Michelle Mekky, MA, CCC-SLP, BRS-S

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Airway Trauma

• Michelle Mekky, MA, CCC-SLP, BRS-S
• Speech-Language Pathologist
• Memorial Hermann Hospital
• Childrens Memorial Hermann Hospital

2
Purpose

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

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Nelson Review Article

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

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Laryngeal Anatomy
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Anatomy continued
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Mechanism of Injury

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

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Blunt Trauma

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

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Examples of Blunt Trauma
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Ex. of Blunt Trauma (cont)
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Internal Trauma
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Fractures and Dislocations

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

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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

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Penetrating Trauma

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

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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

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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

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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

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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

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Reaction to Intubation

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

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Immediate Laryngeal Complications

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

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When to refer to ENT post intubation/extubation

• Hoarse voice greater than 48 hours
• Sore throat greater than 48 hours
• Dysphagia
• Odynophagia
• Stridor

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Management of Arytenoid Dislocation

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

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Treatment of Avulsion of the Epiglottis

• Open repair
• Laser excision

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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

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Late injuries of Intubation

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

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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

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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

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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

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Picture of Glottic Web
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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

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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

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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)

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Picture of Subglottic Stenosis
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Tx of Subglottic Stenosis

• Tracheostomy
• Open reduction
• Cricotracheal resection
• Medical management of GERD/LPRD if in the
  patients known history
• Steroids/Antibiotics
• Grafting

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Consequences of Self-Extubation

• Edema
• Possible vocal cord damage
• Cartilage dislocation

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Thermal and Chemical Trauma

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

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Long term Injuries

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

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What the MD looks for

• Cough
• Carbon particles
• Blood in the sputum
• Voice change
• Stridor
• Dyspnea (shortness of breath)

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Course of Treatment

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

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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)

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Role of the SLP

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

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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

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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

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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

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Edema

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

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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 txs by ENT fat injection
• Permanent txs by ENT medialization
  laryngoplasty or thyroplasty

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Bilateral Vocal Cord Paralysis

• Causes
• Paralysis (neurological)
• Fixation of the cricoarytenoid joints
• Both

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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

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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

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Hearing Loss (cont)

• Audiological/ENT referral is appropriate
• Referral to physical therapy may be indicated
• Speech tx for aural rehabilitation

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Thoughts for the Future

• Research in voice recovery s/p airway trauma
• Research in swallowing function s/p airway trauma