Laryngeal lacerations, stab wounds, and firearm injuries are classified as open laryngeal trauma. These injuries may involve laryngeal cartilage, mucosa, and other structures. If the laryngeal cavity is penetrated, it is termed a penetrating laryngeal trauma. Such injuries often affect major blood vessels in the neck, leading to severe hemorrhage. Firearm injuries caused by shrapnel or bullets may also involve the cervical spine.
Etiology
The causes include:
- Sharp instrument lacerations to the larynx during altercations or suicide attempts.
- Fragmentation injuries or puncture wounds to the larynx from debris, sharp objects, or accidents during construction, traffic incidents, or other emergencies.
- War-related injuries from shrapnel or bullets. Shrapnel injuries often cause extensive damage and fragmentation of the larynx, while bullet wounds typically result in smaller, penetrating injuries.
Clinical Manifestations
Hemorrhage
Bleeding primarily originates from the laryngeal and thyroid vasculature. Severe hemorrhage may lead to shock. Blood entering the lower respiratory tract can cause asphyxia. Injury to the carotid artery or internal jugular vein often results in fatal hemorrhage before emergency intervention is possible.
Subcutaneous Emphysema
Coughing forces air through damaged laryngeal mucosa into the neck subcutaneous tissue or deep fascial spaces, causing subcutaneous emphysema, mediastinal emphysema, or pneumothorax.
Respiratory Distress
This is caused by:
- Laryngeal cartilage fractures (e.g., displaced cricoid arch fractures) narrowing the laryngeal lumen
- Mucosal swelling or hematoma obstructing the airway
- Blood aspiration into the lower respiratory tract, mediastinal emphysema, or pneumothorax causing lung collapse
- Vocal cord paralysis or cricoarytenoid joint dislocation reducing the glottic aperture
Hoarseness or Aphonia
This is caused by injury to the vocal cords, cricoarytenoid joints, or recurrent laryngeal nerve.
Dysphagia
Pain is exacerbated by laryngeal movement during swallowing. If the trauma communicates with the hypopharynx or upper esophagus, saliva or food may leak through the neck wound.
Wound
Wound characteristics:
- Sharp instrument lacerations: Clean, well-defined edges.
- Puncture wounds: Small but variable depth.
- Firearm injuries: Bullet wounds have small entry/exit points; shrapnel wounds show larger, irregular defects.
Treatment
Emergency Measures
The main goals are to control bleeding, manage shock, and alleviate respiratory distress.
In cases of significant active bleeding, identifying the bleeding site and performing ligation are needed. If the bleeding site is deep and difficult to locate, tamponade with pressure can be used to control the bleeding.
For patients showing symptoms of shock, such as a drop in blood pressure, rapid and weak pulse, pale and cold skin, rapid establishment of intravenous access is necessary for the infusion of isotonic solutions or whole blood.
When respiratory distress is observed, identifying the cause and relieving the difficulty in breathing are required. Obstruction caused by laryngeal mucosal swelling, hematoma, or cricoid cartilage arch fracture may necessitate an early tracheotomy. If blood enters the lower respiratory tract, endotracheal intubation or tracheotomy can be performed to aspirate blood from the airways. Closed drainage may be performed for cases involving mediastinal emphysema or pneumothorax.
Early administration of antibiotics, hemostatic agents, and tetanus antitoxins is recommended.
Surgical Treatment
Wound Debridement
Cleaning the neck skin with normal saline, soapy water, and hydrogen peroxide solution is performed first, followed by disinfection with povidone-iodine solution. For laryngeal incisions or puncture wounds, fragmented laryngeal cartilage and tissue should be preserved as much as possible. For firearm injuries, devitalized tissue should be excised. Thorough wound cleaning and hemostasis should be carried out. The wound should be carefully inspected for foreign bodies, and any identified must be removed.
Repair
Proper alignment of the wounded laryngeal tissue should be conducted, with fractured cartilage repositioned and fixed by suturing. The laryngeal mucosa, perichondrium, anterior cervical muscles, subcutaneous tissue, and skin should be sutured layer by layer. Special attention should be given to ensuring that the wounds on the laryngeal cavity are fully closed.
Placement of a Laryngeal Mold
A laryngeal mold is placed inside the laryngeal cavity and secured to prevent laryngeal stenosis.
Placement of a Nasogastric Tube
A nasogastric tube is inserted prior to closing the laryngeal cavity, as this is more convenient than inserting it after completing the surgery.