Chondronecrosis of the cricoid treated with hyperbaric oxygen therapy: A case series.

We present two cases of cricoid chondronecrosis treated with hyperbaric oxygen (HBO2) therapy. Both patients presented with biphasic stridor and dyspnea several weeks after an intubation event. Tracheostomy was ultimately performed for airway protection, followed by antibiotic treatment and outpatient HBO2 therapy. Both patients were decannulated within six months of presentation and after at least 20 HBO2 therapy sessions. Despite a small sample size, our findings are consistent with data supporting HBO2 therapy's effects on tissue edema, neovascularization, and HBO2 potentiation of antibiotic treatment and leukocyte function. We suggest HBO2 therapy may have accelerated airway decannulation by way of infection resolution as well as the revitalization of upper airway tissues, ultimately renewing the structural integrity of the larynx. When presented with this rare but significant clinical challenge, physicians should be aware of the potential benefits of HBO2 therapy.

Epidemiology and Management of Adult Laryngeal Trauma: An Analysis of the National Trauma Data Bank.

INTRODUCTION: Laryngeal injuries are rare but life-threatening airway emergencies. Increased understanding of the epidemiology of these injuries can inform treatment and improve outcomes. We aimed to characterize the demographics and management of adult laryngeal trauma. METHODS: The National Trauma Data Bank (NTDB) was queried from 2007 to 2015 for patients ≥18 years old with laryngeal trauma. Patient demographics, injury characteristics, and treatment course were collected. Outcomes were assessed via multivariate logistic regression. RESULTS: From 7.3 million patients, 6,890 (0.1%) patients with laryngeal trauma were identified. Eighty-five percent of patients were male, and the median age was 40. Of these patients, 343 (5.0%) were dead on arrival and of the remaining patients, 510 (7.8%) of patients were deceased at discharge. Common concomitant injuries included facial fractures (27%), intracranial injuries (21%), and rib and sternum fractures (19%). The most common cause of injury was motor vehicle accident (26%), followed by assault with firearms/explosives (12%) and assault with cutting instruments (8%). Forty-three percent of patients received mechanical ventilation and 15% received surgical repair. After correcting for gender, age, and injury severity, firearm injuries (odds ratio [OR] 3.46, 95% CI: [2.88-4.15]) and cutting/piercing injuries (OR 2.23, 95% CI: [1.89-2.64]) were positively associated with the need for mechanical ventilation. Motor vehicle trauma (OR 0.63, 95% CI: [0.46-0.84]) was negatively associated with surgical repair while striking injuries (OR 1.61, 95% CI: [1.25-2.06]) were positively associated. Lastly, shorter time to tracheostomy was significantly associated with shorter ICU stays (p < 0.0001). CONCLUSION: This study is the largest epidemiologic study of laryngeal trauma to date and identifies the risk of surgical intervention with firearm and cutting injuries as well as the importance of earlier time to tracheostomy for ICU management.

Endotracheal tube forces exerted on the larynx and a novel support device to reduce it.

Objective: Endotracheal tubes (ETTs) are commonly associated with laryngeal injury that may be short lasting and temporary or more severe and life altering. Injury is believed to result from forces that these ETTs exert on the larynx. Here we quantify the forces of ETTs of various sizes on the laryngotracheal complex to gain a more quantitative understanding of these potential damaging forces. Here we also perform preclinical testing of a novel support device to offload these forces. Methods: Endotracheal intubation was performed on a fresh human cadaver using various ETT sizes. A strain-sensitive graphene nanosheet sensor and a commercially available force sensing resistor were secured behind the larynx, anterior to the prevertebral fascia. The forces exerted on the larynx were measured for each of the commonly used ETTs. A novel support device, ETT clip (Endo Clip), was attached to the ETTs and changes in these forces were observed. Results: Forces exerted on the laryngotracheal complex by various ETTs were observed to increase with increasing tube size. This pressure can be significantly reduced with a novel ETT clip. Conclusion: Here we demonstrate the first quantitative measurement of forces that ETTs exert on the larynx. We demonstrate a novel device that can easily clip onto an ETT reducing pressure on the laryngotracheal complex. This preclinical test paves the way for a human clinical trial. Level of evidence: 5.

Laryngeal Trauma.

Laryngeal trauma is rare but potentially fatal. Initial evaluation includes efficient history and physical examination, imaging, bedside flexible laryngoscopy, and if necessary, operative endoscopic evaluation. Multiple classification systems exist for laryngeal trauma, and each has its merits. We recommend a patient-centered approach, rather than using the classification alone. Secure airways are the primary goal of acute management, with awake tracheostomy more often indicated over oral intubation compared with traumas not involving the larynx. More severe injuries typically require surgical intervention. Early intervention results in optimal voice and airway outcomes.

A Neglected Open Laryngeal Wound: A Rare Presentation of Neck Trauma.

Laryngotracheal trauma can be potentially lethal. Improper healing can have long term sequelae such as permanent voice change, laryngotracheal stenosis and impaired swallowing severely affecting an individual's quality of life. Thus early identification and prompt treatment is paramount to achieve good outcomes in laryngotracheal trauma. A 45 year old male presented with an open laryngeal wound 12 days after sustaining the injury. Surgical closure of the wound was done. A suprahyoid drop was done to achieve tension free repair of the laryngeal rent. Chin to chest sutures were used to maintain neck flexion in the post-operative period. We were able to achieve a good surgical outcome with regards to the patients voice, airway and swallowing in spite of the delayed presentation.

Thyroarytenoid Muscle Avulsion.

Thyroarytenoid muscle avulsion is a rare condition in which laryngeal trauma causes a separation of the thyroarytenoid muscle from the arytenoid cartilage. Typically, symptoms are nonspecific but include severe dysphonia and voice fatigue. They are similar to symptoms of vocal process avulsion. Strobovideolaryngoscopy, laryngeal electromyography, and laryngeal computed tomography may be helpful in diagnosis. However, intraoperative palpation under general anesthesia is the most definitive way to establish its diagnosis. We present two cases of thyroarytenoid muscle avulsion, a condition that has not been described previously. Surgical techniques for repair are detailed.

Implications of traumatic unilateral aryepiglottic fold injury on swallowing: A case series.

OBJECTIVE: This retrospective case series examines the effect of traumatic unilateral aryepiglottic fold injury on swallowing and airway protection. It focuses on the longitudinal care of five pediatric patients to determine the dietary modifications required to maintain a safe, functional swallow. METHODS: Retrospective chart review of patients with a diagnosis of unilateral aryepiglottic fold injury was performed. Cases were clinically identified by pediatric otolaryngologists at a single quaternary care pediatric hospital upon operative endoscopic evaluation. Clinical swallow outcomes were measured with the Rosenbek Penetration Aspiration Scale. RESULTS: Average age at diagnosis was 10 months with mean follow-up of 30 months. Eighty percent of patients were female. All patients had right-sided aryepiglottic fold injuries. Four patients were intubated for an average of 3 months and a fifth patient had a traumatic intubation event. All currently take nutrition by mouth, albeit to varying degrees. Four patients adequately protect their airway from aspiration with all oral consistencies. Optimized delivery of thin liquids yielded a Rosenbek penetration aspiration scale (PAS) score of 1 in four patients and 4 in the remaining patient. Four patients required gastric tube placement during severe illness, and three remain partially dependent. Surgical correction was attempted for one patient without improvement. CONCLUSION: Based on a limited and somewhat heterogeneous case series, the data suggests that traumatic unilateral aryepiglottic fold injury does not prohibit oral intake in most cases. While the PAS score under optimized conditions is impressive, implications for a safely tolerated diet remain. There is sparse published literature upon this topic, and the longitudinal data presented may serve as a pilot study for future investigation by shedding light on the consequences of this airway injury.

Two Cases of Atraumatic Laryngeal Fractures.

INTRODUCTION AND AIM: Atraumatic laryngeal fractures are extremely rare and are most commonly provoked by sneezing or coughing. Only seven cases have been described in medical literature, and only one case described a fracture after swallowing. We present two cases of atraumatic laryngeal fracture after swallowing. CASE REPORT: A 37-year-old male presented to the outpatient ENT clinic with severe dysphonia and odynophagia. He reported feeling a crack in the throat after swallowing with a flexed head. The patient's physical examination showed diffuse swelling and tenderness over the thyroid cartilage without subcutaneous emphysema. Flexible nasolaryngoscopy showed a large right true vocal fold hematoma with normal vocal fold movement. Computed tomography (CT) showed a fracture of the thyroid. Treatment consisted of corticosteroids and pantoprazole. Two years later he presented again at the emergency department with extreme odynophagia after suffering a knee punch on the larynx. CT showed a new fracture line, slightly off midline to the left in the thyroid cartilage. A 42-year-old male presented at the emergency department with odynophagia, dysphonia, and fever after feeling a crack in the throat during forceful swallowing in an extended neck position. Physical examination demonstrated a painful thyroid cartilage with subcutaneous emphysema. Flexible nasolaryngoscopy was normal but CT scan showed a slightly displaced fracture line of the median thyroid cartilage. Complaints gradually disappeared with conservative treatment with corticosteroids and antibiotics. CONCLUSION: Congenital anomalies by abnormal mineralization and ossification could lead to focal weakness of the thyroid cartilage and thus predispose to non-traumatic fractures. The double triad of odynophagia, dysphagia, and dysphonia after sneezing, coughing or swallowing should raise the physician's attention to the possibility of thyroid cartilage fracture, especially after feeling or hearing a crack. Further investigation is obligatory with high-resolution CT of the neck and examination by an ENT specialist.

[Acute care of soft tissue injuries in the head and neck region]. / Akutversorgung von Weichteilverletzungen im Kopf-Hals-Bereich.

BACKGROUND: Soft tissue injuries are a common consequence of head and neck trauma. With injuries being highly individual and varying depending on the underlying trauma, it is difficult to establish standardized guidelines for head and neck trauma in general. The main goal of this study was to showcase the distribution of soft tissue injury types and the principles pertaining to acute care of the individual clinical presentations. MATERIALS AND METHODS: A retrospective evaluation was carried out using all trauma-relevant ICD-10 codes for trauma to the head (S00.- to S09.-) and neck (S10.- to S19.-) among patients who were treated at the authors' clinic-a certified national trauma center-during a period of 10 years (2012 to and including 2021). RESULTS: A total of 8375 patients with head and neck trauma were treated during the observation period, i.e., an average of 836 patients per year. Within this collective, 2981 trauma cases involving soft tissue injuries were documented. Superficial injuries to the head (S00.-) and open wounds to the head (S01.-) were the most common head and neck soft tissue injuries, with 1649 and 920 cases, respectively. CONCLUSION: The case numbers of soft tissue injuries generally show an inverse correlation to the required underlying trauma: diagnoses of the categories S00 and S01 occur very often; injuries which only occur after severe trauma, such as traumatic amputation at neck level (S18), are rare. According to current literature, penetrating neck traumas should be treated using a no-zone approach. In Europe, penetrating neck injuries are rather rare because of low crime rates and strict weapon laws.

Laryngeal Trauma Managed with Titanium Mesh Fixation: A Rare Case Report.

Laryngeal fractures are though uncommon they can be potentially life threatening. Comminuted laryngeal cartilage fractures are difficult to manage and various fixation techniques have been described in literature. Outcome results of fixation with different materials can be varied. We report a case of 27 years old male who sustained laryngeal cartilage fracture following accidental fall. Patient underwent emergency tracheostomy and early surgical repair of fractured laryngeal thyroid cartilage with one of the newest techniques "titanium mesh fixation". After a month of surgery tracheostomy tube was removed and patient recovered with good laryngeal function. Titanium mesh fixation gave immediate effective fixation and stability to laryngeal fracture leading to good surgical outcome.

Laryngeal Trauma, Its Types, and Management.

Laryngotracheal wounds are rare; however, they have a significant mortality rate. These wounds can be blunt or penetrating. Usually, the larynx is protected from blunt trauma by the sternum and jaw. A "clothesline" injury happens when the exposed neck is struck by a hard object, such as a wall wire or tree branch, or when an attack is intended to damage the larynx. Additionally, injuries may occur when the neck is stressed due to damage, such as in a rear-end accident that causes a whiplash-like injury or when the larynx is intentionally targeted for harm. Penetrating neck trauma may result in injury to the larynx. Assume a patient has suffered a penetrating or severe neck injury. It is usually evident from their medical history or a quick trauma evaluation in that case. However, it is recommended to be cautious for anterior neck injuries in general and to have a low threshold for establishing a surgical airway. The priority is securing an airway when a patient with a laryngeal injury arrives in the emergency room. The operating surgeon may request any flexible laryngoscopy, computed tomography (CT), esophagram, and chest X-ray for additional examination, depending on the nature of the damage and the patient's health. After the examination, the initial step in treating laryngeal injuries should be to locate and secure the airway. According to the evaluation and management based on the Schaefer classification system for laryngeal injury, the patient is treated based on whether the patient has impending airway obstruction or a stable airway. Medical management or observation and surgical management depend on the site and severity of the injury, patient condition, and type of injury. There are several complications related to laryngotracheal trauma, which can be minor or even fatal. Following successful treatment, postoperative and rehabilitative care, vocal rest, speech therapy, and swallowing therapy may be necessary.

Hyena Bite Injury to the Neck Leading to Laryngotracheal Separation.

Animal-induced trauma can lead to severe injury and death, especially in medically isolated settings. Few reports of hyena attacks on humans have been reported in the literature. The goal of this report is to describe such an attack and the heroic efforts required to preserve life and function in a resource-limited environment. A 55-year-old female was attacked by a hyena in a rural region of Ethiopia. Despite delays in medical care, she was able to survive this attack and was successfully discharged after prolonged treatment efforts. Animal-induced trauma is a potential source of substantial and disfiguring injury, especially in resource-limited environments. Early transfer to tertiary care centers and creative solutions are needed to optimize outcomes in such environments.

A silent laryngeal trauma case: an unexpected late fracture of the superior portion of the thyroid cartilage superior horn.

Attempts to analyze clinical unexpected cases of laryngeal fractures based on mild symptoms and physical findings. Even though a laryngeal fracture is rare in a living patient and when happens it is related to severe airways emergency, this case reported seems important to offer a possible differential diagnosis in patients who present with the same symptoms, if no other causes have been detected, like another one benign laryngeal disease.

Cricoid abscess presenting as progressive dyspnea.

Laryngeal abscess, especially in the posterior larynx and cricoid region, is a rare entity with potential for high morbidity and mortality. The most common etiologies for such abscesses include trauma, prolonged intubation, and supraglottic infection. This case report describes a patient with cricoid abscess of unknown etiology but with a remote history of trauma and intubation. He initially presented with progressive dyspnea and hoarseness, with no signs or symptoms consistent with infection. The report describes airway management techniques and a unique approach to draining the posterior cricoid fluid collection.

Volume-outcome relationships in laryngeal trauma processes of care: a retrospective cohort study.

PURPOSE: The extent to which patients with laryngeal trauma undergo investigation and intervention is largely unknown. The objective of this study was to therefore determine the association between hospital volume and processes of care in patients sustaining laryngeal trauma. METHODS: This retrospective cohort study used the American College of Surgeons Trauma Quality Improvement Program database. Adult patients (≥ 18) who sustained traumatic laryngeal injuries between 2012 and 2016 were eligible. The exposure of interest was average annual laryngeal trauma volume categorized into quartiles. The primary and secondary outcomes of interest were the performances of diagnostic and therapeutic laryngeal procedures respectively. Multivariable logistic regression under a generalized estimating equations approach was utilized. RESULTS: In total, 1164 patients were included. The average number of laryngeal trauma cases per hospital ranged from 0.2 to 7.2 per year. Diagnostic procedures were performed in 31% of patients and therapeutic in 19%. In patients with severe laryngeal injuries, diagnostic procedures were performed on a higher proportion of patients at high volume centers than low volume centers (46% vs 25%). In adjusted analysis, volume was not associated with the performance of diagnostic procedures. Patients treated at centers in the second (OR 1.94 [95% CI 1.29-2.90]) and third (OR 1.67 [95% CI 1.08-2.57]) volume quartiles had higher odds of undergoing a therapeutic procedure compared to the lowest volume quartile. CONCLUSION: Hospital volume may be associated with processes of care in laryngeal trauma. Additional research is required to investigate how these findings relate to patient and health system outcomes.

External penetrating laryngeal trauma caused by a metal fragment: A Case Report.

BACKGROUND: Although external penetrating laryngeal trauma is rare in the clinic, such cases often result in a high mortality rate. The early recognition of injury, protection of the airway, one-stage laryngeal reconstruction with miniplates and interdisciplinary cooperation are important in the treatment of such patients. CASE SUMMARY: A 58-year-old male worker sustained a penetrating injury in the left neck. After computed tomography scanning at a local hospital, he was transferred to our hospital, where he underwent tracheotomy, neck exploration, extraction of the foreign object, debridement and repair of the thyroid cartilage using titanium miniplates. An endo laryngeal stent was inserted, which was removed 12 days later. The patient recovered well and his voice rapidly improved after surgery. CONCLUSION: Penetrating laryngeal trauma is uncommon. We successfully treated a patient with early laryngeal reconstruction and management by interdisciplinary cooperation.

Management of Laryngeal Trauma.

The larynx is a complex anatomic structure and a properly functioning larynx is essential for breathing, voice, and swallowing. Laryngeal trauma is often associated with other injuries, including intracranial injuries, penetrating neck injuries, cervical spine fractures, and facial fractures. Although uncommon, laryngotracheal injuries may lead to life-threatening airway emergencies. Because laryngeal injuries are rare, even surgeons with a great deal of experience in managing maxillofacial trauma have limited exposure to management of laryngeal and tracheal injury. This article reviews a protocol for the evaluation, management, and treatment of these injuries in the trauma patient.

A complex fracture of the hyoid bone and the larynx after a bicycle accident - Case report and review of literature.

INTRODUCTION AND IMPORTANCE: Reports about laryngeal trauma and fractures of the hyoid bone are rare in the literature. Most cases are forensic cases and the results of postmortem analysis. Traumatic larynx and hyoid bone fractures represent a rare but important differential diagnosis of the common symptom hoarseness. CASE PRESENTATION: A 60-year-old female patient presented with unclear dysphonia and globus sensation following intubation for a surgical treatment for a lower leg fracture after a bicycle accident two months ago. Endoscopy and the computed tomography (CT) of the neck revealed a fixed and immobile fractured piece of the larynx, a hyoid bone fracture and a pseudarthrosis between the greater horn of the hyoid bone and the upper edge of the thyroid cartilage. The hyoid bone fracture led to a distortion of the supraglottis. After surgical removal of the fractured part of the hyoid bone and the pseudarthrosis separation, the supraglottis appeared symmetrical again. Four weeks after surgery the patient was symptom-free. CLINICAL DISCUSSION: Though combined hyoid bone and larynx fractures after traumatic injuries are rare, they represent an important differential diagnosis in trauma patients with dysphagia or dysphonia. The clinical symptoms can vary and occur immediately or within a latent period taking weeks or months until the proper diagnosis. Depending on the symptoms, surgical management can be effective. CONCLUSION: An isolated partial resection of the hyoid bone with separation of the pseudarthrosis is a reasonable therapeutic option and can lead to completely resolving symptom. Preoperatively, a CT provides further valuable information.

Investigating blunt force trauma to the larynx: The role of inferior-superior vocal fold displacement on phonation.

Blunt force trauma to the larynx, which may result from motor vehicle collisions, sports activities, etc., can cause significant damage, often leading to displaced fractures of the laryngeal cartilages, thereby disrupting vocal function. Current surgical interventions primarily focus on airway restoration to stabilize the patient, with restoration of vocal function usually being a secondary consideration. Due to laryngeal fracture, asymmetric vertical misalignment of the left or right vocal fold (VF) in the inferior-superior direction often occurs. This affects VF closure and can lead to a weak, breathy voice requiring increased vocal effort. It is unclear, however, how much vertical VF misalignment can be tolerated before voice quality degrades significantly. To address this need, the influence of inferior-superior VF displacement on phonation is investigated in 1.0mm increments using synthetic, self-oscillating VF models in a physiologically-representative facility. Acoustic (SPL, frequency, H1-H2, jitter, and shimmer), kinematic (amplitude and phase differences), and aerodynamic parameters (flow rate and subglottal pressure) are investigated as a function of inferior-superior vertical displacement. Significant findings include that once the inferior-superior medial length of the VF is surpassed, sustained phonation degrades precipitously, becoming severely pathological. If laryngeal reconstruction approaches can ensure VF contact is maintained during phonation (i.e., vertical displacement doesn't surpass VF medial length), improved vocal outcomes are expected.

Unexpected blunt neck trauma resulting in laryngeal fracture, the case of the dangerous wooden box: A case report.

BACKGROUND: Laryngeal fracture is a rare condition but is potentially lethal. These injuries are usually caused by major blunt trauma from motor vehicle accidents, physical assaults, or sports injuries. The high mortality associated with these injuries requires prompt recognition and treatment. CASE REPORT: We present a case of laryngeal fracture caused by falling from standing height and landing onto the edge of a wooden box- a seemingly minor blunt trauma. The patient fractured her thyroid lamina and had a comminuted fracture of the cricoid cartilage. The patient was able to be decannulated and required injection augmentation for return of normal voice. CONCLUSION: This case highlights the importance of maintaining a high level of suspicion for laryngeal fracture in a patient that falls and strikes the anterior neck. Early identification of laryngeal fractures not only allows for airway protection but helps ensure the preservation of voice, swallowing and airway functions.