Injury (injury) of the larynx and trachea: treatment

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

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

The objectives of treating larynx and trachea injuries

All medical measures are carried out with the purpose of restoration of anatomic integrity and functions of the damaged organs.

Indications for hospitalization

All patients with trauma to the larynx and trachea should be hospitalized in the ear, throat, nose, or intensive care department 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, appointing hunger, bed rest (position with a raised head end), and voice rest. Provide humidified oxygen and intensive monitoring for 48 hours. First aid for breathing disorders includes mask ventilation, installation of an intravenous catheter on the side opposite to the lesion. Virtually all patients require the introduction of a nasogastric tube, except isolated trauma of the larynx and trachea of the lung. In the case of mismatch of defects in the esophagus and trachea and their small size with a penetrating wound, conservative treatment is possible with the use of a nasogastric tube. The latter serves as a prosthesis, isolating two wounded holes. Intubation, if necessary, is performed with the participation of an endoscopist.

Medication-based baking

Conservative treatment includes antibacterial, decongestant, analgesic, anti-inflammatory and oxygen therapy: all patients are prescribed antacid agents and inhalations. Conduct a correction of concomitant pathology. If the patient's condition is severe when on admission, first of all, general somatic diseases are treated, possibly postponing surgical intervention for several hours.

Treatment of chemical burns depends on the extent of the lesion. At the first degree of severity the patient is observed for two weeks, performing anti-inflammatory and antireflux therapy. At the second appoint glucocorticoids, antibiotics of a wide spectrum of action, antireflux treatment for approximately 2 weeks. Depending on the condition of the esophagus, the question of the expediency of introducing a nasogastral probe is decided. With a circular lesion of the soft tissues of the patient, it is necessary to observe 4-5 months. Or a year. At the third degree of a burn, glucocorticoids should not be used because of the high risk of perforation development. Assign antibiotics of a wide spectrum of action, antireflux therapy, inject a nasogastric tube, subsequently observed for a year.

A good clinical effect in patients with traumas of the hollow organs of the neck is provided by inhalation therapy - glucocorticoids, antibiotics, alkalis lasting an average of 10 min three times a day. To moisten the mucous membrane, alkaline inhalations can be administered several times a day.

Hemorrhages and hematomas of the larynx are more often lysed independently. A good clinical effect along with anti-inflammatory therapy is provided by physiotherapy and treatment aimed at the resorption of blood clots.

Patients with bruises and injuries of the larynx, not accompanied by cartilage fractures or with those without signs of displacement, are conservatively treated (anti-inflammatory, antibacterial, detoxifying, restorative and physiotherapy, hyperbaric oxygenation).

Surgery

Indications for surgical treatment:

• alteration of the larynx skeleton;
• fractures of cartilage with displacement;
• paralysis of the larynx with stenosis:
• pronounced or growing emphysema;
• stenosis of larynx and trachea;
• bleeding;
• extensive damage to the larynx and trachea.

The results of surgical treatment depend on the time elapsed since the injury. Timely or delayed for 2-3 days, the intervention can restore the structural framework of the larynx and completely rehabilitate the patient. Physiological prosthetics is an obligatory component of treating a patient with a larynx injury.

In case of injury to a foreign body, first of all, it must be removed. With significant secondary changes that make it difficult to search for, anti-inflammatory and antibacterial therapy is performed for two days. Foreign bodies are removed as far as possible using endoscopic technique or laryngeal forceps with indirect microlaringoscopy under local anesthesia. In other situations, removal is carried out with the help of laryngoflesura, especially in the case of embedded foreign bodies.

The granuloma of the larynx is removed after previous treatment, including antireflux, anti-inflammatory local therapy, phononedite to exclude strained phonation. The operation is performed with a reduction in the base of the granuloma and a decrease in perifocal inflammation. The exception is the granuloma of large size, causing stenosis of the lumen.

With a formed hematoma of the vocal fold, in some cases, microsurgical intervention is used. With direct microlaryngoscopy, the mucous membrane is cut above the hematoma, it is removed by the evacuator, as is the varicose knot of the vocal fold.

To ensure breathing in case of obstruction of the upper respiratory tract and impossibility of intubation, tracheostomy or conicotomy is produced. Preference is given to tracheostomy, since a conicomotor may not be effective at an unspecified level of lesion. Closed laryngeal lesions, accompanied by obstruction of the respiratory tract due to swelling or accruing hematoma, require immediate tracheostomy. When the hematoma is resolved, the tracheotomy cannula is removed, and then the stoma is closed independently. With internal bleeding, increasing subcutaneous, intermuscular or mediastinal pressure, the closed wound should be transferred to the open one, exposing the place of organ rupture, trachyotomy as much as possible 1.5-2 cm below it, and then layer-by-layer repair of the defect with reposition of cartilage, sparing the surrounding tissues as much as possible .

When injured, the wound is processed first and wounded layer by layer. Tracheostomy is performed according to indications. In case of damage to the oropharynx and esophagus, a nasogastric tube is installed. Cut wounds tightly sutured with the introduction of small drainage for the first 1-2 days. With stabbed, point wounds of the cervical trachea, which are revealed in fibrobronchoscopy to create conditions for spontaneous closure of the wound, intubation is performed with a tube below the injury site, lasting 48 hours. If necessary, tracheal injuries use standard approaches. Seal the defect through all layers with atraumatic absorbable suture material, impose a tracheostomy below the injury site for up to 7-10 days.

With laryngotracheal trauma, tracheostomy can be made both from access performed for revision and treatment of the neck itself. And from the additional. Preference is given to additional access, since this helps prevent secondary infection of the wound surface in the postoperative period.

Extensive closed and external injuries of the larynx with damage to the skin, cartilage and mucous membrane require urgent surgical treatment, is to provide breathing and reconstruction of injured trauma structures of the laryngeal tracheal complex. At the same time reposition of cartilaginous fragments is carried out, non-viable fragments of cartilage and mucous membrane are removed. Obligatory prosthetics of the formed skeleton on a removable prosthesis (thermoplastic tubes with obturators, T-shaped tubes). Early operation allows an adequate reposition and fixation of fragments, a satisfactory restoration of the function of the organs.

For the revision of the larynx and trachea, standard surgical approaches are used according to Razumovsky-Rozanov or transverse access of the Kocher type. If extensive lesions of the cartilaginous skeleton of the larynx are revealed after repositioning the fractures, atraumatic suture material is sewn. If the seam is not sealed, the edges of the wound are as close as possible, and the wound defect is closed with a cutaneous muscle flap on the leg. In case of significant lesions of the larynx, a laryngophisis is performed from the longitudinal access along the middle line, the inner walls of the larynx are inspected. Inspection allows you to identify the extent of damage to the mucous membrane and outline a plan for its reconstruction. Day of chondrite prophylaxis and prevention of development of cicatricial stenosis of the edge of the cartilaginous wound is economically resected, and the larynx skeleton is carefully re-inserted, then the plasty of the mucous membrane is carried out due to the movement of its unchanged areas.

When the tracheal wall is damaged for more than 1 cm, the patient is urgently tracheostomy with a revision of the damage area and the plasticity of the tracheal defect, followed by prosthetic replacement with removable laryngeal-tracheal prostheses. In this case, the tracheal edge can be brought together for 6 cm. In the postoperative period, it is necessary to observe a certain position of the head (chin is brought to the sternum) within a week.

The most severe injuries are accompanied by subcutaneous ruptures of the hollow organon of the neck. Such damage is accompanied by ruptures of the anterior group of neck muscles with the formation of fistulas. The edges of the ruptured organs can fall apart, which in the future can lead to the formation of stenosis, up to complete obliteration of the lumen. In these cases, in the early periods after trauma, the restoration of organ integrity through the application of anastomosis and peccia - suspension of the distal segment on the filaments is shown. In case of fractures of the hyoid bone, accompanied by larynx detachment, laryngiioidopexy is produced (laryngeal stitching over the lower horns of the hyoid bone) or tracheolaringopexy (tracheal stitching to the lower horns of the thyroid cartilage) when the larynx is separated from the trachea.

Among the complications of surgical treatment, displacement of the prosthesis, restenosis due to scarring and granulation, paralysis of the larynx are noted.

Further management

Inspection is repeated after 1 and 3 months.

If the esophagus is damaged, esophagogastroscopy is performed 1 month after the injury, then every 3 months during the year. The terms of repeated surgical interventions aimed at decanulation and restoration of anatomic integrity and laryngeal and tracheal lumen are decided individually depending on the general condition of the patient and the clinical and functional state of the hollow organs of the neck.

With burns, the esophagus, larynx and trachea should be repeated at 1 and 3 months, in severe cases - every 3 months during the year.

Information for the patient. With neck injuries. Including internal damages of hollow organs, first aid consists in ensuring the restoration of airway patency - removal of fragments of teeth, foreign bodies from the oral cavity, elimination of tongue twisting: with chemical burns - removal of residues and washing with water. Neutralizing substances should not be introduced, since the resulting chemical reaction can 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 can prevent the development of asphyxia, bleeding, damage to the cervical spine.

Forecast

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

Prevention of injuries (trauma) of the larynx and trachea

Preventative measures for traumas of the larynx and trachea are secondary, aimed at preventing complications and consequences of damage. Emergency hospitalization and thorough clinical and laboratory examination, dynamic observation of the patient, timely implementation of the surgical intervention, full therapy and subsequent long-term management will avoid the severe consequences of trauma - the formation of scar strictures, fistulas, paralysis, leading to serious anatomical and functional changes in the hollow organs of the neck.

[1], [2], [3], [4], [5], [6], [7], [8]