Cervical Trauma

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Airway Management. The first priority in management of upper airway injury is establishment of a dependable airway. Even the patient with little or no sign of airway obstruction, but with suspected or demonstrated airway separation may decompensate rapidly. Equipment for intubation, flexible broncho-scopy, rigid bronchoscopy, and tracheostomy should be immediately available. An anesthesiologist should be in attendance. The surgeon should attempt to pass an endotracheal tube, preferably over a flexible bronchoscope (see Figure 10-1A in Chapter 10, "Tracheostomy: Uses, Varieties, Complications"). Blind intubation is better avoided, although it may succeed. The ends of the separated trachea may be offset, and the appearance of the gap on bronchoscopy may be confusing, with torn tissue and blood. The fact that the patient can breathe, however poorly, proves that there is an air channel through the disruption. Usually, a flexible bronchoscope can be threaded into the distal trachea and the endotracheal tube slipped in over it. Some assessment of the larynx also is made in passing, but it may not be entirely satisfactory. Rigid bronchoscopy is considerably more difficult, unless the patient is less responsive. It should not be used if there is any hint of cervical spine injury. Drugs that depress respiration are to be avoided. If an attempt to insert a flexible bronchoscope fails, the surgeon should proceed directly to emergency tracheostomy. This is one of the few remaining indications for emergency tracheostomy. Since all maneuvers may have to be telescoped into a few minutes, it is essential that necessary instruments be at hand at the outset. Upon entering the neck, the surgeon may encounter a mass of lacerated, swollen, and contused tissues and blood clots. The trachea will not be seen if it has retracted into the mediastinum. The simplest way to find the distal trachea in these circumstances is to insert a finger into the mediastinum to seek the lumen. The edge of the trachea is grasped with an instrument such as Allis forceps and drawn upward into the base of the neck. The torn distal end is intubated directly across the field.

After suctioning and stabilization of the patient, two courses of action are open. Examination of extent of injury may be completed and the airway injury repaired. If more pressing concerns demand attention, such as major vascular injury, intracranial damage, or intra-abdominal hemorrhage, or if the attending surgeon is not versed in the techniques of airway reconstruction, it may be preferable to settle for the security of a tracheostomy. The distal end of the severed trachea is fixed to tissues at the base of the neck with a few sutures, and a cuffed tracheostomy tube is placed directly into the distal end. Minimal or no débridement is done. The neck is drained. Damage to the esophagus or pharynx must be repaired at once and suitably reinforced to prevent secondary leakage. If tracheostomy alone is elected for interim management of the injury, the tube should be placed in the already open end of the distal trachea and not in a new opening made in the tracheal wall below the rupture. The latter would further damage the trachea, accomplish nothing of value, and complicate future definitive repair. The proximal airway opening is exteriorized or drained.

Approach. The cervical trachea is approached through a low-collar incision. Extension is not often needed, but the field should be prepared to permit vertical partial or complete sternotomy.

Tracheal Laceration. A partial injury confined to the anterior tracheal wall alone is débrided conservatively if the injury is blunt, and repaired directly, if possible, with interrupted 4-0 Vicryl sutures. A penetrating injury caused by a sharp instrument such as a knife is more simply repaired (Figure 31-1A). Loss of a piece of anterior tracheal wall, as occurs due to a missile, whether a flying industrial fragment or a bullet, on rare occasions may be débrided and repaired. However, if the damaged segment is of any great length, it is best managed by resection of the involved segment of trachea and end-to-end anastomosis (Figure 31-1B). The surgeon must be wary of wide wedge resections, which can result in obstructive kinking of the trachea. In these missile-induced injuries, the airway is established easily by endotracheal intubation because the trachea remains in continuity. Tracheostomy is not routinely necessary. Its use depends on the adequacy of glottic function. If tracheostomy is performed distal to the level of injury, it is sealed from the anastomosis by suturing strap muscles or the thyroid isthmus over the anastomosis and to the trachea. If the level of the injury pushes the tracheostomy into potential proximity to the brachiocephalic artery, the artery is protected from the tracheostomy site by suturing a strap muscle obliquely across the anterior surface of the trachea beneath the tracheostomy and above the artery (Figure 31-1C).

Erosion Trachea

figure 31-1 Acute cervical tracheal injuries. A, A sharp wound such as that caused by a knife is cleansed and sutured with interrupted 4-0 Vicryl sutures, after inspection of the surrounding structures (esophagus, carotid artery, jugular vein). A recurrent laryngeal nerve may be traumatized. B, Irregular penetrating injury caused by a bullet or a military or industrial fragment requires debridement at minimum. Usually, limited circumferential resection is preferable to angulated closure after wedge excision, and to local tissue patches, which are subject to leakage, accumulation of granulation tissue, and cicatricial stenosis. C, Tracheal separation is most often due to blunt cervical trauma ("clothes line" or "dashboard" injuries). One or both recurrent laryngeal nerves may be injured. Limited debridement and a direct anastomosis is performed. Hence, tracheostomy distal to injury and repair is needed. If the tracheostomy is adjacent to the brachiocephalic artery, sternohyoid muscle is sutured to the trachea beneath the stoma to protect the artery from erosion. The anastomosis is covered by suturing strap muscles together or by suturing the thyroid isthmus over the anastomosis (and to the trachea). If endotracheal intubation is selected but tracheostomy is likely to be needed after a few days, coverage of the anastomosis and the artery is done, and the site of the future tracheostomy is marked with a single silk suture.

Tracheal Separation. A patent airway must be ensured urgently after acute tracheal separation. Cervical tracheal separation due to blunt injury often occurs just beneath or a short distance below the cricoid cartilage (see Figure 31-1C). Serrated tracheal margins are conservatively débrided. Careful determination is made by esophagoscopy and intraoperative examination that the esophagus is not lacerated. Instillation of dye high into the esophagus may be difficult to interpret since dye may flood up through the cricopha-ryngeus and down through the glottis, and appear in the operative field. Following débridement, the trachea is precisely anastomosed with 4-0 Vicryl sutures, using the technique described in Chapter 24, "Tracheal Reconstruction: Anterior Approach and Extended Resection." Since negligible loss of trachea has occurred, approximation is without tension, despite the apparently wide separation initially observed of the tracheal ends. In complete tracheal separation, recurrent laryngeal nerves are either temporarily or, more often, permanently injured unilaterally or bilaterally. Tracheostomy is usually needed distal to the line of repair. If tracheostomy is clearly necessary, the endotracheal tube for intraoperative ventilation may be placed at the outset through a vertical tracheostomy incision in an elective location below the laceration, thus simplifying débridement and anastomosis. Tracheostomy should lie at least 1 to 1.5 cm away from the anastomosis and not directly adjacent to the brachiocephalic artery. If these conditions cannot be met, it may be safer to manage the patient with endotracheal intubation for 4 or 5 days until the area has sealed, and then to establish a tracheostomy in a previously marked site.

Recurrent laryngeal nerves are not dissected since there are presently no reliable methods for reanastomosis. The larynx is reassessed by a skilled otolaryngologist after initial healing to determine what further procedures may be necessary to improve function, thereby permitting eventual closure of the tracheostomy.

Tracheal Separation with Laryngeal Damage. It is not the purpose of this section to describe all intricacies of blunt or sharp trauma to the larynx. However, the larynx may incur diverse injuries due to the level and force of the trauma in addition to avulsion of trachea from larynx (see Figure 9-1 in Chapter 9, "Tracheal and Bronchial Trauma"). Conservative débridement is the rule. Assessment of laryngeal injury is best performed with the cooperation of an experienced otolaryngologist. Early repair of complex laryngeal injuries should be made by an otolaryngologist. Therefore, only a brief statement about these injuries follows. Laryngeal structures such as a fractured or separated thyroid or cricoid cartilages should be repaired carefully with Vicryl sutures. Arytenoid and vocal cord injuries require repair. A trimmed tracheal edge is precisely anastomosed to the inferior margin of a repaired cricoid cartilage (Figure 31-2A). If laryngeal injuries are significant, internal splinting is advisable. Stents have been devised for this purpose, such as the molded silicone stents devised by Montgomery.1 The tracheostomy is placed distal to a laryngotracheal anastomosis (Figure 31-2B). In some cases, a T tube passing through the vocal cords may serve as an appropriate splint (Figure 31-2C). Eliachar and Nguyen devised a hollow-shaped laryngeal stent that rests on a tracheostomy tube lying just below it (Figures 31-3A,B).2

Separation of the airway at the cricotracheal junction may cause avulsion of posterior subglottic laryngeal mucosa from the cricoid plate. If this occurs, only limited débridement of the irregular edges of the flap attached to the trachea should be done. The preserved flap is used to resurface the bared posterior cricoid cartilaginous plate (Figure 31-4A). All bared cartilage should be covered with mucosa. If the flap is of insufficient length to surface the cartilage easily, slight further removal of anterior tracheal cartilage, especially on the lateral sides, will adequately lengthen the posterior flap. This flap is similar to that prepared surgically for primary repair of laryngotracheal stenosis (see Chapter 25, Laryngotracheal Reconstruction"). If the cricoid cartilage has not also been divided anteriorly by the injury, exposure for repair is facilitated by a limited anterior midline cricoid fissure (Figure 31-4B).

Tracheal and Esophageal Separation. Blunt injuries that lead to laryngotracheal separation or upper tracheal rupture also may produce laceration or separation of the upper esophagus, or pharyngoesophageal separation.

Trauma Posterior Bronchi

figure 31-2 Blunt trauma resulting in laryngotracheal separation and laryngeal fracture. A, Many patterns of injury may occur, including fractures of supra- and infraglottic larynx, vocal cord injury, arytenoid dislocation, and mucosal laceration. Very conservative laryngeal and conservative tracheal debridement precedes repair. The larynx and glottis are meticulously repaired, and laryngotracheal anastomosis is performed. A mattress suture can be employed at the "T" meeting of laryngeal and laryngotracheal suture lines. Distal tracheostomy is used for intraoperative anesthesia, since it is required postoperatively due to recurrent nerve injuries. B, If the larynx is crushed or deformed by the injury, it is reconstructed around a Montgomery laryngeal molded stent. The tracheostomy tube is in place. C, Silicone T tube employed as a stent. The proximal end lies in the laryngeal ventricle, below the false vocal cords.

Misshapen Trachea

figure 31-3 A, Montgomery molded silicone laryngeal stent designed to conform to the endolaryngeal surface. It is available in three sizes: adult male, adult female or adolescent, and child. The stent is held in place with sutures. B, Eliachar laryngeal stent. It is held in place against a tracheostomy tube and by contour, with an added strap tied to the neck.

Complete traumatic separation of the airway provides easy access to the esophagus (Figure 31-5A). However, anatomic planes may be confused by the trauma. Access is improved by placing traction sutures of 2-0 Vicryl in the lateral laminae of the cricoid cartilage. These must be firmly anchored in cartilage, but they do not enter the lumen of the larynx. Elevation of the larynx by traction on these sutures improves access to the retracted proximal pharyngoesophageal or esophageal tissues. Identifying sutures are placed at critical points in the esophageal mucosa proximally. The distal end is similarly identified. Very conservative debridement is accomplished. Precise two-layer anastomosis of the distal to the proximal esophageal segments or of the distal esophagus to the proximal pharyngeal segment is accomplished (Figure 31-55). The author prefers 4-0 Vicryl sutures. In circumferential separation, the first layer consists of interrupted mattress sutures from the posterior mus-cularis of the distal esophagus to the proximal posterior esophageal or cricopharyngeal musculature. Next, the posterior mucosa is approximated with interrupted sutures, placed so that the knots lie inside the lumen. After completing the back wall of the mucosal anastomosis, these sutures are continued anteriorly, inverting the mucosa as they are tied. Anastomosis is difficult when avulsion is at the cricopharyngeus. Minimal dissection may be required anteriorly to free up an edge of tissue between the pharyngeal mucosa and the back of the pos-

Scm Flap Tracheal Injury

figure 31-4 Blunt laryngotracheal rupture with avulsion of posterior laryngeal mucosa. A, Anterior fissure of cricoid and cricothyroid membrane provides access to posterior subglottic larynx. Mucosal edges are very conservatively trimmed. The posterior mucosal flap avulsed from over the posterior plate of cricoid is conservatively debrided, as is the trachea anteriorly and laterally. B, The avulsed posterior flap is used to cover the bared posterior plate of cricoid. Interrupted 4-0 Vicryl sutures are placed with knots outside of the mucosa. The technique is as described for laryngotracheal reconstruction in Chapter 25, "Laryngotracheal Reconstruction." Tracheostomy is used for intraoperative anesthesia as in Figure 31-2A.

figure 31-4 Blunt laryngotracheal rupture with avulsion of posterior laryngeal mucosa. A, Anterior fissure of cricoid and cricothyroid membrane provides access to posterior subglottic larynx. Mucosal edges are very conservatively trimmed. The posterior mucosal flap avulsed from over the posterior plate of cricoid is conservatively debrided, as is the trachea anteriorly and laterally. B, The avulsed posterior flap is used to cover the bared posterior plate of cricoid. Interrupted 4-0 Vicryl sutures are placed with knots outside of the mucosa. The technique is as described for laryngotracheal reconstruction in Chapter 25, "Laryngotracheal Reconstruction." Tracheostomy is used for intraoperative anesthesia as in Figure 31-2A.

Trauma Posterior BronchiLaryngotracheal Separation Procedure

figure 31-5 Combined cervical tracheal and esophageal rupture due to blunt injury. A, The esophageal injury may be anterior or circumferential. Access is improved with traction sutures of 2-0 Vicryl firmly placed extraluminally in the lateral cricoid laminae. Irregular edges are debrided. Note the endotracheal tube in the elective tracheostomy incision. The laryngeal and tracheal margins also are conservatively debrided. B, Esophageal or pharyngoesophageal reconstruction is performed with two layers of interrupted 4-0 Vicryl (or silk) sutures, according to Richard Sweet's technique (see text). The mucosal layer is inverted. Limited dissection behind the posterior margin of posterior cricoid provides sufficient mucosa and tissue for a layered anastomosis. Special care is used in dissection, even though recurrent laryngeal nerves are likely to have been divided in such an injury if esophageal division is complete.

terior cricoid plate. After the mucosal closure has been completed, it is usually possible to suture the anterior esophageal musculature either to muscle or to connective tissue lying just behind the lower edge of posterior cricoid. With lower lacerations, suturing is correspondingly easier. Extreme care and precision is necessary to obtain satisfactory closure. A pedicled strap muscle is sutured transversely over the esophageal closure prior to restoring the airway (Figure 31-5C). This interposition prevents later tracheoesophageal fistula. Tracheostomy is almost always needed (Figure 31-5D). Linear esophageal lacerations are minimally debrided, closed in two layers with interrupted sutures, and covered with a pedicled strap muscle.

Iatrogenic Tracheal Laceration. Lacerations of the trachea caused by endotracheal intubation are linear and occur in the membranous wall of the distal trachea centrally or at the junction with the cartilaginous wall. These may extend into the main bronchus, principally the right side (see Chapter 9, "Tracheal and Bronchial Trauma"). Upper lacerations are approached cervically. Lower injuries are usually repaired

Trachea Trauma

figure 31-5 (continued) C, A pedicled sternohyoid muscle is sutured over the enteric anastomosis. Its bulk does not interfere with laryngotracheal anastomosis. D, Laryngotracheal (or tracheotracheal) anastomosis is completed in the usual fashion using 4-0 Vicryl sutures. A tracheostomy tube is placed at the conclusion of the operation.

figure 31-5 (continued) C, A pedicled sternohyoid muscle is sutured over the enteric anastomosis. Its bulk does not interfere with laryngotracheal anastomosis. D, Laryngotracheal (or tracheotracheal) anastomosis is completed in the usual fashion using 4-0 Vicryl sutures. A tracheostomy tube is placed at the conclusion of the operation.

transthoracically. Angelillo-Mackinlay has described access to a midtracheal membranous tear via anterior linear tracheotomy.3 A laceration near the carina, especially if it extends into the main bronchus, is approached most readily by thoracotomy, usually on the right side. In the unlikely case in which the entire trachea must be exposed, a cervicomediastinothoracic or "trapdoor" incision extending to the right side may be used. Although concomitant esophageal injury is rare in these patients, it should be ruled out.

Tracheal laceration generally is best repaired when recognized. In selected cases, conservative treatment may be successful but only with careful observation.4 The laceration should be linear and short in length, clinical manifestations should be minor, and the situation should be stable and without progression of signs or symptoms. When these are in question, prompt and skillful repair is more appropriate.

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