Injuries (trauma) to the larynx and trachea - Treatment

The probability of persistent structural changes and functional disorders in case of neck trauma is reduced with correct and timely assistance. Treatment methods used for larynx and trachea trauma depend on the timing, nature of the injury and the traumatic agent, the extent of damage to the organs and soft tissues of the neck, and the severity of the patient's condition.

Treatment tactics for open and closed injuries of the larynx and trachea are different. Open wounds and extensive injuries of the larynx with the development of an internal hematoma are the most dangerous in terms of the development of respiratory disorders and in most cases require surgical treatment.

Goals of treatment for injuries to the larynx and trachea

All treatment measures are carried out with the aim of restoring the anatomical integrity and functions of damaged organs.

Indications for hospitalization

All patients with laryngeal and tracheal trauma should be admitted to an ear, nose, throat or intensive care unit for detailed examination and follow-up.

Non-drug treatment

First of all, it is necessary to create rest for the injured organ by immobilizing the neck, prescribing fasting, bed rest (position with the head end elevated) and vocal rest. It is necessary to provide a supply of humidified oxygen and intensive observation for 48 hours. First aid for respiratory failure includes mask ventilation, installation of an intravenous catheter on the side opposite the injury. Almost all patients require the introduction of a nasogastric tube, the exception being isolated injuries of the larynx and trachea of mild course. In case of mismatch of defects of the esophagus and trachea and their small size with penetrating injury, conservative treatment is possible against the background of the use of a nasogastric tube. The latter serves as a prosthesis isolating two injured openings. Intubation, if necessary, is carried out with the participation of an endoscopist.

Medicinal cookies

Conservative treatment includes antibacterial, decongestant, analgesic, anti-inflammatory and oxygen therapy: all patients are prescribed antacids and inhalations. Concomitant pathology is corrected. If the patient's condition is severe upon admission, general somatic diseases are treated first, if possible postponing surgical intervention for several hours.

Treatment of chemical burns depends on the degree of damage. In the first degree of severity, the patient is observed for two weeks, anti-inflammatory and antireflux therapy is administered. In the second degree, glucocorticoids, broad-spectrum antibiotics, antireflux treatment are prescribed for approximately 2 weeks. Depending on the condition of the esophagus, a decision is made on the advisability of introducing a nasogastric tube. In case of circular damage to soft tissues, the patient should be observed for 4-5 months or a year. In the third degree of burns, glucocorticoids should not be used due to the high risk of perforation. Broad-spectrum antibiotics, antireflux therapy are prescribed, a nasogastric tube is inserted, and the patient is then observed for a year.

Inhalation therapy with glucocorticoids, antibiotics, and alkalis for an average of 10 minutes three times a day gives a good clinical effect in patients with injuries to the hollow organs of the neck. Alkaline inhalations can be prescribed several times a day to moisturize the mucous membrane.

Hemorrhages and hematomas of the larynx are more often lysed on their own. Physiotherapy and treatment aimed at resorption of blood clots along with anti-inflammatory therapy provide a good clinical effect.

Patients with laryngeal contusions and injuries that are not accompanied by cartilage fractures or with such fractures without signs of displacement are given conservative treatment (anti-inflammatory, antibacterial, detoxifying, general strengthening and physiotherapy, hyperbaric oxygenation).

Surgical treatment

Indications for surgical treatment:

• changes in the laryngeal skeleton;
• displaced cartilage fractures;
• laryngeal paralysis with stenosis:
• severe or increasing emphysema;
• stenosis of the larynx and trachea;
• bleeding;
• extensive damage to the larynx and trachea.

The results of surgical treatment depend on the time that has passed since the injury. Timely or delayed intervention for 2-3 days allows to restore the structural framework of the larynx and fully rehabilitate the patient. Physiological prosthetics is a mandatory component of the treatment of a patient with a laryngeal injury.

In case of injury by a foreign body, its removal is necessary first. In case of significant secondary changes that make it difficult to find, anti-inflammatory and antibacterial therapy is administered for two days. Foreign bodies are removed, if possible, using endoscopic techniques or laryngeal forceps during indirect microlaryngoscopy under local anesthesia. In other situations, removal is performed using laryngoflexure, especially in the case of embedded foreign bodies.

Laryngeal granuloma is removed after preliminary treatment, including antireflux, anti-inflammatory local therapy, phononedito to exclude tense phonation. The operation is performed when the base of the granuloma is reduced and perifocal inflammation is reduced. The exception is large granulomas that cause stenosis of the lumen.

In some cases, when a vocal fold hematoma has formed, microsurgical intervention is used. During direct microlaryngoscopy, an incision is made in the mucous membrane above the hematoma, and it is removed with an evacuator, as is the varicose node of the vocal fold.

To ensure breathing in case of upper respiratory tract obstruction and impossibility of intubation, tracheostomy or conicotomy is performed. Tracheostomy is preferred, since conicotomy may be ineffective if the level of damage is not specified. Closed laryngeal injuries accompanied by airway obstruction due to edema or growing hematoma require immediate tracheostomy. When the hematoma resolves, the tracheotomy cannula is removed, and the stoma subsequently closes on its own. In case of internal bleeding, growing subcutaneous, intermuscular or mediastinal emphysema, the closed wound must be converted into an open one, exposing the site of organ rupture, performing a tracheotomy, if possible, 1.5-2 cm below it, and then suturing the defect layer by layer with reposition of cartilage, sparing the surrounding tissues as much as possible.

In case of injuries, primary wound treatment and layer-by-layer suturing is performed. Tracheostomy is performed as indicated. In case of damage to the oropharynx and esophagus, a nasogastric tube is installed. Incised wounds are tightly sutured with the introduction of small drains for the first 1-2 days. In case of stab, point wounds of the cervical trachea, which are detected during fibrobronchoscopy, intubation is performed with the introduction of a tube below the site of injury, lasting 48 hours, to create conditions for spontaneous wound closure. If it is necessary to treat the tracheal wound, standard approaches are used. The defect is sutured through all layers with atraumatic absorbable suture material, a tracheostomy is applied below the site of injury for up to 7-10 days.

In case of laryngotracheal trauma, tracheostomy can be performed either from the access made for revision and treatment of the neck wound itself, or from an additional one. Preference is given to an additional access, as it helps to prevent secondary infection of the wound surface in the postoperative period.

Extensive closed and external injuries of the larynx with damage to the skin, cartilaginous framework and mucous membrane require emergency surgical treatment, which consists of ensuring breathing and reconstructing the structures of the laryngeal-tracheal complex damaged by trauma. In this case, repositioning of cartilaginous fragments is carried out, non-viable fragments of cartilage and mucous membrane are removed. Prosthetics of the formed framework on a removable endoprosthesis (thermoplastic tubes with obturators, T-shaped tubes) is mandatory. Early surgery allows for adequate repositioning and fixation of fragments, satisfactory restoration of organ function.

For revision of the larynx and trachea, standard surgical approaches according to Razumovsky-Rozanov or transverse approach of the Kocher type are used. If extensive damage to the cartilaginous skeleton of the larynx is detected after reposition of fractures, suturing is performed with atraumatic suture material. If it is not possible to achieve hermeticity of the suture, the edges of the wound are brought together if possible, and the wound defect is covered with a skin-muscle flap on a pedicle. In case of significant damage to the larynx, a laryngofissure is performed from a longitudinal approach along the midline, and revision of the internal walls of the larynx is performed. Examination allows to identify the extent of damage to the mucous membrane and outline a plan for its reconstruction. For the prevention of chondritis and prevention of development of cicatricial stenosis, the edges of the cartilaginous wound are economically resected, and the skeleton of the larynx is carefully repositioned, then plastic surgery of the mucous membrane is performed by moving its unchanged areas.

In case of open damage to the tracheal wall over a length of more than 1 cm, the patient undergoes an urgent tracheostomy with revision of the damaged area and plastic surgery of the tracheal defect with subsequent prosthetics with removable laryngeal-tracheal prostheses. In this case, the edges of the trachea can be brought together over a length of 6 cm. In the postoperative period, it is necessary to maintain a certain position of the head (the chin is brought to the sternum) for a week.

The most severe injuries are accompanied by subcutaneous ruptures of the hollow organs of the neck. Such injuries are accompanied by ruptures of the anterior group of neck muscles with the formation of fistulas. The edges of the torn organs can diverge to the sides, which can subsequently lead to the formation of stenosis, up to complete obliteration of the lumen. In these cases, in the early stages after the injury, restoration of the integrity of the organ is indicated by applying anastomosis and pexy - hanging the distal section on threads. In case of fractures of the hyoid bone, accompanied by a tear of the larynx, laryngohyoidopexy (suturing the larynx to the lower horns of the hyoid bone) or tracheolaryngopexy (suturing the trachea to the lower horns of the thyroid cartilage) is performed when the larynx is torn from the trachea.

Complications of surgical treatment include displacement of the prosthesis, restenosis due to scarring and granulation, and laryngeal paralysis.

Further management

The examination is repeated after 1 and 3 months.

In case of damage to the esophagus, esophagogastroscopy is performed 1 month after the injury, then every 3 months for a year. The timing of repeated surgical interventions aimed at decannulation and restoration of the anatomical integrity and lumen of the larynx and trachea is decided individually depending on the general condition of the patient and the clinical and functional state of the hollow organs of the neck.

In case of burns, examinations of the esophagus, larynx and trachea should be repeated after 1 and 3 months, in severe cases - every 3 months for a year.

Information for the patient. In case of neck injuries, including internal damage to hollow organs, first aid consists of restoring airway patency - removing tooth fragments, foreign bodies from the oral cavity, eliminating tongue retraction; in case of chemical burns - removing residues of the substance and rinsing with water. Neutralizing substances should not be administered, since the resulting chemical reaction may be exothermic. It is necessary to immobilize the cervical spine. It is better to transport the patient in a semi-sitting position, as this facilitates breathing. Proper provision of emergency care helps prevent the development of asphyxia, bleeding, and damage to the cervical spine.

Forecast

In cases of primary plastic surgery and prosthetics of the lumen of a hollow organ, deformation of the organ with a gross violation of its function, as a rule, does not occur.

Prevention of damage (injuries) of the larynx and trachea

Preventive measures for secondary laryngeal and tracheal injuries are aimed at preventing complications and consequences of damage. Emergency hospitalization and thorough clinical and laboratory examination, dynamic observation of the patient, timely surgical intervention, full therapy and subsequent long-term management will help to avoid severe consequences of the injury - the formation of cicatricial strictures, fistulas, paralysis, leading to serious anatomical and functional changes in the hollow organs of the neck.

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