a permanent tracheostomy or laryngectomy. A single surgical procedure ... avoid a laryngectomy in non-malignant pathology. The long-term results of this ...
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Clinical Report
POST TRAUMATIC LARYNGEAL INCOMPETENCE A.S.Banerjee, A.M.Shaaban, D.Gibson, M.G. Dilkes
Abstract: Self-inflicted laryngeal injuries are rare. This is a case of attempted suicide with a knife. The patient was brought into A&E and initial attempts at repair of the laryngo-skeletal structures were performed. Later it became evident that the patient had an insensate hypofunctioning larynx. We present a technique aimed at rehabilitating the poorly functioning, incompetent larynx without the necessity for a permanent tracheostomy or laryngectomy. A single surgical procedure combining a cricopharyngeal myotomy, an anterior hyoid suspension and vocal fold augmentations was performed in an attempt to avoid a laryngectomy in non-malignant pathology. The long-term results of this surgery would need to be subjected to further evaluation. Key words: Laryngeal injury, Aspiration, Anterior hyoid suspension, Cricopharyngeal myotomy
INTRODUCTION Laryngeal trauma is rare, with estimates suggesting that between 1:15,000 and 1:42,000 patients attending A+E have this condition.[1] The introduction of seat belt legislation has been a factor in this. Sharp injuries to the anterior neck usually slide off structures such as the larynx, upwards or downwards into the thyrohyoid and cricothyroid membranes respectively. Injuries to these areas can often lead to respiratory embarrassment.[2] It is important to treat laryngeal injury quickly and effectively, a reasonable algorithm for this was published by Schaefer in 1991 [Figure 1].[3] An incompetent larynx occurs when the larynx cannot adequately perform its main function – protection of the airway when swallowing. This condition is very rarely associated with trauma, usually being iatrogenic, whether caused by surgery or radiotherapy. Chronic aspiration is a potentially dangerous condition that may lead to recurrent pneumonia and bronchiectasis.[4] CASE REPORT A 53 year old man presented to the Accident and Emergency department with self inflicted knife wounds to the anterior and lateral neck. These were sustained in a suicide attempt. Initial assessment showed him to have a transected trachea at the level of the cricothyroid membrane, this injury extended into the pharynx. There was a fracture of the right-sided thyroid lamina, and the left vocal cord had been transected anteriorly. A tracheostomy was performed. The larynx was explored and debrided. Mucosal injuries were repaired, where
possible. The fractured cartilage was repaired using stainless steel wires. The damaged pharynx and trachea were repaired, as was other damage in the anterior and lateral neck. A size 10 endotracheal tube was shortened and secured within the laryngeal lumen as a makeshift stent. Following recovery from his injuries and removal of the stent, severe aspiration was noted on feeding/swallowing saliva. Video-swallow imaging suggested up to 95% of food and saliva was being aspirated. Vocal quality was poor. On flexible endoscopy there was incomplete glottic closure due to the poor healing of laryngeal tissue after surgery. The general laryngeal structure was abnormal, as a result of the injury and surgical repair. After assessment in the voice clinic by a senior speech therapist and consultant ENT surgeon, it was felt that bilateral superior laryngeal palsies were also present, contributing to the aspiration. Despite intensive speech therapy, the problem persisted. After 2 months of prolonged therapy, no progress was being made. The decision was made to perform a cricopharyngeal myotomy, along with anterior hyoid suspension and augmentation of the vocal folds with Bioplastic. This was performed in a standard fashion, the rationale being that anterior hyoid suspension would pitch the laryngeal introitus forward, helping the epiglottis to close over the larynx, and deflect food into the hypopharynx. The cricopharyngeal myotomy was performed to allow ingested food to drop freely through into the oesophagus. The vocal folds were augmented to improve glottic closure, both to strengthen the voice and
Department of ENT surgery, St Bartholomew’s Hospital, London EC1Y 0DT,A.S.Banerjee, 43 Daylesford Drive, South Gosforth, Newcastle upon Tyne, NE3 1TW Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 57, No. 3, July - September 2005 260 CMYK
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radical techniques being tried first. We settled on the operation described since it offered a low morbidity procedure with grounds for believing that a good result could be achieved. Cricopharyngeal myotomy is more often performed for chronic cricopharyngeal spasm usually of neurological origin. It is also commonly carried out after laryngectomy to aid voice rehabilitation[7] Anterior hyoid suspension is more commonly performed on severe sleep apnoeics who have tongue base obstruction at night.[8] The technique involves drilling channels through the anterior mandible and body of the hyoid bone, then inserting and tightening wires to bring the two bones together. An anterior displacement of between 1 and 2 centimeters can often be achieved. It is not an unduly morbid procedure post operatively. REFRENCES 1.
De Mello-Filho FV, Carrau RL. The Management of Laryngeal Fractures Using Internal Fixation. Laryngoscope 2000:110:2143-6.
Figure 1: Courtesy of Professor S. Schaefer. New York
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Maran AG. Trauma and Stenosis of the Larynx. Scott Brown Otolaryngology. 5th Edn 1987. p. 144–54
3.
further reduce aspiration.
Schaefer SD. The Treatment of Acute External Laryngeal Injuries. Arch Otolaryngol Head Neck Surg 1991;117:35-9.
4.
After surgery a significant improvement in aspiration occurred, such that 1 week later, the tracheostomy was removed. There was a good cough present. A further videoswallow test showed a significant improvement in aspiration. After further speech and physiotherapy, the patient was felt to be fit enough to go home.
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Olsen NR. Laryngeal Suspension and Epiglottic Flap in Laryngopharyngeal Trauma. Ann Otol 1976;85:533-7.
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Delaere PR, Ostyn F, Segers A, Vandyck W. Epiglottoplasty for Reconstruction of Post-traumatic Laryngeal Stenosis. Ann Otol Rhinol Laryngol 1991;100:447-50.
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DISCUSSION The treatment of severe aspiration due to an incompetent larynx is difficult.[5] A permanent tracheostomy may be required both for airway toilet and protection. On occasion, a laryngectomy may be required to completely separate the airway from the swallowing tract. There are a number of different surgical procedures used to treat this condition.[6] In this patient, who had a long history of severe depression and occasional psychotic episodes, it was not felt that surgery as radical as laryngectomy should be attempted without less
Logeman JA. Aspiration in Head and Neck Surgical Patients. Ann Otol Rhinol Laryngol 1985;94:373-6.
Bowdler DA. Pharyngeal Pouches. Scott Brown Otolaryngology 5th Edn. 1987. p. 271-82
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Warwick-Brown NP, Richards AE, Cheesman AD. Epiglottopexy: A Modification Using Additional Hyoid Suspension. J Laryngol Otol 1986;100:1155-8.
Address for Correspondce Department of ENT surgery, 43 Daylesford Drive, South Gosforth, Newcastle upon Tyne, NE3 1TW
Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 57, No. 3, July-September 2005 261 CMYK
