Management of penetrating laryngotracheal injuries

Penetrating laryngotracheal injuries are uncommon; however, these injuries are associated with significant morbidity and mortality. In an attempt to define the management of penetrating laryngotracheal injuries, we reviewed our experience with these injuries.

We retrospectively analyzed the records of all patients admitted to a Level I trauma center who required operative management for penetrating laryngotracheal injuries. During the period of this study all patients with penetrating neck injuries were managed according to a protocol of selective exploration.

Of fifty-seven patients with penetrating laryngotracheal injury 32 patients sustained gunshot wounds and 25 had stab wounds. The injuries were to the larynx in 24 (42%) and trachea in 33 (58%). Forty-six (81%) had isolated airway injuries and 11 (19%) had combined airway and digestive-tract injuries. Emergent airway management in 32 (56%) patients included: tracheostomy (15), endotracheal intubation (14), and cricothyroidotomy (3). Respiratory distress and subcutaneous crepitus were the commonest clinical findings. Diagnostic evaluation included: laryngoscopy/ tracheoscopy (17), esophagoscopy (12), contrast esophagography (9), angiography (8), and bronchoscopy (3). Repair of laryngotracheal and esophageal injury was performed in the majority of patients. Selected patients with milder laryngotracheal injury did not have tracheostomy performed, with no increase in morbidity or mortality. There were 2 (3.5%) early deaths from associated major vascular injury.

Mortality can be minimized by aggressive airway control. Endotracheal intubation can be accomplished safely in selected patients with penetrating laryngotracheal injuries. Digestive-tract injuries can often clinically occult and contribute significantly to morbidity and mortality; therefore, early evaluation of the esophagus is vital. Simple repair of laryngotracheal and digestive-tract injuries can be performed safely with good results. In patients with minor injuries, tracheostomy does not appear to be mandatory.