS
• Haematoma and oedema of
• Supraglottic or subglottic region.
• Tears in laryngeal or pharyngeal mucosa leading
subcutaneous emphysema.
• Dislocation of cricoarytenoid joints
• Arytenoid
• Cartilage may be displaced anteriorly
• Dislocated
• Avulsed
• Dislocation of cricothyroid joint
• Recurrent laryngeal nerve paralysis
• traverses just behind this joint.
• Fractures of the hyoid bone
PATHOLOGY
• Fractures of thyroid cartilage.
• Vertical
• Transverse.
• Fracture of upper part of thyroid cartilage
• May result in avulsion of epiglottis
• One or both false cords.
• Fractures of lower part of thyroid
• Displace or disrupt the true vocal cords.
• Fractures of cricoid cartilage.
• Fractures of upper tracheal rings.
• Trachea may separate from the cricoid cartilage
• Retract into upper mediastinum
• Injury to recurrent laryngeal
DIAGNOSTIC EVALUATION
• Direct laryngoscopy
• BRONCHOSCOPIC
• FOL
• X-ray Soft tissue
• CT scan
ASSOCIATED INJURIES
• Examine for other injuries like
• Injury to head
• Cervical spine
• Chest
• Abdomen and extremities.
• X-ray chest for pneumothorax
• Gastrograffin swallow for oesophageal tears
MANAGEMENT OF LARYNGEAL INJURIES
• Unstable patients : investigation + treatment
• Stable patients : investigation followed by treatment.
Investigations:
1. Penetrating injuries:
2. Zone 1 and Zone 3 : angiography
3. Zone 2 : endoscopy + radiological examination
4. Blunt injuries:
radiology: X – ray soft tissue neck :
CT- scan :negative gastrograffin swallow
Flexible endoscopy :
Principle of treatment : early identification and prompt treatment
prevention is better than cure multidisciplinary approach
TREATMENT OF PENETRATING INJURIES
• Zone 1 and 3: multidisciplinary approach
Emergency exploration in stridor, bleeding and expanding hematoma
Zone 1 vascular injury : sternotomy
Zone 3 vascular injury : Fogarty catheter and stent placement
• Zone 2: selective Vs mandatory exploration controversial -
evacuation & drainage from potential space via laryngofissure
• C.C.A and I.C injury : end to end anastomosis
• Oesophageal repair: 2 layer repair followed by muscle coverage
TREATMENT
Laryngeal
CONTD. keel
• Cricoid injury: primary
closure cover with
perichondrium internal laryngeal splint
Aboulker
• Tracheal injury: stents
laceration <1/3 : primary closure
debridement interrupted sutures
extraluminal
Montgome
Supportive treatment: ry T-tube
oxygen, steam steroid
antibiotics
Swiss
Laryngeal stent: Duration < 3 months To silastic roll
support laryngeal frame work To
separate mucosal laceration Types
PATHOPHYSIOLOGY OF LARYNGEAL STENOSIS
• Preventable than curable condition.
• Soft tissue : mucosal loss, adhesion, fibrosis, organized hematoma
• Skeletal : Perichondritis and loss of cartilage
• Glottic incompetence : web
RLN paralysis
arthodesis of arytenoid
• Tissue memory :
• cartilage disturbed – heal by fibrosis – has directional memory most
important in cricoidlapse of 18 month for reconstructive surgery
use of stent and skin graft
CLASSIFICATION – SEVERITY
• Laryngotracheal injuries are classified into 5 distinct
groups based on the severity of the injury
COMPLICATIONS
• Subcutaneous Emphysema
• Laryngeal stenosis,
• Supraglottic
• Glottic
• Subglottic.
• Perichondritis
• Laryngeal abscess.
• Vocal cord paralysis.
FEW
CONTROVERSIES:
• 40% better chance of good voice
• 3 times less chance of permanent tracheotomy
• No tracheotomy : no surgery
• Persistent restenosis: acceptance of problem
SUBCUTANEOUS EMPHYSEMA
• May be a benign symptom or an indication of a deeper, more concerning
pathologic disease state.
May indicate that air is occupying another deeper area within the body
not visible to the unaided eye. !
Etiology : surgical, Traumatic, infectious, Injury - thoracic cavity, sinus
cavities, facial bones, barotrauma, bowel perforation, or pulmonary bleb.
Iatrogenic causes - malfunction or disruption of the ventilator circuit,
inappropriate closure of the pop-off valve
Injury to the esophagus during gastric tube placement
via cervical soft tissues during tracheotomy
SUBCUTANEOUS EMPHYSEMA
• Pathophysiology
• Injury to the parietal pleura pleural and subcutaneous tissues
• Air from the alveolus endovascular sheath and lung hilum
endothoracic fascia
• The air in the mediastinum cervical viscera connected tissue planes
• Air originating from external sources
• Imaging – X Ray / CT SCAN
• GINKO LEAF Appearance
D/d
subcutaneous emphysema has been mistaken for
allergic reactions and angioedema
TAKE AWAY POINTS
• High index of suspicion is required in order to manage these
cases successfully.
• Patients with an unstable airway require definitive
management either via
endotracheal intubation or tracheotomy.
• Increased use of endoscopic techniques if feasible
avoid morbidity and potential complications
associated with open exploration
THANK YOU !
