Management of laryngo-tracheal injuries associated with craniomaxillofacial trauma

David S Verschueren, R Bryan Bell, Shahrokh C Bagheri, Eric J Dierks, Bryce E Potter
Journal of Oral and Maxillofacial Surgery 2006, 64 (2): 203-14

PURPOSE: Laryngeal fractures can occur in association with maxillofacial injuries and may lead to life-threatening airway obstruction. Because of a low incidence and a paucity of peer-reviewed information, there is no universally accepted treatment protocol and few clinicians have extensive experience with complex laryngo-tracheal trauma. The purpose of this retrospective analysis is to validate a treatment protocol for the management of laryngo-tracheal injuries occurring in severely injured patients by assessing the outcome of a consecutive series of patients who were treated by the same surgeons over a 12-year period.

PATIENTS AND METHODS: All patients with laryngeal fractures admitted to the trauma service at Legacy Emanuel Hospital and Health Center (LEHHC; Portland, OR) from 1992 to 2004 were managed by the same surgeons, using a standard protocol based on the stability of the airway, and were retrospectively identified using the LEHHC Trauma Registry. Using information from the Trauma Registry and individual physician chart notes, a database was created for the purpose of assessing outcome. The following data were collected: age, gender, mechanism of injury, number of associated injuries and the Injury Severity Score, Glasgow Coma Scale on admission, initial hematocrit, airway management techniques, length of hospital stay, LEHHC laryngeal injury classification, treatment modality, disposition, and any available follow-up. Descriptive statistics were used to describe demographics, treatment, and outcome. Outcome measures were defined as complications, airway patency, speech, and deglutition.

RESULTS: A total of 16,465 patients were identified from the Trauma Registry as having sustained head, neck, or facial injuries, of which 37 patients were diagnosed with laryngeal fractures. Complete patient records were available for 27 patients (mean age, 35.5 +/- 15.3 years; range, 8 to 80 years; 23 males, 4 females) who were classified according to the LEHHC laryngeal injury classification scheme. Most patients sustained injuries as the result of blunt trauma (n = 23; 85.1%) and almost all of them had concomitant maxillofacial injuries (n = 26; 96.3%). Twenty patients (74.1%) required advanced airway intervention (tracheostomy, 14; endotracheal intubation, 5; emergent cricothyrotomy, 1), of which 13 patients underwent neck exploration. Eight of these patients required open reduction and internal fixation with titanium plates and screws, and 2 patients required the addition of an endolaryngeal stent. There was a general trend toward poorer outcome with increased LEHHC laryngeal injury classification. However, all patients were successfully decannulated, maintained patent airways, and ate a normal diet. Hoarseness was common in patients who underwent surgical exploration; however, long-term perioperative complications were rare and included infection requiring hardware removal (n = 1), unilateral vocal cord paralysis (n = 1), and subjective dysphagia.

CONCLUSION: Fractures of the larynx are uncommon injuries that are frequently associated with maxillofacial trauma and are potentially associated with significant morbidity. Management of laryngo-tracheal injuries using a protocol based on airway status as described in this report results in airway patency, functional vocal quality, and normal deglutition for almost all patients.

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