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International Journal of Scientific & Engineering Research, Volume 5, Issue 9, September-2014 1197
ISSN 2229-5518
compromise. After 1 week, CECT was done to rule out abscess formation or mediastinitis and to
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International Journal of Scientific & Engineering Research, Volume 5, Issue 9, September-2014 1198
ISSN 2229-5518
see degree of emphysema left. Review CT revealed significant decrease in both subcutaneous emphysema of the neck (Figure 5a, 5b) and pneumomediastinum (Figure 6) . No complications were seen. The patient was followed for few months. There was no difficulty in breathing or swallowing. However, a little change in patient’s voice was noticed. So, the patient was managed under steroid cover and close observation without active surgical intervention with good recovery.
The diagnosis of penetrating laryngeal injury is quite obvious but blunt laryngeal injury requires high clinical suspicion. It is often associated with head injury, facial fractures, cervical spine or vascular injuries, so may be missed. The accompanying history is very important. The patient may present with progressive dyspnoea, stridor, hoarseness of voice, hemoptysis, dysphagia, odynophagia and local tenderness, crepitus and swelling [5]. Lateral cervical X-ray may show subcutaneous emphysema and cervical vertebral injuries and posteroanterior chest X-ray may reveal pneumomediastinum and associated injuries. Laryngoscopy may be done to assess the airway patency above the trachea, vocal cord movements and injury to laryngeal mucosa. CT is the modality of choice for assessing the laryngeal architecture and evaluation of associated injuries. CT is not done in patients who require direct operative interventions. It is also not done
in those cases in which minor injury is suspected.
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Schaefer-Fuhrman classification is followed which divides laryngotracheal injuries into five groups. Conservative management is for the group 1 and some group 2 patients and involves observation. The rest require surgical intervention like tracheostomy, stent placement and exploration and repair. Indications for surgical repair include large mucosal lacerations, lacerations involving the free margin of the vocal cord, exposed cartilage, multiple and displaced cartilage fractures, arytenoids avulsion or dislocation and immobility of vocal cords. The definite goal of therapy is to restore all laryngeal functions like ventilation, airway protection, phonation and deglutition. The most common complication is granulation tissue formation which is sequelae to both laryngotracheal injury and surgery [6]. However, the management of laryngotracheal injury is still controversial and should be individualized. Follow up is recommended to evaluate long term complications like laryngeal stenosis, breathing difficulties, pulmonary aspiration and dysphonia. Monitoring is required for recovery of vocal fold paralysis and for neurovascular injury [7].
Panendoscopy and radiological imaging is required to assess the severity of aerodigestive injury in blunt neck trauma and the treatment should be individualized.
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1. Haris M. Qadri, Poonam Goyal, Abhinav Bansal. External laryngeal trauma: a management dilemma. Journal of Laryngology and Voice. 2012; 2: 98-100.
2. Pneumomediastinum and subcutaneous emphysema due to blunt neck injury: A case report and review of the literature. Ozgur Sogut, Muazzez Cevik, Mehmet Emin Boleken, Halil Kaya, Mehmet Akif Dokuzoglu. J Pak Med Assoc 2011; 61(7): 702-04.
3. Je Hyeok Oh, Hyun Seok Min, Tae Ung Park, Sang Jin Lee, Sung Eun Kim. Isolated cricoid fracture associated with blunt neck trauma. Emerg Med J. 2007 ; 24(7): 505–506.
4. Cliff Peady. Initial Airway Management of Blunt Upper Airway Injuries: A Case Report and Literature Review. Australasian Anaesthesia 2005; 13-21.
5. Michael Underbrink et al. Laryngeal Trauma.
Grand Rounds Presentation, UTMB, Dept. of Otolaryngology
2003.
6. Susan Edionwe et al. Blunt Neck Trauma and Laryngotracheal Injury. Grand Rounds
Presentation, University of Texas Medical Branch (UTMB), Dept. of Otolaryngology
2010.
7. Dr. Kohli A, Dr. Bhadoria P, Dr. Bhalotra A, Dr. Anand R, Dr. Goyal P. AN UNUSUAL LARYNGEAL INJURY. Indian J Anaesth 2007; 51(1):57-59.
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treatment shows almost complete disappearance of pneumomediastinum.
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