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Ann Thorac Surg 2004;77:1211-1215
© 2004 The Society of Thoracic Surgeons

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Original article: general thoracic

Complete laryngotracheal disruption caused by blunt injury

^a Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan
^b Department of Surgery, Chi-Mei Hospital, Tainan, Taiwan

Accepted for publication August 6, 2003.

^* Address reprint requests to Dr Lin, Department of Surgery, National Cheng Kung University Hospital, No 138 Sheng-Li Rd, Tainan, Taiwan
e-mail: muyenlin{at}mail.ncku.edu.tw

	Abstract

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BACKGROUND: We reviewed the clinical courses and evaluated the surgical results of 7 patients with complete laryngotracheal disruption caused by blunt injury.

METHODS: Seven patients with complete laryngotracheal disruption caused by blunt injury were successfully treated in a 13-year period. Six of the seven incidents involved men younger than 30 years on motorcycles. All but one had intact cutaneous tissue of the neck. Six of seven laryngotracheal disruptions were at the cricotracheal junction and the other was at the junction of second and third tracheal ring. In the emergency departments, 4 of these 7 patients underwent endotracheal intubation and three others underwent tracheostomy after failed intubation. Two of 7 patients underwent delayed surgery (posttrauma day 3 and day 5) because of delayed diagnosis. All patients underwent laryngotracheoplasty with (n = 3) or without (n = 4) concomitant tracheostomy.

RESULTS: Total hospital stays ranged from 9 to 28 days (average 15 days). Intensive care unit stay ranged from 2 to 10 days (average 5.8 days). All 7 patients had paralysis of bilateral vocal cords that were revealed by postoperative bronchoscopy. In 3 patients who underwent concomitant tracheostomy, the tracheostomy tubes were removed within 3 to 5 months after surgery. In the other 4 patients who underwent laryngotracheoplasty only, the endotracheal tube was used as an airway support for 2 to 6 days (average 3.5 days). All patients had patent airways. Vocal cord function partially recovered in one side (n = 6) or both sides (n = 1). Their voices were audible but still husky 5 months or 1 year later.

CONCLUSIONS: Complete laryngotracheal disruption can be treated by laryngotracheoplasty with or without concomitant tracheostomy, and phonation can be partially recovered.

	Introduction

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Complete transection of cervical trachea caused by blunt injury is rare and usually results in death or complicated sequelae if diagnosis or treatment is delayed. The unique injury may occur by avulsion of the trachea from the larynx just below the cricoid cartilage or at a lower level. The trauma mechanism is associated with the neck of motorcyclist being caught on a cable or an object, or the neck of the driver of a vehicle being struck by the edge of the steering wheel or dashboard. Other mechanisms of injury include the contact sports such as karate and victims of assault or strangulation [1, 2]. This type of injury represents a great diagnostic and therapeutic challenge for emergency physicians, anesthetists, and surgeons. Herein, we report a case series of 7 young adults suffering from this unique injury.

	Material and methods

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Between March 1989 and December 2002, 7 patients were successfully treated at the National Cheng Kung University Hospital and Chi Mei Foundation Hospital, Tainan, Taiwan. The causes of injury, injury severity, emergency management, definite surgery, and outcome all are reviewed. Seven patients with complete laryngotracheal disruption caused by blunt injury were initially treated (n = 5) or transferred from other hospitals for definite surgery (n = 2) in a 13-year period (Table 1). There were 6 men and one women, including 6 motorcyclists and 1 automobile driver. The age of the patients ranged from 17 to 35 years (mean 24.7 years). All but 1 had intact cutaneous tissue of the neck. Six of 7 laryngotracheal disruptions were located at the cricotracheal junction and 1 was located at the junction of second and third tracheal ring. The interval between injury and definite surgery ranged from 3 to 120 hours (median 5 hours). Two of 7 patients underwent delayed surgery (posttrauma day 3 and day 5) because of delayed diagnosis. Finally, 4 patients underwent definite primary repair or laryngotracheoplasty by the first author, and three other patients underwent primary repair and concomitant tracheostomy by two coauthors.

Emergency management and preoperative evaluation
Emergency physicians usually manage these patients according to the guideline of advanced trauma life support. If the patient's airway is totally obstructed or the patient is in severe respiratory distress, an attempt at intubation is warranted. If intubation is unsuccessful, a tracheostomy is indicated [3]. All facilities for performing endotracheal intubation, tracheostomy, and flexible bronchoscopy were provided. In the emergency departments, four of these seven patients underwent successful endotracheal intubation including one was aided by flexible bronchoscope, and three others underwent tracheostomy after failed intubation. The patients' general condition and their associated injuries were carefully assessed. Roentgenographs of the chest and cervical spine were routinely taken after airway maintenance. Deep cervical emphysema (n = 5), subcutaneous emphysema (n = 5), pneumomediastinum (n = 2), and bilateral pneumothoraces (n = 2) were demonstrated. Computerized tomography of the neck was also performed for delineating the extension of injury. Tube thoracostomy was performed for associated pneumothoraces.

Technical consideration
Laryngotracheoplasty was performed urgently through a collar incision when the injuries were diagnosed. Injury severity, site and shape of laryngotracheal transection, and associated injuries of the laryngopharynx and esophagus were carefully evaluated at surgery. Multiple traction sutures were applied on wound edges of the airway, which were essential for facilitating approximation and correct sutures at surgery. Interrupt monofilament absorbable suture, 3-0 (Maxon, Davis & Geck, Wayne, NJ), was preferred for the anastomosis. The recurrent laryngeal nerve was often irreversibly injured during tracheal transection; it was unrewarding to search for it at surgery. Meanwhile, lateral sides of the airway were carefully sutured to avoid iatrogenic injury on the recurrent laryngeal nerves. The fractured cricoid cartilage was firmly sutured to the thyroid cartilage which serving as a splint. Careful and thorough debridement and correct approximation usually resulted in a good laryngotracheoplasty. Ragged edges or badly damaged areas of the trachea should be debrided before anastomosis, and the tracheal length was not usually a problem in primary repair. Laryngeal release was not necessary. Partial split of anterior larynx with telescoped laryngotracheal anastomosis was performed for an uneven complete laryngotracheal disruption (Fig 1). The first author did not perform the concomitant tracheostomy. Two coauthors performed the concomitant tracheostomy using a 7.5-mm inner diameter tracheostomy tube, inserted near the third tracheal ring through another small incision wound.

View larger version (72K): [in this window] [in a new window]   Fig 1. Partial split of anterior larynx (the middle dotted line) with telescoped laryngotracheal anastomosis was performed for an uneven complete laryngotracheal disruption.

	Results

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Total hospital stay ranged from 9 to 28 days (average 15 days). Intensive care unit stay ranged from 2 to 10 days (average 5.8 days). All 7 patients had bronchoscopic finding of bilateral vocal cords paralysis postoperatively. In 3 patients undergoing concomitant tracheostomy, the tracheostomy tubes were removed within 3 to 5 months after surgery. In the other 4 patients who underwent laryngotracheoplasty only, the endotracheal tube was used as an airway support for 2 to 6 days (average 3.5 days). No anastomotic disruption, airway stenosis, or other operative complications were noted. All 7 patients had patent airways; function of the vocal cords partially recovered in one side (n = 6) or both sides (n = 1). Their voices were audible but still husky 5 months or 1 year later.

	Comment

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With cars and motorcycles being commonly used methods of transportation in Taiwan, motor vehicle accident has become the main cause of blunt laryngotracheal trauma. Other causes of injury are contact sports such as karate and victims of assault or strangulation [1, 2]. In Taiwan, motorcycles serve as transportation tools for many young adults and contribute a large proportion of traffic accidents, including complete transection of cervical trachea.

With regard to the mechanism of injury, the cricotracheal junction is a relatively weak point. A shearing force produced by severe and sudden deceleration may tear the junction completely [4]. A "clothesline" type injury while riding a motorcycle and direct cervical impact against the steering wheel or dashboard are two usual etiologies [5, 6]. The cervical skin and muscle of the victims are relatively unharmed. The injured airway is frequently hidden under the grossly intact cutaneous tissue. Therefore, the diagnosis and management may be overlooked initially. In our series, only one patient had a cervical laceration deep to the transected trachea. Few obvious signs of laryngotracheal disruption resulted in two late diagnosis. High index of suspicion is indicated by the following triad: hoarseness, subcutaneous emphysema, and palpable crepitus [3].

Complete laryngotracheal transection usually causes acute respiratory distress and requires emergency endotracheal intubation or tracheostomy to secure the airway. Endotracheal intubation is faster and less invasive compared with tracheostomy [5]. In our patients, 4 of 7 underwent successful endotracheal intubation in the emergency department. However, a false extratracheal intubation may occur in the separated trachea [7, 8]. We preferred a tracheostomy on patient 3. The neck of the motorcyclist was caught on the back of a stopped truck resulting in an associated neck wound deep to the separated trachea. Also, patients in whom intubation failed required immediate tracheostomy. The emergency tracheostomy was sealed at surgery by the first author. However, a concomitant tracheostomy was performed at the third tracheal ring through another small incision by other two coauthors.

In addition, because laryngotracheal injuries are frequently accompanied by pneumothoraces, tube thoracostomy is necessary. In contrast with pneumothorax resulted from bronchial rupture, bilateral lung collapse usually occurs, and persistent and massive air leak from chest tube is uncommon. If the collapsed lung cannot be expanded after endotracheal intubation and tube thoracostomy, associated lung injury should be suspected.

Surgical considerations for complete laryngotracheal disruption depended on two factors: operative timing and injury severity. Simple separation of laryngotracheal junction can be primarily repaired with interrupted absorbable suture immediately after trauma [9–11]. All cervical associated injuries, including pharyngoesophageal injury, were carefully evaluated at surgery. In the cases of delayed diagnosis, however, local infection and fibrous tissue between the two ends may be presented. Adequate debridement of surrounding septic tissues and lysis of adhesions must be performed in these patients. Even to restore a satisfactory mucosa-to-mucosa anastomosis, both injured ends should be resected up to healthy tissue before repair [5]. If extensive laryngotracheal injury occurs, a variety of techniques may be required to achieve approximation of larynx and trachea that prevent subsequent stenosis [6, 9, 12]. In patient 4, a complex laryngotracheal disruption was found resulting in uneven edge of both ends, fractures of cricoid cartilage, avulsion of posterior laryngeal mucosa lead to exposure of cricothyroid cartilage. To repositioning the degloved mucosa, the anterior laryngeal wall was partially split (Fig 1-left). The uneven edge of distal trachea is reformed to smooth edge. The tracheal end was telescoped into the split thyroid cartilage (Fig 1-right). Good approximation is required before suture. Concomitant tracheostomy is usually performed through third tracheal ring. However, need of the procedure is controversial and depends on surgeon's preference. All 4 patients treated by the first author did not undergo concomitant tracheostomy. Other surgeons recommended concomitant tracheostomy for airway security. Theoretically, without tracheostomy, the injured young adults could tolerate the postoperative course if a good laryngotracheoplasty was performed. The endotracheal tube was removed by the surgeon himself in intensive care unit, with an average of 3.5 days after surgery, and was backed up by all facilities of reintubation. Fortunately, these 4 patients did not require reintubation.

Complete laryngotracheal disruption may result in voice impairment and airway stenosis. These complications generally are caused by injury of recurrent laryngeal nerves, distortion of laryngeal framework, scar contraction or excess granulation tissue formation [6, 12]. There was no evidence of iatrogenic trauma to the bilateral recurrent laryngeal nerves in these patients. Delays in diagnosis and definitive treatment will also increase the possibility and severity of long-term sequelae [8, 9]. In our study, 2 of 7 patients underwent definitive treatment beyond 24 hours after injury. Fortunately, no airway stenosis occurred. Postoperative bronchoscopy demonstrated bilateral vocal cord palsy in the 7 patients. The function of the vocal cord was partially recovered in one side (n = 6) or both sides (n = 1). However, all voices were audible but still husky 5 months or 1 year later.

In conclusion, two types of tracheostomy were usually performed in the management of complete laryngotracheal disruption. One was emergency tracheostomy that was performed by emergency physician because of failed intubation. The other was concomitant tracheostomy that was performed at laryngotracheoplasty by some surgeons for postoperative airway security. Complete laryngotracheal disruption can be treated by laryngotracheoplasty with or without concomitant tracheostomy and phonation can be partially recovered.

	References

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1. Schaefer S.D., Close L.G. Acute management of laryngeal trauma update. Ann Otol Rhinol Laryngol 1989;98:98-104.[Medline]
2. O'Connor P.J., Russell J.D., Moriarty D.C. Anesthetic implications of laryngeal trauma. Anesth Analg 1998;87:1283-1284.[Free Full Text]
3. Alexander RH, Proctor HJ. Thoracic trauma. In: American College of Surgeons, ed. Advanced trauma life support program for physician instructor manual. 1997:111–25
4. Chu C.P.W., Chen P.P. Tracheobronchial injury secondary to blunt chest trauma: diagnosis and management. Anaesth Intensive Care 2002;30:145-152.[Medline]
5. Couraud L., Velly J.F., Martigne C., N'Diaye M. Post traumatic disruption of the laryngo-tracheal junction. Euro J Cardiothorac Surg 1989;3:441-444.[Abstract/Free Full Text]
6. Sofferman R.A. Management of laryngotracheal trauma. Am J Surg 1981;141:412-417.[Medline]
7. Baumgartner F.J., Ayres B., Theuer C. Danger of false intubation after traumatic tracheal transection. Ann Thorac Surg 1997;63:227-228.[Abstract/Free Full Text]
8. Fuhrman G.M., Stieg F.H., Buerk C.A. Blunt laryngeal trauma: classification and management protocol. J Trauma 1990;30:87-92.[Medline]
9. Mathisen D.J., Grillo H. Laryngotracheal trauma. Ann Thorac Surg 1987;43:254-262.[Abstract/Free Full Text]
10. Wu M.H., Tseng Y.L., Lin M.Y., Lai W.W. Surgical results of 23 patients with tracheobronchial injuries. Respirology 1997;2:127-130.[Medline]
11. Norwood S.H., McAuley C.E., Vallina V.L., Berne J.D., Moore W.L. Complete cervical tracheal transection from blunt trauma. J Trauma 2001;51:568-571.[Medline]
12. Harris H.H., Tobin H.A. Acute injuries of the larynx and trachea in 49 patients. Laryngoscope 1970;80:1376-1384.[Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Wu, M.-H. Articles by Fong, Y. Search for Related Content PubMed PubMed Citation Articles by Wu, M.-H. Articles by Fong, Y. Related Collections Trachea and bronchi