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• W4241634905 abstract "Section Editor: Peter M. Suter. Laryngotracheal trauma is a significant threat to life but is rarely encountered in clinical practice. Management of the deteriorating airway in such cases is controversial and ideally requires joint assessment by the anesthetist and surgeon. We report a case of blunt laryngotracheal trauma in which a 22-yr-old man survived bilateral disruption of the vocal cords and a 270[degree sign] tear in the cricothyroid membrane. Case Report A 22-yr-old man was admitted to a district general hospital with a history of blunt trauma to the anterior aspect of the neck. On arrival, he was alert and oriented but presented with hemoptysis, aphonia, and severe stridor. Physical examination revealed a small abrasion at the site of injury associated with tenderness and subcutaneous emphysema. Analysis of arterial blood gases was normal. Radiographs of the patient's chest and cervical spine revealed no bony injuries, and he was taken to the operating room (OR) to establish a secure airway. After an inhaled induction of anesthesia, his trachea was intubated with a size 7.0 cuffed endotracheal tube, and the patient was transferred to a tertiary referral center. The patient was sedated with IV infusions of morphine and midazolam, despite which he self-extubated his trachea and immediately developed airway obstruction and cyanosis. After the administration of midazolam and succinylcholine, direct laryngoscopy was performed, which revealed severe laryngeal edema. The patient's trachea was reintubated with the aid of a gum elastic bougie. Computed tomography (CT) of the larynx confirmed the presence of marked edema of the epiglottis, glottis, and subglottic area, as well as a fracture of the posterior third of the thyroid lamina. Two days after admission, the patient was taken to the OR. Anesthesia was induced by inhalation of sevoflurane, and laryngoscopy revealed disruption of the vocal cords and arytenoids. The esophagus was intact. A formal tracheostomy was performed via a low collar incision, and a full exploration of the larynx revealed the following: 1) the anterior commissure was disrupted and the vocal cords were retracted into the paramedian position; 2) there was disruption of the arytenoids and the mucosa of the posterior commissure; 3) there was a large defect in the thyroid lamina with an open perforation into the larynx; and 4) there was a tear in the anterior two thirds of the cricothyroid membrane, causing partial cricothyroid separation. Surgical repair consisted of reapposition of the mucosal edges, reconstruction of the vocal cords, and insertion of a vocal cord stent. The patient made a good postoperative recovery. He required laser surgery for the removal of granulation tissue on two occasions, and another procedure is planned. He complains of breathlessness on strenuous exertion, and his voice is hoarse but continues to improve, and his airway has been graded as satisfactory. Discussion The estimated incidence of laryngotracheal trauma is 1:15,000 to 1: 43,000 visits to emergency rooms [1,2]. Such injuries are potentially lethal, with a mortality rate of approximately 20% [3]. Blunt laryngotracheal trauma typically occurs in a motor vehicle accident in which the head is extended and the larynx is exposed to a direct impact. Other mechanisms of injury include the classic clothesline injury involving motorcycling, contact sports such as karate, and victims of assault or strangulation. Associated injuries are common and may include closed head injuries, chest trauma, and damage to the cervical spine, esophagus, major vessels in the neck, and recurrent laryngeal nerves. Analysis of the presenting features in case series published since 1990 involving a total of 133 patients with blunt and penetrating laryngeal trauma reveals that hoarseness was the most common symptom, seen in 54% of cases [3-7]. This was followed by tenderness (53%), surgical emphysema (43%), respiratory distress (38%), dysphagia (32%), and hemoptysis (26%). Only one published series reported the correlation between any sign or symptom suggestive of laryngeal trauma and the actual severity of injury [7]. In this series of 30 patients, the authors found a significant correlation between the symptoms of hemoptysis and stridor and the severity of the injury. Other authors stress the significance of airway compromise (dyspnea, stridor, and, in particular, inability to tolerate the supine position) [2-5]. Symptoms of voice change (including dysphonia and aphonia) and surgical emphysema are other hallmarks that should alert the anesthetist to the possibility of major injury with the attendant risk of acute deterioration or loss of the airway. There may also be a surprising lack of clinical signs, which places the onus on the physician to exercise a high index of suspicion when assessing patients with an appropriate history [3,8]. Investigation of a patient with suspected laryngeal injury and a stable airway should always include radiographs of the chest and cervical spine. In addition to cervical vertebral injuries, important findings suggestive of a breach of the airway include an abnormal tracheal outline, pneumothorax, pneumomediastinum, or cervical emphysema. When possible, fiberoptic nasopharyngoscopy should be performed. This provides information about airway patency, endolaryngeal hematomas, and mucosal lacerations without endangering the cervical spine. CT examination of the neck may be used selectively in cases in which the result will determine further management [1,2,5] or, perhaps, even in cases of severe trauma that obviously require surgery [9]. Surgical intervention may be deferred for 48 h to reduce edema but should not be delayed >1 wk to minimize the formation of scar tissue. Airway stability and endoscopic findings are important determinants of the anesthetic management of these patients. When the airway is stable and the larynx is essentially normal on fiberoptic examination, orotracheal intubation under general anesthesia is a reasonable choice. Controversy arises when the airway is unstable or, alternatively, when it is stable but the laryngeal mucosa is disrupted and/or a laryngoskeletal fracture is evident on CT scan. Under these circumstances, intubation by direct laryngoscopy may be difficult and may increase the danger to the patient. Difficulties arise because of the presence of soft-tissue edema, lacerations, hemorrhage, laryngoskeletal fractures, and cricotracheal disruption. Complications include further trauma to the larynx, the creation of a false passage, and the possibility of complete occlusion of an already tenuous airway due to an unrecognized tracheal transection [3,4,11]. If time permits and the patient is able to cooperate, the use of fiberoptic intubation under sedation and local anesthesia [4,8] or, alternatively, tracheostomy under local anesthesia [2,5,6,8,11,12] are options that minimize the risks. However, if the patient is confused and uncooperative, a general anesthetic may be necessary, inhaled induction being preferred despite the potential for gastric regurgitation. With the advent of newer volatile anesthetics with a rapid onset of action, this should be possible in almost all cases. In the event of complete airway obstruction, rapid-sequence induction of anesthesia is the best option. It is interesting to note that our patient was successfully tracheally intubated on two occasions. We consider, however, that the management of this case (from the time of arrival at our institution) could have been improved by the use of a different drug for sedation in the intensive care unit to avoid the hazards of reintubation. A recent review of propofol suggests that it may be an appropriate choice in this setting [13]. Finally, our recommendations for the approach to securing the airway in these cases are summarized as follows. - When the airway is stable and the larynx is essentially normal at endoscopy, orotracheal intubation under general anesthesia is a reasonable choice. - When the airway is unstable, the laryngeal mucosa is disrupted, or there is a laryngoskeletal fracture on CT scan, awake fiberoptic intubation or awake tracheostomy are options that minimize the risk of airway obstruction. - Inhaled induction of anesthesia followed by orotracheal intubation may be necessary when the patient is confused or uncooperative. - Rapid-sequence induction of anesthesia is indicated in cases of complete airway obstruction. We emphasize that, in all cases except the gravest emergencies, patients should be taken to the OR and an otorhinolaryngologic surgeon should be present and fully prepared before any effort to secure the airway is attempted." @default.
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• W4241634905 title "Anesthetic Implications of Laryngeal Trauma" @default.
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