Michelle Mekky, MA, CCC-SLP, BRS-S Speech-Language Pathologist Memorial Hermann Hospital & Children’s Memorial Hermann Hospital

Purpose

Educate the SLP on the medical diagnosis, medical treatment, and ultimate rehabilitation of voice and swallowing following airway/laryngeal trauma.

Nelson Review Article • Why this article • Lack of clinical research on this patient population in the SLP literature

Laryngeal Anatomy

Anatomy continued

Mechanism of Injury • Blunt Trauma-fractures/dislocation • Penetrating Trauma • Intubation Trauma • Thermal and Chemical Trauma

Blunt Trauma • Larynx is relatively well-protected • Lateral shielding by sternocleidomastoid muscle • Posterior protection from cervical vertebrae • Anterior protection by mandible

Examples of Blunt Trauma

Ex. of Blunt Trauma (cont)

Internal Trauma

Fractures and Dislocations • Midline or paramedian are most common • Comminution & complex fractures do occur • Surgical Management: ORIF &/or tracheostomy • Use of stents

Laryngeotracheal Separation • Severe airway compromise • Many die at the scene of the accident, unless mucosal attachment remains • Tracheostomy performed ASAP • Intubation in the field may do more harm than good • Bilateral recurrent nerve injury and subglottic stenosis are common complications • Ultimate surgical intervention is sometimes a total laryngectomy

Penetrating Trauma • Car accidents • Knifes • Bullets (handgun versus shotgun) • Other accidents: falling on sticks or glass • Blast injuries

Vascular Injuries • Occur in 25-56% of penetrating neck wounds • Most commonly to the carotid and subclavian arteries-most common cause of death • 20-30% of penetrating neck wounds result in laryngeal, tracheal, or esophageal injuries

Intubation Trauma • Prolonged intubation leads to trauma in 4-13% of cases • Larger endotracheal tubes cause more trauma • History of smoking or ETOH consumption can be very drying to the mucosa • GERD/LPRD

Intubation trauma caused by: • Abnormal anatomy (~10% of the population) • Difficult laryngescopy • Multiple intubations/extubations • Skill of person placing (resident vs. attending) • Emergent versus Elective

When trachs are placed • In most hospitals tracheostomies are performed after 10-14 days of endotracheal intubation • If multiple trips to the OR are required • Policies vary greatly between the different ICUs

Reaction to Intubation • Within 48 hours of intubation granulation tissue begins to form • Mucosal ulceration is usually present

Immediate Laryngeal Complications • Glottic or subglottic edema • Mucosal laceration • Dislocation of the arytenoids • Avulsion of the epiglottis • Vocal cord paralysis

When to refer to ENT post intubation/extubation • Hoarse voice greater than 48 hours • Sore throat greater than 48 hours • Dysphagia • Odynophagia • Stridor

Management of Arytenoid Dislocation • Needs to occur by ENT with 24-48 hours of identification • Can sometimes be treated by direct endoscopy

Treatment of Avulsion of the Epiglottis • Open repair • Laser excision

True VC Paralysis • May occur as result of intubation &/or extubation • Brandwein et al. discovered that the anterior branch of the recurrent laryngeal nerve is vulnerable to compression between the inflated cuff of the ETT, the lateral projection of the abducted arytenoids, and the thyroid cartilage.

• Cord is usually lying in the paramedian position

Late injuries of Intubation • Intubation granuloma • Cricoarytenoid ankylosis (fibrosis) • Glottic webs • Subglottic stenosis

Avoiding Late Injuries of Intubation • Limiting amount of time the pt is intubated • Using the smallest ETT which will permit adequate respiratory support • Using low-pressure cuffs • Careful fixation of the tube to limit movement during assisted ventilation • Use of steroids and antibiotics • Early recognition/tx of such laryngeal injuries

Intubation Granuloma • Forms when blood supply is poor • Area is exposed to potential contamination • Steroids is a medical tx • Antibiotics to promote healing of the mucosa • Late presentations: voice changes, globus, repetitive medical course of tx • Sometimes permanent

Glottic Web • Can result from simultaneous denudation of both VFs near the anterior commissure • When they heal together they produce a web • Probably occurs more often as a complication or surgery rather than from intubation

Picture of Glottic Web

Medical tx of Glottic Webs • Surgical placement of anterior tantalum keel • Endoscopic management with a laser or mechanical lysis-followed by placement of an internal Teflon keel

Subglottic Stenosis • Definition: narrowing of the subglottic space above the inferior margin of the cricoid cartilage and below the level of the glottis • Can be anterior, posterior, or complete

Subglottic Stenosis (cont) • Grade I - Obstruction of 0-50% of the lumen obstruction • Grade II - Obstruction of 51-70% of the lumen • Grade III - Obstruction of 71-99% of the lumen • Grade IV - Obstruction of 100% of the lumen (ie, no detectable lumen)

Picture of Subglottic Stenosis

Tx of Subglottic Stenosis • Tracheostomy • Open reduction • Cricotracheal resection • Medical management of GERD/LPRD if in the patient’s known history • Steroids/Antibiotics • Grafting

Consequences of Self Extubation • Edema • Possible vocal cord damage • Cartilage dislocation

Thermal and Chemical Trauma • Inhalation of hot gases (caustic or not) cause trauma • Stabilize the airway • Sudden edema is of primary concern

Long term Injuries • Loss of mucosal integrity • Infection • Chondritis (inflammation of cartilage) • Fibrosis

What the MD looks for: • Cough • Carbon particles • Blood in the sputum • Voice change • Stridor • Dyspnea (shortness of breath)

Course of Treatment • At least admitted for observation • Difficult to determine if tracheostomy is indicated

Medical Management of the Airway • Oral intubation after spine is clear • Rarely a cricothyroidotomy is performed for an emergent airway when a trach cannot be completed • Must be revised to a tracheostomy ASAP (within a few hours)

Role of the SLP • Aphonia/Hoarseness • Aspiration/Penetration • Avulsed/Amputated Epiglottis • Edema • Unilateral VC paresis/paralysis • Bilateral VC paralysis • Hearing Loss

Aphonia/Hoarseness • Get dx from ENT • Medical management is the best course of tx for bringing back voicing • Facilitate communication with a communication board and/or written communication systems

Aspiration/Penetration • Determine if postural changes are helpful during MBS/FEES • MUST take into account fatigue on ability to perform maneuvers (respiration and structural) • May try: supraglottic swallow, super supraglottic swallow, head down, or head rotation.

• Diet Modification is usually necessary with or without enteral access

Avulsed/Amputated Epiglottis • May lead to initial odynophagia with all oral intake • Chin down or super-supraglottic swallow may be a helpful to try during MBS/FEES

Edema • Vocal rest • Medical Management – Steroids – Anti-inflammatories

Unilateral VC Paresis/Paralysis • Many patients with unilateral paresis recover in the first 7-10 days post trauma • Those with paralysis usually overcompensate with the good cord in 1-3 weeks • Temporary tx’s by ENT: fat injection • Permanent tx’s by ENT: medialization laryngoplasty or thyroplasty

Bilateral Vocal Cord Paralysis • Causes – Paralysis (neurological) – Fixation of the cricoarytenoid joints – Both

Tx of Bilateral VC Paralysis • Usually trached and NOT a candidate for a speaking valve • Written communication/Communication board/electrolarynx during acute hospital stay • If permanent with no recovery to either cord then: Speech generating device with or without electrolarynx

Hearing Loss • Reported cases of acoustic trauma SN HL following blunt neck trauma • Segal et. al suggests it could be due to sheer forces acting on the cervical spine that transition to the inner cranium • Other theories suggest a neuromuscular mechanism, a neuro-vascular mechanism, or a mechanical vascular obstruction • Tinnitus/Balance difficulties

Hearing Loss (cont) • Audiological/ENT referral is appropriate • Referral to physical therapy may be indicated • Speech tx for aural rehabilitation

Thoughts for the Future • Research in voice recovery s/p airway trauma • Research in swallowing function s/p airway trauma