Eur Arch Otorhinolaryngol (2006) 263: 228–232 DOI 10.1007/s00405-005-0989-z
MISCELLANEOUS
Davorin Danic Æ Drago Prgomet Æ Alen Sekelj Krunoslav Jakovina Æ Ana Danic
External laryngotracheal trauma
Received: 11 March 2004 / Accepted: 21 April 2005 / Published online: 5 October 2005 Ó Springer-Verlag 2005
Abstract Differences in acute external injuries of the larynx and cervical trachea between peacetime and war trauma were studied. Twenty-six patients with peacetime injuries and 39 patients with war injuries were retrospectively analyzed. The incidence of peacetime laryngotracheal injuries was 0.91% of the total number of patients hospitalized for head and neck injuries. In the groups of wounded in action (WIA) and killed in action (KIA) with head and neck war injuries, the incidence of laryngotracheal injuries was 4.8 and 6.2%, respectively. According to the type of the wound, blunt injuries were most common among peacetime and penetrating wounds among war injuries. There was no difference between peacetime and war injuries according to the wound localization. War wounds were more severe, caused more extensive local tissue and organ defects, were associated with a greater number of lesions to the neck and other body regions and more often required reconstructive surgical procedures than peacetime injuries. The mortality of war laryngotracheal injuries was two times greater than that of peacetime lesions (9 vs. 3.8%). Keywords Trauma Æ Larynx Æ Trachea Æ War
D. Danic (&) Æ A. Sekelj Æ A. Danic Department of Otorhinolaryngology and Cervicofacial Surgery, General Hospital Dr. Josip Bencˇevic´, 35000 Slavonski Brod, Croatia E-mail:
[email protected] Tel.: +385-35-446018 Fax: +385-35-446018 D. Prgomet Clinic of Otorhinolaryngology and Cervicofacial Surgery KBC Zagreb, University School of Medicine, Zagreb, Croatia K. Jakovina Department of Pathology and Forensic Medicine, General Hospital Dr. Josip Bencˇevic´, Slavonski Brod, Croatia
Introduction External laryngotracheal injuries are clinically significant and potentially lethal lesions. As differentiated from internal laryngotracheal trauma, which is more common and occurs following intubation and endolaryngeal procedures, the less common external injuries of the larynx and trachea are caused by a variety of mechanical forces. The early and accurate identification of these lesions and their timely and appropriate medical management are the basis of prevention of serious complications, including acute respiratory obstruction, laryngeal and/or tracheal stenosis or the potential death of the patient. The epidemiology, conditions of infliction and management of these injuries differ significantly between war and peacetime lesions. Gussack et al. reported on the incidence (less than 1%) of peacetime injuries for all external lesions of the larynx [7]. A significant contribution to the analysis of peacetime injuries to the larynx has been provided by Schaefer and by Jewett et al. in the largest series to date, including 392 patients [8, 15]. The reported mortality rate ranged from 0 to 18% [6, 8]. In spite of a number of classifications proposed for peacetime laryngotracheal injuries aimed at better understanding and defining the extension of these lesions to allow for proper planning of a specific therapeutic protocol, there are still many controversies concerning the evaluation of lesions in a polytraumatized patient, diagnostic methods and strategies to be used, as well as timing and methods of their surgical management [10]. In the medical literature, there are only few studies analyzing external war injuries to the larynx and trachea [1, 4]. The highest number of these injuries [5] was recorded by Zayton et al. in 1,021 patients with head and neck wounds during the 10-year war in Lebanon, whereas Jones et al. described six tracheal and cricoid lesions in 1,011 patients from the war in Vietnam [9, 17]. War trauma is assessed according to the mechanism of infliction, cause and place of death and frequency,
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distribution and severity of the lesions [11]. According to Bellamy et al. [3], war casualties are divided into four categories: (1) killed in action (KIA), defined as those who died on the battlefield before reaching a medical facility; (2) died of wounds (DOW), defined as those who died after arriving at a medical facility staffed by a physician; (3) wounded in action (WIA), defined as those who were injured severely enough to require admission to the hospital for at least 24 h; (4) carded for record only (CRO), defined as those with minor injuries who were treated and returned to duty on the same day. The aim of our study was to determine the similarities and differences between peacetime and war trauma according to the incidence of wounding, mortality, predominant mechanism of wounding, localization and severity of lesions. In addition, therapeutic modalities, as well as useful experience acquired during the war for further progress of peacetime medicine are presented.
Patients and methods Sixty-five patients with external laryngotracheal injuries recorded at Dr. Josip Bencˇevic´ General Hospital in Slavonski Brod were included in the study.
Peacetime trauma Twenty-six patients with peacetime laryngotracheal injuries over a 10-year period (1994–2003) accounting for 0.91% of patients were hospitalized for head and neck trauma. There were 21 male and 5 female patients aged 21–78 years (median 39.7). Blunt injuries were present in 16 (61%) and penetrating injuries in 10 (39%) patients (Table 1). The most common cause of trauma was car accident (11 patients), followed by suicide attempts (8) and violence (7). War trauma During the 1991–1992 war in Croatia, 7,720 patients with war wounds, 39 of them with larynx and/or trachea injuries, were recorded. Table 1 Etiology of peacetime and wartime external laryngotracheal trauma (n=48) Group
Mild (n=12) Intermediate (n=11) Severe (n=25)
Type of injury, number of patients
Peace War Peace War Peace War
Blunt injuries
Penetrating injuries
Total
9 1 5 0 2 15
1 1 2 4 7 1
10 2 7 4 9 16
KIA: killed in action There were 271 KIA cases with head and neck injuries recorded at the Department of Pathology and Forensic Medicine, 17 (6.2%) of them with laryngotracheal lesions. In this group, the cause of death could not be thoroughly investigated, i.e., complete autopsy to positively determine the organ injury that had caused death could not be performed because of the civilian hospital location in the area directly involved in war actions, lack of medical professionals and massive tissue and organ destruction. Explosive wounds were present in 74.9%, gunshot wounds in 22.1% and other causes of wounding in 2.8% of cases.
WIA: wounding requiring hospital admission This group consisted of 449 patients with head and neck injuries, excluding craniocerebral and eye injuries; 22 (4.8%) patients had sustained external laryngotracheal lesions. All these patients were males, aged 5–22 years (median 22.4), 68% of them soldiers and 32% civilians. Penetrating wounds were present in 21 (91%) and blunt wounds in 2 (9%) patients (Table 1). Shell and mine fragments were the causes of wounding in 18 (82%), bullets in 2 (9%) and explosives and contusion in 1 (4.5%) patient each. Rigid and flexible endoscopies, X-ray and computed tomography scanning were used in the diagnostic procedure.
Results Out of 65 patients with external laryngotracheal injuries, 26 were peacetime injuries, yielding a incidence of 0.91% and mortality of 3.8%. The WIA group of war wounds included 22 patients with this type of injury, with a 4.8% incidence and 9% mortality. The KIA group consisted of 17 cases, with a prevalence of 6.2%. According to wound localization, laryngeal lesions were present in 37 (21 peacetime and 16 war traumas), laryngeal and tracheal lesions in 8 (4 peacetime and 4 war traumas) and isolated lesions (peacetime and war trauma) of the cervical trachea in 2 of 48 hospitalized patients. Conservative treatment was used in 12 (24%) patients, 11 of them with peacetime trauma and 1 with war trauma, whereas 36 (76%) patients underwent surgical treatment, 15 of them for peacetime trauma and 21 with war trauma. Three (6.2%) patients, two of them with war wounds and one with peacetime trauma, died during the 1st week postoperatively. Evaluation of respiratory function and phonation at 12 months of treatment was performed in 36 patients. Twelve dropouts were recorded during the follow-up period. On the basis of our clinical experience and analysis of the type and mechanism of infliction, severity and extent of injuries and methods of treatment, the external
230 Table 2 Classification of external laryngotracheal trauma (n=48) Group
Characteristics
Treatment modalities
Mild (n=12)
Edema, hematomas of the mucosa Minimal respiratory obstruction Mucosa laceration, hematoma Fracture without dislocation Respiratory obstruction Large endolaryngeal lesion Multiple fractures with defects Severe respiratory obstruction
Conservative Surgery without exploration of the larynx Surgical Exploration of the larynx
Intermediate (n=11) Severe (n=25)
injuries to the larynx and trachea were classified into three groups (Table 2). Group I: mild In this group, a great majority of injuries were caused by blunt external mechanical force that did not entail major tissue defects. The injuries were confined to the larynx or trachea without involvement of other organ lesions. In most cases, these injuries were recorded in the peacetime period. Clinically, edema or mucosal hematomas with minimal respiratory obstruction were observed in the larynx or trachea. In most patients, therapy was conservative, whereas surgical management without laryngeal or tracheal exploration was only occasionally used. Respiratory function and phonation recovered successfully after the treatment. There were 12 patients in this group (Table 3). Group II: intermediate The injuries included in this group were inflicted by blunt mechanical force, but penetrating wounds were also present. Besides injuries of the larynx and/or trachea, lesions to other organs of the neck and/or other parts of the body were recorded. These injuries were equally encountered in peacetime and during the war. Clinically, mucosal lacerations with edema and hematomas, and small areas of denuded cartilage were endolaryngeally and/or endotracheally observed. Minor fractures of the cartilaginous skeleton without fragment dislocation could be present. These injuries were accompanied by moderate respiratory dysfunction. Table 3 Treatment results of peacetime and wartime external laryngotracheal trauma (n=36)*
Group III: severe The majority of wounds from this group were inflicted by penetrating force with major injuries to adjacent or distant organs. These injuries were more frequently encountered during the war. Locally, major fractures of the laryngeal and/or tracheal cartilage accompanied by cartilaginous skeleton instability and lesions to the muscle, ligaments and laryngeal nerves were present and associated with major respiratory obstruction. These injuries required surgical treatment with various methods of reconstruction. Surgical repair is mandatory for reduction of displaced fractures, cleaning the laryngeal wounds, removing foreign objects, meticulously readapting anatomical structures and suturing of cartilage fragments and mucosal lacerations. Patients with a severely disrupted anterior larynx need endolaryngeal stents. In the present study, 25 patients were classified in this group of laryngotracheal injuries. Good respiration after treatment was present in 78%, and good phonation in 66% of the cases (Table 3).
Outcome, number of patients Respiration
Intermediate (n=9) Severe (n=18) Unknown data for 12 patients
Surgical therapy was used, with exploration of the wound. In general, access to the larynx is gained through the wound itself with further extension as required. Surgical debridment, laryngofissure, internal fixation of the fragments and suturing mucosal laceration without stenting were performed. The anatomic location of the injury determined the need for tracheostomy. Appropriate treatment of these injuries resulted in good respiration and satisfactory phonation. In our study, 11 patients were classified in this group of laryngotracheal injuries (Table 3).
Group
Mild (n=9)
*
Surgical Exploration and reconstruction of the larynx
Peace War Peace War Peace War
Phonation
Good
Bad
Good
Bad
8 1 6 3 5 9
0 0 0 0 1 3
8 1 5 2 4 8
0 0 1 1 2 4
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Discussion Analysis of external laryngotracheal trauma in our group of patients revealed the incidence of these injuries among war casualties to be greater than that recorded in patients with peacetime trauma (4.8 vs. 0.91%). The prevalence types of peacetime injuries were comparable to the reports from western countries [7]. In contrast, in the analysis of injuries among pilots involved in fatal general airplane accidents, Wiegemann and Taneja found a high incidence a fractured larynx in 14.7% of the cases, a finding that has not been further reported in the literature [18]. On the other hand, different types of war, the development of various weapons and of protective measures have led to variations in the rate of these injuries during war. During the war in Vietnam, a low rate of 0.5% of exogenous laryngotracheal lesions was recorded [17]. The rate of 5.2% was reported from the war in Lebanon [9], which is comparable to our results. Apart from the rate differences, significant variation in the type of trauma has been observed. In our group of patients with peacetime trauma, blunt injuries prevailed, which is consistent with most of the literature reports [10, 13]. Peacetime blunt and penetrating injuries resulted in similar types of tracheal and laryngeal injuries. Management of the injuries depends on the injury severity and locations [16]. In these cases, blunt injuries caused isolated trauma and minor organ lesions. Most of these patients were conservatively treated or sparing surgical procedures were used, with good therapeutic results. In contrast to this, most of the war injuries were penetrating wounds inflicted by shell or mine fragments, which were one of the main features of the war in Croatia. Penetrating trauma can cause both direct and indirect (blast) injury to the laryngotracheal region. These wounds caused massive destruction of the local tissue, frequently accompanied by adjacent organ defects. Operative intervention was required in all patients. Clearing the wounds, surgical debridment, removal of foreign objects, extralaryngeal repositioning and endo-extralaryngeal fixation of the cartilaginous fragments by sutures without stenting were performed. Patients with a severely disrupted anterior larynx needed endolaryngeal stents. We used cervical fascia in the reconstruction for defect of the thyroid cartilage or tracheal lumen. Based on our experience, cervical fascia proved to be useful for covering denuded cartilage surface and for additional external fixation of thyroid, cricoid or tracheal cartilages in lesions that caused instability of the laryngotracheal framework [4]. In most cases, satisfactory therapeutic results were achieved. In our study, there was no difference in the lesion localization between peacetime and war traumata. The highest incidence of laryngotracheal injuries (6.2%) was recorded in the KIA group. Severe multiple organ lesions were found in most KIA cases; however, laryngotracheal lesions could have been the cause of death in most of them. The main difference between peacetime
and war traumata was observed at the medical system level at which death occurred. The death rate of 3.8% recorded in our group of patients with peacetime injuries is comparable to that reported by Grewal et al., and significantly lower than some other literature reports [5, 6, 12]. However, a greater rate (9%) was recorded in the group of war trauma, confirming the results of Bellamy who compared war and civilian casualties and found the probability of death from war wounds to be several-fold that for peacetime trauma, the same also holding for the probability of death before reaching a medical facility [2]. This is supported by two facts. First, penetrating war injuries are inflicted by high-velocity projectiles, whereas most civilian injuries are caused by low-velocity bullets. These two types of wounds differ considerably in the grade of tissue destruction and wound contamination. Analysis of the grade of tissue destruction and mortality in our patients confirmed the data reported elsewhere. Secondly, the mortality rate depends on the type of war, i.e., on the intensity of war actions involved. The number of deaths has been postulated to be considerably lower in low-intensity than in high-intensity war actions, whereas the probability of death at the hospital level appears to be identical to that recorded for civilian trauma [2, 14]. The main causes of death in our DOW group were the associated injuries of the cervical spine, and not laryngotracheal lesions. The higher mortality from war wounds primarily results from different etiologic factors, which lead to more severe local organ defects, frequently associated with multiorgan lesions and generally poorer medical care conditions. In conclusion, the results of the present study showed that external laryngotracheal trauma was more common during the war than in peacetime. As differentiated from peacetime injuries, war wounds are characterized by a greater proportion of penetrating injuries with more severe and more extensive local organ defects, and a greater number of associated lesions to adjacent organs. There was no difference in the localization of exogenous laryngotracheal injuries between the peacetime and war wounds. War wounds were more severe, and more often required reconstructive surgical procedures than peacetime injuries, which resulted in poorer treatment outcome and higher postoperative mortality. Acknowledgements We wish to express our special thanks to Prof. Dr. Ana Marusˇ ic´ and Prof. Dr. Matko Marusˇ ic´ for assistance with the preparation of the manuscript.
References 1. Banfield GK, Chowdhury CR, Brookstein R (1995) Penetrating laryngeal injury: two case reports from Bosnia. J Laryngol Otol 109:144–146 2. Bellamy RF (1984) The causes of death in conventional land warfare: implications for combat casualty care research. Milit Med 149:55–62
232 3. Bellamy RF, Maningas PA, Vayer JS (1986) Epidemiology of trauma: military experience. Ann Emerg Med 15:1384–1388 4. anic´ D, Milicˇic´ D, Prgomet D, Leovic´ D (1996) Acute laryngeal trauma: a comparison between peacetime and war injuries. J Laryngol Otol 110:435–439 5. Flynn AE, Thomas AN, Schecter WP (1989) Acute tracheobronchial injury. J Trauma 29:1326–1330 6. Grewal H, Prakashchandra MR, Mukerij S, Ivatury RR (1995) Management of penetrating laryngotracheal injuries. Head Neck 17:494–502 7. Gussack GS, Jurkovich GJ, Luteman A (1986) Laryngotracheal trauma: a protocol approach to rare injury. Laryngoscope 96:660–665 8. Jewett BS, Shockley WW, Rutledge R (1999) External laryngeal trauma analysis of 392 patients. Arch Otolaryngol Head Neck Surg 125:877–880 9. Jones EL, Peters AF, Gasior RM (1986) Early management of battle causalities in Vietnam. Arch Surg 97:1–15 10. Kleinsasser NH, Priemer FG, Schulze W, Kleinsasser F (2000) External trauma to the larynx: classification, diagnosis, therapy. Eur Arch Otorhinolaryngol 257:439–444 11. Mabry RL, Holcomb JB, Baker AM, Cloonan CC, Uhochak JM, Perkins DE, Canfield AJ, Hagmann JH, Cann C, Hirsch EF
12. 13. 14.
15. 16. 17. 18.
(2000) United States Army Ranges in Somalia: An analysis of combat causalities on an urban battlefield. J Trauma 49:515–529 Minard G, Kudsk KA, Croce MA, Butts JA, Cicala RS, Fabian TC (1992) Laryngotracheal trauma. Am Surg 58:181–187 Perdikis G, Schmitt T, Chait D, Richards AT (2000) Blunt laryngeal fracture: another airbag injury. J Trauma 48:544–546 Prgomet D, anic´ D, Milicˇic´ D, Puntaric´ D,Soldo-Butkovic´ S, Jelic´ J, Jakovina K, Leovic´ D (1998) Mortality caused by war wounds to the head and neck encountered at the Slavonski Brod Hospital during the 1991–1992 war in Croatia. Milit Med 163:482–485 Schaefer SD (1992) The acute management of external laryngeal trauma. Arch Otolaryngol Head Neck Surg 109:598–604 Stassen NA, Hoth JJ, Scott MJ, Day CS, Lukan JK, Rodriguez JL, Richardson D (2004) Laryngotracheal injuries: does the injury mechanism matter? Am Surg 70:522–525 Zaytoun GM, Shikhani AH, Salaman SD (1986) Head and neck injuries: 10-years experience at the American University of Beirut Medical Center. Laryngoscope 96:899–903 Wiegmann DA, Taneja N (2003) Analysis of injuries among pilots involved in fatal general aviation airplane accidents. Accid Anal Prev 35:571–577
