In case of a laryngeal injury complicated by bleeding, the victim should. External neck injuries

External;

Internal; “dumb;

- pricked,

- cut.

By degree of damage: isolated;

Combined.

Depending on the involvement of the skin: closed;

Open.

Upon penetration into the hollow organs of the neck: penetrating;

Non-penetrating. By etiology:

Mechanical (including iatrogenic);

Firearms:

- end-to-end,

- blind,

- tangents;

Knife;

Chemical;

Thermal.

Injury to the larynx and trachea can occur with general neck trauma. The causes of closed laryngotracheal injuries are a blow with a fist or an object, a car injury, attempts at suffocation, a blunt blow to the chest. Penetrating wounds are usually knife or gunshot wounds.

Isolated injuries to the larynx and trachea occur with internal trauma. Internal trauma to the larynx and trachea is often iatrogenic in nature (intubation, prolonged artificial ventilation). Injury to the larynx and trachea is possible during any manipulation of the larynx, including during endoscopic examinations and surgical interventions. Another cause of internal injury to the larynx and trachea is the entry of a foreign body (fish bone, parts of dentures, pieces of meat, etc.). Internal trauma to the larynx and trachea also includes burn injuries (thermal, chemical).

The larynx is protected by the lower jaw above, the clavicles below; its lateral mobility plays a certain role. In the event of a direct blow, such as a car or sports injury, a fracture of the cartilage of the larynx is caused by displacement of the larynx and compression of it against the spine. Blunt trauma to the larynx and cervical trachea may be accompanied by a fracture of the hyoid bone, cartilage of the larynx and trachea, or separation of the larynx from the trachea or from the hyoid bone. The vocal folds may be torn, there may be displacement of them or the arytenoid cartilages, and paresis of the larynx. Hemorrhages develop in the subcutaneous tissue and muscles, and hematomas are formed that can compress the structures of the neck and lead to respiratory failure. Traumatic injuries inside the larynx and trachea, submucosal hemorrhages, linear ruptures of the mucous membrane, and internal bleeding are of great importance. Injuries are especially severe when exposed to multiple traumatic agents in sequence.

External trauma, as a rule, entails damage to the tissues and organs surrounding the larynx and trachea: the esophagus, pharynx, cervical spine, thyroid gland, and neurovascular bundles of the neck.

Analyzing the possible mechanism of injury, three zones of the neck are conventionally distinguished. The first continues from the sternum to the cricoid cartilage (high risk of injury to the trachea, lungs, bleeding due to damage to blood vessels); the second - from the cricoid cartilage to the edge of the lower jaw (the area of ​​injury to the larynx, esophagus, possible damage to the carotid arteries and veins of the neck, is more accessible for examination); the third - from the lower jaw to the base of the brain (the area of ​​injury to large vessels, the salivary gland, and the pharynx).

With penetrating gunshot wounds, both walls of the larynx are often damaged. In approximately 80% of observed laryngeal wounds, the entry and exit wounds were located in the neck. In other cases, the entrance hole may be on the front of the head. It is difficult to determine the passage of the wound channel: this is explained by the mobility of the larynx and trachea, their displacement after injury. The skin edges of the wound often do not coincide with the wound canal, and its course is usually tortuous. In case of blind neck wounds accompanied by damage to the larynx and trachea, the exit hole may be located in the lumen of the larynx and trachea. Tangential wounds have a more favorable outcome due to the fact that the skeleton of the larynx and trachea is not damaged. However, it should be remembered that injury to neighboring organs and the development of chondroperichondritis of the larynx and trachea or phlegmon of the neck are possible in the early stages after injury.

Stab and cut wounds are often severe, as they are penetrating and are accompanied by injury to blood vessels. If a foreign body enters the larynx or trachea, asphyxia may immediately develop. If a foreign body penetrates soft tissue, inflammation and swelling develop, often bleeding. In the future, the inflammation process can spread to surrounding tissues, causing the development of mediastinitis and phlegmon of the neck. As with other injuries, penetrating injuries to the esophagus and the development of subcutaneous emphysema are possible.

In case of burn lesions, external damage to the mucous membrane of the oral cavity and larynx may not reflect the true severity of damage to the esophagus and stomach. In the first 24 hours, swelling of the mucous membranes increases, then ulceration occurs within 24 hours. Over the next 2-5 days, the inflammatory process continues, accompanied by vascular stasis (thrombosis). Rejection of necrotic masses occurs on the 5-7th day. Fibrosis of the deep layers of the mucous membrane and the formation of scars and strictures begins from the 2-4th week. Against the background of inflammation, perforation of hollow organs, the appearance of a tracheoesophageal fistula, the development of pneumonia and mediastinitis are possible. The risk of developing esophageal carcinoma increases sharply. As a result of such inflammation, cicatricial narrowings of the hollow organs of the neck often form.

The pathogenetic process of intubation trauma includes: hemorrhages in soft tissues, laryngeal hematomas;

Ruptures of the mucous membrane of the larynx and trachea;

Dislocation and subluxation of the cricoarytenoid joint;

Granulomas and laryngeal ulcers.

The outcomes of such injuries are scar deformation of the larynx and trachea, vocal fold cysts, post-intubation granulomas and laryngeal paralysis. Severe injuries can also be caused by bougienage of the narrowed lumen of the larynx and trachea in order to expand their lumens due to scar deformity. In this case, penetration of bougies into the paratracheal space is possible with the subsequent development of mediastinitis and damage to neighboring organs and large vessels.

In some cases, traumatic damage to the larynx (hemorrhage into the vocal folds, granuloma, subluxation of the cricoarytenoid joint) occurs with a sharp increase in subglottic pressure during screaming, severe coughing, against the background of constant overstrain of the vocal apparatus using a harsh attack of sound. Predisposing factors include gastroesophageal reflux, changes in microcirculation of the vocal folds, and taking medications containing acetylsalicylic acid.

With traumatic injury of any etiology, emphysema, hematoma and swelling of the laryngeal mucosa can increase within two days and instantly cause respiratory failure, stenosis of the larynx and trachea.

Dysphonia is characteristic of any damage to the larynx, especially its vocal tract. Voice quality may deteriorate suddenly or gradually. With damage to the trachea or bilateral paralysis of the larynx with stenosis of the lumen, vocal function suffers to a lesser extent.

Pain when swallowing, in the projection of the larynx and trachea, and “foreign body sensation” are also considered characteristic symptoms. Dysphagia, a violation of the separation function of the larynx, more often occurs with pathology of the entrance to the larynx or with paresis of the larynx, pathology of the esophagus or pharynx. The absence of dysphagia does not indicate the absence of pathology of the larynx and esophagus.

Cough- also an unstable symptom, it can be caused by the presence of a foreign body, an acute inflammatory reaction or internal bleeding.

The appearance of subcutaneous emphysema indicates the penetrating nature of the injury to the larynx or trachea. In the latter case, emphysema grows especially quickly, spreading to the neck, chest, and mediastinum. An increase in infiltration, leading to changes in the contour of the neck, is a sign of a more severe course of the wound process.

Bleeding from damage to hollow organs and soft tissues of the neck is considered life-threatening with open trauma to large vessels and the development of internal bleeding, causing aspiration of blood or the formation of hematomas, narrowing the lumen of the larynx and trachea.

Cough, hemoptysis, pain, dysphonia, shortness of breath, the development of subcutaneous and intermuscular emphysema are expressed to a large extent in transverse ruptures of the larynx and trachea. When the larynx is separated from the hyoid bone, laryngoscopic examination reveals elongation of the epiglottis, unevenness of its laryngeal surface, abnormal mobility of the free edge, low location of the glottis, accumulation of saliva, and impaired mobility of the elements of the larynx. By changing the configuration of the neck. mutual topography of the larynx, trachea and hyoid bone; by the areas of retraction of soft tissues in the rupture zone, one can judge the separation of the larynx from the hyoid bone, the larynx from the trachea, and the transverse rupture of the trachea. An increase in the distance between the upper edge of the thyroid cartilage and the hyoid bone by 2-3 times indicates a rupture of the thyrohyoid membrane or a fracture of the hyoid bone with avulsion of the larynx. In this case, the separation function is disrupted, which is confirmed by X-ray contrast examination of the esophagus - a prolapse of the larynx by 1-2 vertebrae and a high position of the epiglottis are detected. When the larynx is separated from the trachea, a high standing epiglottis, laryngeal paralysis, impaired separation function, swelling and infiltration of soft tissues in the damaged area are noted; The integrity of the anterior pharyngeal wall may be compromised.

With penetrating wounds in the area of ​​the thyrohyoid membrane (sublingual pharyngotomy), as a rule, the epiglottis is completely crossed and displaced upward, and laryngeal paralysis occurs. There is a forward tilt of the thyroid cartilage and drooping of the larynx. Upon examination, a gaping defect is visible. With a penetrating injury to the conical ligament, a defect is formed between the cricoid and thyroid cartilage, which subsequently leads to the formation of cicatricial stenosis in the subglottic region of the larynx.

Laryngeal hematomas can be limited, occupying only one vocal fold, or extensive, leading to obstruction of the airway. Laryngoscopy reveals infiltration of soft tissues and imbibition with blood. The mobility of the elements of the larynx is sharply impaired and can be normalized after the hematoma resolves. Deformation of the internal walls of the larynx and trachea, their thickening and infiltration indicate the onset of chondroperichondritis.

Intubation trauma is characterized by tissue injury in the posterior part of the larynx. With dislocation and subluxation of the arytenoid cartilage, it moves medially and anteriorly or laterally and posteriorly. In this case, the vocal fold is shortened and its mobility is impaired, which can be determined by probing. Hemorrhages into soft tissues, linear ruptures of the mucous membrane with bleeding, ruptures of the vocal folds, and the development of acute edematous or edematous-infiltrative laryngitis are possible. Post-intubation trauma can cause the formation of granulomas and ulcers, paralysis of the larynx, synechiae, cicatricial deformities of the larynx and trachea in the long term. Hemorrhage into the vocal fold disrupts its vibrator ability, which leads to hoarseness. In the future, a cyst, scar deformity, or persistent vascular changes in the vocal fold may form.

Burn lesions that occur when exposed to hot liquids are usually limited to the epiglottis and manifest as acute edematous-infiltrative laryngitis, often with stenosis of the airway lumen. When exposed to chemicals, changes in the esophagus may be more severe than changes in the oropharynx and larynx. Patients often complain of pain in the throat, chest and abdomen, dysphagia, dysphonia and respiratory distress. Inhalation burn injuries are much more serious. A severe inflammatory process develops, accompanied by edema, then granulation, scarring and stenosis of the airway lumen; changes appear in the mucous membrane of the nose and oropharynx in the form of acute edematous-infiltrative inflammation.

Burn injuries are often complicated by pneumonia. The general condition of the patient in such situations depends on the toxicity of the traumatic agent and the extent of the lesion.

Based on the endoscopic picture, several degrees of burn damage can be distinguished: the first is swelling and hyperemia of the mucous membrane;

The second is damage to the mucous, submucosal layer and muscle lining (can be linear or circular, the latter is usually more severe);

The third is extensive damage with the development of necrosis, mediastinitis and pleurisy, accompanied by high mortality).

Physical examination

Includes a general examination and assessment of the patient’s general somatic condition. When examining the neck, the nature of the injury is determined, the condition of the wound surface is assessed, and hematomas are identified. Palpation of the neck allows you to determine the safety of the skeleton of the larynx and trachea, identify areas of compaction, zones of crepitus, the boundaries of which are marked in order to track the dynamics of emphysema or infiltration of soft tissues. In case of penetrating wounds, in some cases probing of the wound canal is permissible. Manipulation must be carried out with great care to avoid causing additional iatrogenic injury.

In addition to a general clinical examination that determines the severity of the patient’s general somatic condition, it is necessary to determine the gas and electrolyte composition of the blood and conduct a microbiological examination of the wound discharge.

Indirect laryngoscopy and microlaryngoscopy;

X-ray tomography of the larynx and trachea;

Endofibroscopy of the larynx, trachea and esophagus;

X-ray of the lungs and mediastinum, esophagus with barium;

CT scan of the hollow organs of the neck;

Study of external respiration function;

Microlaryngostroboscopic examination (indicated in the absence of severe injuries or long after injury in order to examine the vibrator function of the vocal folds).

Surgical revision of wounds in cases of extensive injuries.

Non-drug treatment

First of all, it is necessary to create rest for the injured organ: immobilize the neck, prescribe hunger, bed rest (position with the head end elevated) and vocal rest. Humidified oxygen should be provided and intensive observation should be provided for 48 hours. First aid for respiratory failure includes mask ventilation, installation of an intravenous catheter on the side opposite to the injury. Almost all patients require the insertion of a nasogastric tube; the exception is mild isolated injuries of the larynx and trachea. If, with a penetrating wound, the defects of the esophagus and trachea do not coincide and their sizes are small, conservative treatment is possible using a nasogastric tube, which serves as a prosthesis that isolates two wound openings. Intubation, if necessary, is carried out with the participation of an endoscopist.

Conservative treatment includes antibacterial, decongestant, analgesic, anti-inflammatory therapy and oxygen therapy; All patients are prescribed antacids and inhalations. Concomitant pathology is corrected. If the patient’s condition is severe upon admission, treatment of general somatic diseases is carried out first, postponing surgical intervention for several hours if possible.

Treatment for chemical burns depends on the extent of the injury. In the first degree of severity, the patient is observed for 2 weeks and given anti-inflammatory and antireflux therapy. In the second case, glucocorticoids, broad-spectrum antibiotics, and antireflux treatment are prescribed for approximately 2 weeks. Depending on the condition of the esophagus, the question of the advisability of introducing a nasogastric tube is decided. For third-degree burns, glucocorticoids should not be used due to the high risk of perforation. Broad-spectrum antibiotics, anti-reflux therapy are prescribed, a nasogastric tube is inserted, and the patient is monitored for a year.

A good clinical effect in patients with injuries to the hollow organs of the neck is achieved by inhalation therapy - with glucocorticoids, antibiotics, alkalis for an average of 10 minutes three times a day.

Hemorrhages and hematomas of the larynx often lyse on their own. Along with anti-inflammatory therapy, physiotherapy and treatment aimed at resorption of blood clots have a good clinical effect.

In patients with bruises and injuries of the larynx, not accompanied by cartilage fractures or accompanied by fractures without signs of displacement, conservative treatment is carried out (anti-inflammatory, antibacterial, detoxification, restorative therapy, physiotherapy and hyperbaric oxygenation).

Changes in the skeleton of the larynx;

Displaced cartilage fractures;

Laryngeal paralysis with stenosis;

Severe or increasing emphysema;

Stenosis of the larynx and trachea;

Bleeding;

Extensive damage to the larynx and trachea.

The results of surgical treatment depend on how much time has passed since the injury. Timely or delayed intervention for 2-3 days allows you to restore the structural frame of the larynx and completely rehabilitate the patient. Physiological prosthetics is an obligatory component of the treatment of a patient with a laryngeal injury.

When injured by a foreign body, it is first necessary to remove it. In case of significant secondary changes that complicate its search, anti-inflammatory and antibacterial therapy is carried out for 2 days. Foreign bodies are removed, if possible using endoscopic techniques or laryngeal forceps during indirect microlaryngoscopy under local anesthesia. In other situations, removal is carried out using a laryngofissure, especially in the case of embedded foreign bodies.

When a hematoma of the vocal fold has formed, in some cases microsurgical intervention is resorted to. With direct microlaryngoscopy, an incision is made in the mucous membrane above the hematoma, and it is removed with a evacuator, just like a varicose node of the vocal fold.

To ensure breathing in case of obstruction of the upper respiratory tract and the impossibility of intubation, a tracheostomy or conicotomy is performed. In case of internal bleeding, increasing subcutaneous, intermuscular or mediastinal emphysema, the closed wound must be transferred to an open one, exposing the site of organ rupture, tracheostomy should be performed 1.5-2 cm below it, if possible, and then the defect should be sutured layer by layer with cartilage reposition, sparing the surrounding tissue as much as possible .

In case of wounds, primary treatment of the wound and its layer-by-layer suturing are performed, tracheostomy is performed according to indications. If the oropharynx and esophagus are damaged, a nasogastric tube is installed. Incised wounds are tightly sutured, introducing small drainages for the first 2 days. For puncture, pinpoint wounds of the cervical trachea, which are identified during fiberoptic bronchoscopy, in order to create conditions for spontaneous closure of the wound, intubation is performed by passing the tube below the site of injury, lasting 48 hours. If it is necessary to treat the tracheal wound, standard approaches are used. The defect is sutured through all layers with atraumatic absorbable suture material, and a tracheostomy is applied below the site of injury for up to 7-10 days.

In case of laryngotracheal injury, tracheostomy can be performed from an access made for revision and treatment of the neck wound itself, or from an additional access. Preference is given to additional access, as this helps prevent secondary infection of the wound surface in the postoperative period.

Extensive closed and external injuries of the larynx with damage to the skin, cartilaginous frame and mucous membrane require emergency surgical treatment, the purpose of which is to ensure breathing and reconstruct the structures of the laryngeal-tracheal complex damaged by injury. In this case, the cartilaginous fragments are repositioned and non-viable fragments of cartilage and mucous membrane are removed. Prosthetics of the formed frame on a removable endoprosthesis (thermoplastic tubes with obturators, T-shaped tubes) is mandatory.

For revision of the larynx and trachea, standard surgical approaches according to Razumovsky-Rozanov or transverse access of the Kocher type are used. If extensive damage to the cartilaginous framework of the larynx is detected after repositioning the fractures, suturing is performed with atraumatic suture material. If it is not possible to achieve a tight seal, the edges of the wound are brought together as much as possible, and the wound defect is covered with a pedunculated musculocutaneous flap. In case of significant damage to the larynx, a laryngofissure is performed from a longitudinal approach along the midline, and the internal walls of the larynx are inspected. The examination allows us to identify the extent of damage to the mucous membrane and outline a plan for its reconstruction. To prevent chondritis and prevent the development of cicatricial stenosis, the edges of the cartilaginous wound are sparingly resected, and the skeleton of the larynx is carefully reduced, then plastic surgery of the mucous membrane is carried out by moving its unchanged sections.

In case of open damage to the tracheal wall for more than 1 cm, an urgent tracheostomy is performed with revision of the damaged area and plastic surgery of the tracheal defect, and then prosthetics with removable laryngeal-tracheal prostheses. In this case, it is possible to bring the edges of the trachea closer together for up to 6 cm. In the postoperative period, the patient must maintain a certain position of the head (chin brought to the sternum) for 1 week.

The most severe injuries are those accompanied by subcutaneous ruptures of the hollow organs of the neck. Such injuries are accompanied by ruptures of the anterior group of neck muscles with the formation of fistulas. The edges of ruptured organs may diverge to the sides, which can subsequently lead to the formation of stenosis, up to complete obliteration of the lumen. In these cases, it is recommended to restore the integrity of the organ as soon as possible after the injury by performing an anastomosis and suspending the distal section on threads (pexy). In case of fractures of the hyoid bone, accompanied by separation of the larynx, laryngogiondopexy is performed (suturing the larynx by the lower horns of the hyoid bone), or tracheolaryngopexy (suturing the trachea to the lower horns of the thyroid cartilage) when the larynx is separated from the trachea.

In case of burns, it is necessary to repeat examinations of the esophagus, larynx and trachea after 1 and 3 months, in severe cases - every 3 months for a year.

Forecast During primary plastic surgery and prosthetics of the lumen of a hollow organ, deformation of the organ with gross disruption of its function, as a rule, does not occur.

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The larynx, in its structure and location, is a fairly protected organ from various environmental influences. It is covered from above and in front by the lower jaw, from behind by the spine, from the side by developed neck muscles, and from below by the collarbones and the manubrium of the sternum. But despite this, with gunshot wounds or strong mechanical impacts, the larynx is still damaged.

In general, laryngeal injuries are among the most life-threatening injuries. They often cause death or condemn the patient to disability. The situation is further aggravated by the proximity of this organ to the main vessels and large nerve trunks. Violation of their integrity leads either to the immediate death of the victim or contributes to the development of a state of shock. The incidence of laryngeal injuries is 1 case per 25,000 visits for all types of injuries.

The nature and severity of injuries to the larynx, as well as the severity of the condition and tactics of patient management depend on the type of traumatic factor, the strength and duration of its effect on the body. Let's take a closer look at the classification of such injuries.

All injuries to the larynx, depending on the mechanism of action of the aggression factor, are divided into:

• internal and external;
• closed and open;
• blunt and sharp (cutting, piercing).

Considering the causes of this condition, injuries are distinguished:

• mechanical;
• knife;
• firearms;
• thermal;
• chemical.

In addition, damage can be isolated or combined, penetrating or non-penetrating.

Injuries to the larynx most often occur in the following cases:

• blows to the area where the organ is located (with a hand, foot, sports equipment);
• knife wounds;
• injuries from shell fragments and gunshot wounds;
• hitting the front of the neck against any objects (a stretched wire, the corner of a table, the steering wheel of a car, motorcycle or bicycle);
• suicide attempts (hanging).

Mechanical injuries may cause contusions, bruises, soft tissue ruptures, dislocations and fractures of the laryngeal cartilage, or various combined injuries. In this case, bruises usually cause the development of shock in the victim, and damage that violates the integrity and structure of the larynx leads to bleeding and the inability to perform its functions in full. In the near future, after exposure to a traumatic agent, laryngeal edema develops, which contributes to respiratory disorders.

Dislocations and fractures of the cartilaginous rings of the larynx in their pure form are rare. Persons over 40 years of age are more susceptible to such damage, since at this age the larynx becomes less elastic and mobile. Displaced fractures can injure the mucous membrane, thereby causing internal bleeding and the development of emphysema of surrounding tissues, which poses a threat of asphyxia.

With penetrating wounds, the laryngeal cavity may be open and communicate with the esophageal cavity or the cellular spaces of the neck.

The most severe of all external injuries to the larynx are shrapnel and gunshot wounds. In most cases, they are incompatible with life, as they affect nearby vital structures (large vessels and nerves, as well as the spinal cord).

Injuries to the larynx of this type are considered less traumatic than external ones. However, they are dangerous due to the development of asphyxia and secondary infection. The most common causes of their occurrence are:

• invasive interventions (endoscopic operations, tracheal intubation);
• chemical or thermal burns;
• foreign bodies (FB).

Sometimes acute injuries to the larynx occur during prolonged singing, dry paroxysmal coughing, or forced screaming.

Foreign bodies in the larynx are more often detected in young children, as well as in mentally ill individuals and the elderly. These can be fish or chicken bones, needles, metal objects, batteries, etc. In addition, aspiration of pieces of tissue into the larynx can be observed during surgery (tonsillo- or adenotomy).

If the FB is large, it can get stuck in the larynx, causing muscle spasm, swelling and asphyxia. Smaller pieces irritate and damage the mucous membrane, causing inflammation and suppuration of the wound. Pointed objects can perforate the wall of an organ and penetrate nearby organs and tissues. Prolonged stay of FB in the lumen of the larynx causes various undesirable phenomena: ulcers, bedsores, purulent-inflammatory processes of surrounding tissues, sepsis.

Burns of the larynx are usually combined with damage to the oral cavity, trachea, and esophagus. They may be caused by swallowing hot or caustic liquids or inhaling their vapors.

The severity of the clinical picture in case of injury depends on the degree and extent of the injury, its nature and the general condition of the victim:

1. One of the main symptoms of this pathology is respiratory failure of varying severity. In this case, respiratory failure may develop acutely immediately after injury, or may appear at a later date due to the increase in edema or hematoma.
2. Damage to any part of the larynx is characterized by dysphonia. Voice function disorders can also occur acutely or delayed (hoarseness increases gradually). If there are foreign bodies in the lumen of the organ or internal bleeding, victims are bothered by coughing.
3. Another sign of this pathology is dysphagia. Patients experience pain and difficulty swallowing, and a sensation of a foreign body. More often, swallowing disorders occur due to pathology of the entrance to the larynx and its paresis.
4. Penetrating wounds of the larynx may be indicated by subcutaneous emphysema, which changes the contours of the neck and quickly spreads to the neck, chest and mediastinum.
5. External or internal bleeding in case of extensive damage to the larynx, soft tissues of the neck, and large vessels poses a threat to the life of victims. With limited accumulation of blood in the folds of the organ, hematomas can form, impairing the patency of the airways.
6. With ruptures of the larynx, all of the above symptoms are significant. The presence of ruptures can be judged by changes in the configuration of the neck, changes in the topography of its organs and the presence of areas of soft tissue retraction.
7. Burn injuries to the larynx caused by hot liquids lead to severe swelling of its walls and stenosis of the airways. When liquid chemicals enter the body, the symptoms of a burn to the esophagus come to the fore. The most serious damage occurs from inhalation burns of the larynx. In this case, a severe inflammatory process develops with scarring and narrowing of its lumen. In addition, with burns, the general condition of patients changes.

Diagnosis of laryngeal injuries is not as simple as it might seem at first glance. The fact of injury and the nature of the damaging factor are quite easy to establish. However, it is not always immediately possible to accurately determine the extent and severity of damage. First of all, the victim’s ability to breathe on his own is assessed and bleeding is excluded. Palpation of the neck allows you to determine the integrity of the laryngeal skeleton and identify the presence of emphysema. Further examination is carried out in a hospital setting. This uses:

• indirect laryngoscopy;
• endoscopic examination of the larynx;
• X-ray examination of the chest organs;
• computed tomography of the hollow organs of the neck;
• control of external respiration function.

If necessary, the list of studies can be expanded. In case of serious condition of patients, a mandatory general clinical examination is carried out.

All patients with traumatic injuries to the larynx are hospitalized in the ENT or intensive care department.

The choice of management tactics for the patient depends on the severity of the injuries received and his condition. Moreover, all therapeutic measures are aimed at restoring the structure and function of the damaged organ.

In the absence of severe injuries requiring emergency care, the patient is monitored for 48 hours. He is recommended bed rest, vocal rest and fasting.

Patients with mild injuries receive only conservative treatment, which includes antibacterial, anti-inflammatory and decongestant therapy. Antacids and various inhalations (alkaline, with corticosteroids) can also be used. In some cases, the introduction of a nasogastric tube is added to this treatment.

Some patients with laryngeal injuries undergo surgical treatment. Indications for it are:

• severe damage to laryngeal tissue;
• fractures of its cartilaginous rings with displacement;
• heavy bleeding;
• laryngeal paralysis;
• severe stenosis;
• increasing emphysema;
• foreign bodies.

Severe injuries to the larynx that threaten the lives of patients require emergency surgical intervention.

A timely operation allows you to restore the structure of the larynx as an organ and rehabilitate the victim. For extensive wounds and stenoses, laryngoplasty and prosthetics are used.

Rehabilitation of patients with laryngeal injuries is a complex and lengthy process. With timely treatment, complete restoration of the functions of the damaged organ is possible. The main thing is to be patient and follow all the recommendations of your doctor.

External laryngeal injuries

The larynx, due to its topographic-anatomical position, can be considered an organ that is fairly well protected from external mechanical influence. It is protected above and in front by the lower jaw and thyroid gland, below and in front by the manubrium of the sternum, on the sides by strong sternocleidomastoid muscles, and behind by the bodies of the cervical vertebrae. In addition, the larynx is a mobile organ, which, when subjected to mechanical impact (impact, pressure), easily absorbs and moves both en masse and in parts due to its articular apparatus. However, with excessive mechanical force (blunt trauma) or with piercing and cutting gunshot wounds, the degree of damage to the larynx can vary from mild to severe and even incompatible with life.

The most common causes of external laryngeal injuries are:

1. impacts with the front surface of the neck on protruding hard objects (steering wheel or handlebars of a motorcycle, bicycle, stair railing, back of a chair, edge of a table, stretched cable or wire, etc.);
2. direct blows to the larynx (from a palm, a fist, a leg, a horse’s hoof, a sports equipment, an object thrown or torn off during rotation of the unit, etc.);
3. suicide attempts by hanging;
4. knife piercing-cutting, bullet and shrapnel wounds.

External injuries of the larynx can be classified according to criteria that have a certain practical significance both for making an appropriate morphological and anatomical diagnosis, and for determining the severity of the lesion and making an adequate decision on providing assistance to the victim.

Situational criteria

1. household:
   1. for murder;
   2. for suicide.
2. production:
   1. as a result of an accident;
   2. as a result of non-compliance with safety regulations.
   3. wartime injuries.

By severity

1. Light (non-penetrating) - injuries in the form of bruises or tangential wounds without violating the integrity of the walls of the larynx and its anatomical structure, which do not cause immediate disruption of all functions.
2. Moderate severity (penetrating) - damage in the form of fractures of the cartilage of the larynx or penetrating wounds of a tangential nature without significant destruction and separation of individual anatomical structures of the larynx with immediate, non-severe disruption of its functions, not requiring emergency assistance for life-saving reasons.
3. Severe and extremely severe - extensive fractures and crushing of the cartilage of the larynx, cut or gunshot wounds that completely block all respiratory and phonatory functions, incompatible (severe) and combined (extremely severe and incompatible with life) with injuries to the main arteries of the neck.

According to anatomical and topographic-anatomical criteria

Isolated injuries of the larynx.

• For blunt trauma:
  • rupture of the mucous membrane, internal submucosal hemorrhage without damage to cartilage and dislocations in the joints;
  • fracture of one or more cartilages of the larynx without their dislocation and disruption of the integrity of the joints;
  • fractures and avulsions (separation) of one or more cartilages of the larynx with ruptures of the joint capsules and dislocations of the joints.
• For gunshot wounds:
  • tangential injury to one or more cartilages of the larynx in the absence of penetration into its cavity or into one of its anatomical parts (vestibule, glottis, subglottic space) without significant impairment of respiratory function;
  • penetrating blind or through wound of the larynx with varying degrees of impairment of respiratory and vocal functions without combined damage to surrounding anatomical formations;
  • penetrating blind or through wound of the larynx with varying degrees of impairment of respiratory and vocal functions with the presence of damage to surrounding anatomical structures (esophagus, neurovascular bundle, spine, etc.).

Internal injuries of the larynx are less traumatic injuries of the larynx compared to external injuries. They may be limited to damage to the mucous membrane only, but can be deeper, damaging the submucosal layer and even the perichondrium, depending on the cause of the damage. An important reason complicating internal injuries of the larynx is secondary infection, which can provoke the occurrence of abscesses, phlegmon and chondroperichondritis, followed by more or less severe cicatricial stenosis of the larynx.

Acute laryngeal injuries:

• iatrogenic: intubation; as a result of invasive interventions (galvanocaustics, diathermocoagulation, endolaryngeal traditional and laser surgical interventions);
• damage by foreign bodies (piercing, cutting);
• burns of the larynx (thermal, chemical).

Chronic laryngeal injuries:

• bedsores resulting from prolonged tracheal intubation or the presence of a foreign body;
• intubation granulomas.

The criteria for the classification of external laryngeal injuries may be applicable to this classification to a certain extent.

Chronic injuries of the larynx most often occur in persons weakened by long-term illnesses or acute infections (typhoid, typhus, etc.), in which general immunity is reduced and saprophytic microbiota is activated. Acute laryngeal injuries can occur during esophagoscopy, and chronic injuries can occur when the probe remains in the esophagus for a long time (during tube feeding of the patient). During intubation anesthesia, swelling of the larynx often occurs, especially often in the subglottic space in children. In some cases, acute internal injuries of the larynx occur during forced screaming, singing, coughing, sneezing, and chronic injuries occur during prolonged professional vocal stress (singers' nodules, laryngeal ventricular prolapse, contact granuloma).

Symptoms of laryngeal injuries depend on many factors: the type of injury (bruise, compression, wound) and its severity. The main and first symptoms of external mechanical injury are shock, respiratory obstruction and asphyxia, as well as bleeding - external or internal, depending on the damaged vessels. In case of internal bleeding, mechanical obstruction of the respiratory tract is accompanied by the phenomena of aspiration asphyxia.

With contusions of the larynx, even if external signs of damage are not detected, a pronounced state of shock occurs, which can lead to a rapid reflex death of the victim from respiratory arrest and cardiac dysfunction. The starting points of this fatal reflex are the sensory nerve endings of the laryngeal nerves, the carotid sinus and the perivascular plexuses of the vagus nerve. A state of shock is usually accompanied by loss of consciousness; upon recovery from this state, the patient feels pain in the larynx, intensifying when trying to swallow and talking, radiating to the ear(s) and the occipital region.

A special clinical case is hanging, which is compression of the neck by a noose under the weight of one’s own body, leading to mechanical asphyxia and, as a rule, death. The direct cause of death may be asphyxia itself, impaired cerebral circulation due to compression of the jugular veins and carotid arteries, cardiac arrest as a result of compression of the vagus and upper laryngeal nerves due to their compression, damage to the medulla oblongata by a tooth of the II cervical vertebra when it is dislocated. When hanging, laryngeal injuries of various types and locations may occur, depending on the position of the strangulation instrument. Most often, these are fractures of the cartilage of the larynx and dislocations in the joints, the clinical manifestations of which are detected only with timely rescue of the victim, even in cases of clinical death, but without subsequent decortication syndrome.

Wounds to the larynx, as noted above, are divided into cuts, stabs and gunshots. The most common are incised wounds on the anterior surface of the neck, among which are wounds with damage to the thyrohyoid membrane, thyroid cartilage, wounds localized above and below the cricoid cartilage, transcricoid and laryngeal-tracheal wounds. In addition, wounds in the anterior surface of the neck are divided into wounds without damage to the cartilage of the larynx, with damage to them (penetrating and non-penetrating) and combined injuries of the larynx and pharynx, larynx and neurovascular bundle, larynx and cervical vertebral bodies. According to A.I. Yunina (1972), wounds of the larynx, in accordance with clinical and anatomical feasibility, should be divided:

• for wounds of the supra- and sublingual region;
• areas of the vestibular and vocal folds;
• subglottic space and trachea with or without damage to the esophagus.

With injuries of the first group, the pharynx and laryngopharynx are inevitably damaged, which significantly aggravates the injury, complicates surgical intervention and greatly lengthens the postoperative period. Injury to the thyroid cartilage invariably leads to injury to the area of ​​the vocal folds, pyriform sinuses, and often the arytenoid cartilages. This type of injury most often leads to laryngeal obstruction and suffocation. The same phenomena occur with injuries to the subglottic space.

Damage to the larynx due to incised wounds can vary in severity - from barely penetrating to complete transection of the larynx with damage to the esophagus and even the spine. Injury to the thyroid gland leads to parenchymal bleeding that is difficult to stop, and injury to large vessels, which occur much less frequently for the reasons noted above, often leads to profuse bleeding, which, if it does not immediately end in the death of the victim from blood loss and hypoxia of the brain, is fraught with the danger of death a patient from asphyxia caused by the flow of blood into the respiratory tract and the formation of clots in the trachea and bronchi.

The severity and scale of the wound to the larynx do not always correspond to the size of the external wound, this is especially true for puncture wounds and bullet wounds. Relatively minor skin injuries can hide deeply penetrating wounds of the larynx, combined with wounds of the esophagus, neurovascular bundle, and vertebral bodies.

A penetrating cut, stab or gunshot wound has a characteristic appearance: as you exhale, air bubbling with bloody foam comes out of it, and as you inhale, air is sucked into the wound with a characteristic hissing sound. Aphonia and coughing attacks are noted, which increase “before our eyes” the beginning emphysema of the neck, spreading to the chest and face. Breathing disorders can be caused by either blood flowing into the trachea and bronchi, or destructive phenomena in the larynx itself.

A victim with a laryngeal injury may be in a state of traumatic shock in a twilight state or with a complete loss of consciousness. In this case, the dynamics of the general condition may acquire a tendency to move toward a terminal state with disruption of the rhythm of respiratory cycles and heart contractions. Pathological breathing is manifested by changes in its depth, frequency and rhythm.

An increase in the breathing rhythm (tachypnea) and a decrease in breathing rate (bradypnea) occur when the excitability of the respiratory center is impaired. After forced breathing, due to weakening of the excitation of the respiratory center caused by a decrease in the carbon dioxide content in the alveolar air and blood, apnea, or a prolonged absence of respiratory movements, may occur. With a sharp depression of the respiratory center, with severe obstructive or restrictive respiratory failure, oligopnea is observed - rare shallow breathing. Periodic types of pathological breathing that arise as a result of an imbalance between excitation and inhibition in the central nervous system include periodic Cheyne-Stokes breathing, Biot and Kussmaul breathing. With shallow Cheyne-Stokes breathing, shallow and rare respiratory movements become more frequent and deeper and, after reaching a certain maximum, they weaken and slow down again, then there is a pause for 10-30 s, and breathing resumes in the same sequence. Such breathing is observed in severe pathological processes: impaired cerebral circulation, head injury, various diseases of the brain with damage to the respiratory center, various intoxications, etc. Breathing Biota occurs when the sensitivity of the respiratory center decreases - alternating deep breaths with deep pauses of up to 2 minutes. It is characteristic of terminal conditions and often precedes respiratory and cardiac arrest. Occurs with meningitis, brain tumors and brain hemorrhages, as well as with uremia and diabetic coma. Big Kussmaul breathing (Kussmaul symptom) - gusts of convulsive, deep breaths, audible at a distance - occurs in comatose states, in particular in diabetic coma, renal failure.

Shock is a severe generalized syndrome that develops acutely as a result of the action of extremely strong pathogenic factors on the body (severe mechanical trauma, extensive burns, anaphylaxis, etc.).

The main pathogenetic mechanism is a severe circulatory disorder and hypoxia of organs and tissues of the body, primarily the central nervous system, as well as secondary metabolic disorders resulting from a disorder of the nervous and humoral regulation of vital centers. Among the many types of shock caused by various pathogenic factors (burn, myocardial infarction, transfusion of incompatible blood, infection, poisoning, etc.), the most common is traumatic shock, which occurs with extensive wounds, fractures with damage to nerves and brain tissue. The most typical shock state in its clinical picture occurs with a laryngeal injury, in which four main shockogenic factors can be combined: pain due to injury to the sensory laryngeal nerves, incoordination of autonomic regulation due to damage to the vagus nerve and its branches, airway obstruction and blood loss. The combination of these factors greatly increases the risk of severe traumatic shock, often leading to death at the scene.

The main patterns and manifestations of traumatic shock are the initial generalized excitation of the nervous system, caused by the release of catecholamines and corticosteroids into the blood as a result of the stress reaction, which leads to a slight increase in cardiac output, vasospasm, tissue hypoxia and the emergence of the so-called oxygen debt. This period is called the erectile phase. It is short-term and cannot always be traced to the victim. It is characterized by agitation, sometimes screaming, restlessness, increased blood pressure, increased heart rate and breathing. The erectile phase is followed by a torpid phase, caused by worsening hypoxia and the emergence of foci of inhibition in the central nervous system, especially in the subcortical regions of the brain. Circulatory disorders and metabolic disorders are observed; part of the blood is deposited in the venous vessels, the blood supply to most organs and tissues decreases, characteristic changes in microcirculation develop, the oxygen capacity of the blood decreases, acidosis and other changes in the body develop. Clinical signs of the torpid phase are manifested by the victim’s lethargy, limited mobility, weakened response to external and internal stimuli or the absence of these reactions, a significant decrease in blood pressure, rapid pulse and shallow breathing of the Cheyne-Stokes type, pallor or cyanosis of the skin and mucous membrane, oliguria, hypothermia. These disorders, as shock develops, especially in the absence of therapeutic measures, gradually, and in severe shock quite quickly, worsen and lead to the death of the body.

There are three degrees of traumatic shock: degree I (mild shock), degree II (moderate shock) and degree III (severe shock). In stage I (in the torpid stage), consciousness is preserved, but clouded, the victim answers questions in monosyllables in a muffled voice (with a laryngeal injury that even leads to a mild form of shock, vocal communication with the patient is excluded), pulse 90-100 beats/min, blood pressure (100-90)/60 mm Hg. Art. In case of second degree shock, consciousness is confused, lethargic, the skin is cold, pale, pulse is 130 beats/min, blood pressure is (85-75)/50 mm Hg. Art., breathing is frequent, there is a decrease in urination, the pupils are moderately dilated and react sluggishly to light. In case of third degree shock - blackout, lack of response to irritants, pupils are dilated and do not respond to light, pale and cyanotic skin covered with cold sticky sweat, frequent shallow irregular breathing, threadlike pulse 120-150 beats/min, blood pressure 70/30 mmHg Art. and below, a sharp decrease in urination, up to anuria.

In case of mild shock, under the influence of adaptive reactions of the body, and in case of moderate shock, additionally and under the influence of therapeutic measures, there is a gradual normalization of functions and subsequent recovery from shock. Severe shock often, even with the most intensive treatment, becomes irreversible and ends in death.

Injuries to the larynx are often combined with injuries to the pharynx, parapharyngeal space, masticatory apparatus, thyroid gland, trachea, esophagus, and spine. Laryngeal injuries are divided into closed and open. Closed ones, in turn, are divided into internal and external.

Internal damage They mainly concern the entrance to the larynx, epiglottis, arytenoid cartilages, aryepiglottic folds and pyriform sinuses. Depending on the damaging factor, injuries can be chemical, thermal and mechanical.

Chemical burns larynx are caused by strong alkalis (caustic soda) and acids (sulfuric, hydrochloric, nitric). Naturally, such burns are combined with burns in the oral cavity, pharynx and esophagus, the clinical manifestations of which are much more severe than in the larynx.

Thermal burns larynx from hot liquids, steam or smoke are very rare. There are no local large changes in the larynx with such burns, with the exception of the development of edema in complicated cases.

Mechanical internal injuries are caused by foreign bodies entering the larynx (fish and meat bones, medical instruments) during various medical procedures. Such injuries usually do not cause serious functional impairment; an abrasion and hemorrhage are found at the site of injury. Sometimes swelling develops at the wound site, limited or increasing as a result of infection.

External damage are divided into closed and open. Closed injuries include bruises, compression, fractures of the laryngeal cartilage and hyoid bone, and separation of the larynx from the trachea. These injuries are caused by a blunt instrument or occur accidentally as a result of an impact when falling on an object. With closed injuries, the victim often immediately loses consciousness (reflex shock from irritation of the cervical neurovascular bundle). Hemoptysis also appears with fractures of the larynx - subcutaneous emphysema, pain when swallowing and neck movements, pain intensifies when talking and coughing. Breathing is usually difficult.

Upon external examination, hemorrhages are detected on the skin of the anterior surface of the neck. When emphysema occurs, the contours of the neck are smoothed out and it thickens significantly. Emphysema can spread to the chest and back, face, and mediastinum. The characteristic crepitation is determined by palpation. The voice is hoarse, sometimes aphonic.

With cartilage fractures, deformation of the contours of the larynx and a crunching sound at the fracture site are determined. Most often the thyroid cartilage is affected, followed by the cricoid and arytenoid cartilages. Retraction or depression of one or another section of cartilage can be recognized only a few days after the injury, when swelling and emphysema decrease.

Laryngoscopically, with bruises of the larynx, hemorrhages and hematomas are determined. The mucous membrane takes on a bluish tint, and blue-purple hematomas form under it. If the integrity of the cartilage of the larynx is damaged, you can see their fragments protruding into its lumen. The lumen of the larynx is narrowed. If a laryngeal injury is combined with a fracture of the hyoid bone, then the described picture is accompanied by retraction of the tongue, pain when protruding it, and immobility of the epiglottis. For mild to moderate bruises, symptoms disappear within 1-2 weeks. With more severe trauma, when along with a rupture of the mucous membrane there are cartilage fractures, the dominant symptoms are suffocation, cough with hemoptysis and increasing emphysema. However, despite the severity of symptoms, unless the breathing tube is completely ruptured, the condition is usually not life-threatening. Emphysema gradually resolves. Voice rest, avoiding irritating foods, and taking codeine help the pain gradually subside, and prescribing antibiotics prevents complications.

The picture of exceptional severity is represented by closed neck injuries with rupture of the trachea and especially its complete separation from the larynx. The dominant symptoms in such cases are suffocation, severe emphysematous swelling of the neck, face and chest. In the subsequent minutes after the injury, as the suffocation intensifies, loss of consciousness, extinction of reflexes, and impaired cardiac activity are observed.

However, the victim can still be brought out of such a state, close to atonal, if a tracheotomy is performed as quickly as possible and blood is suctioned from the respiratory tract. After restoration of respiratory and cardiac activity, it is necessary to suture the trachea to the larynx, but this is not always possible due to damage to the cricoid cartilage and lowering of the severed trachea into the chest. In this case, it is advisable to perform a laryngotracheotomy with the introduction of a tracheoscope tube, which places the trachea in the correct position in relation to the larynx. This facilitates their cross-linking and subsequent consolidation against the background of general and local use of antibiotics. Tube feeding is established. In the future, in order to avoid traumatic perichondritis of the larynx and for better formation of scars at the site of tracheal avulsion, long-term dilatation treatment with wearing a laryngostomy tube may be required.

If there is a significant displacement of fragments of the cartilage of the larynx, it is necessary to open the larynx (laryngofissure), remove crushed non-viable tissue, straighten the displaced fragments and fix them by suturing the perichondrium or tamponing the lumen of the larynx.

In case of fractures of the hyoid bone, the reduction of its fragments is done with fingers inserted into the mouth.

In the absence of difficulty breathing and bleeding or after their elimination, the patient is prescribed a silent regime; codeine or dionine is prescribed to reduce cough; In the first hours after injury, swallowing pieces of ice is recommended. Liquid and mushy food is prescribed. Prescription of antibiotics and sulfonamides in the first days after injury is mandatory.

Open injuries (wounds) of the larynx can be cuts, stabs or gunshots.

Cut and puncture wounds. In peacetime they are found almost exclusively cut wounds. They are inflicted with a knife or razor for the purpose of murder or suicide. These wounds are usually localized on the front surface of the neck, and wounds inflicted by one's own hand are directed from left to right and from top to bottom (for right-handed people). The deeper wound is at the beginning of the cut. Wounds inflicted by another person may have different directions depending on the position of the attacker (front, back, side). These data are taken into account during forensic medical examination.

With wounds inflicted directly under the hyoid bone, due to contraction of the cut muscles, the wound gapes wide. The larynx, pharynx, and sometimes the entrance to the esophagus become clearly visible. The epiglottis can move upward in whole or in part. The voice in such patients is preserved, but speech disappears, since the larynx and articular apparatus are disconnected. However, as soon as the wounded person lowers his head and thereby connects the edges of the wound, speech becomes possible.

When the wound is located high (above the entrance to the larynx), breathing is only partially impaired, since air passes freely through the wound. When injured at the level of the vocal folds, and especially in the subglottic space, breathing is significantly difficult.

The general condition of patients, especially immediately after injury, is significantly worsened. Shock symptoms are often observed. When the carotid artery is injured, death occurs immediately. However, when the head is thrown back, the carotid arteries are rarely crossed, since in this position they are displaced posteriorly, and the sternocleidomastoid muscles cover them in front.

For wounds of the neck with cold steel, layer-by-layer suturing of the wound is indicated. Sutures are placed on the mucous membrane, muscles and skin. Rubber graduates are placed in the corners of the wound. To reduce tissue tension and bring the edges of the wound closer together, the patient’s head is tilted forward during suturing. It should remain in this position in the postoperative period for at least 7 days. Breathing is carried out through a tracheotomy or naturally (according to indications), nutrition is provided using a gastric tube inserted through the nose or mouth.

Gunshot wounds are rarely isolated. As a rule, they are combined with damage to the esophagus, pharynx, thyroid gland, vessels and nerves of the neck, as well as the maxillofacial area, cranium, cervical spine and spinal cord.

With penetrating wounds in the larynx, as a rule, two openings are identified - the entrance and exit, but there may be only an entrance opening. When the head is tilted, the larynx is covered by the lower jaw, so one of the wound holes may be in the facial area, and depending on the path of the wounding projectile, the entrance hole may be on the chest or even on the back. It is not always possible to determine which hole in the neck is the entrance and which is the exit.

In case of blind wounds, the wounding projectile gets stuck in the tissues of the larynx, but it may not exist, since, having entered a hollow organ (larynx, trachea, esophagus), it can be released out by a cough impulse, swallowed or aspirated.

Tangential wounds are those in which a shrapnel or bullet strikes the wall of the larynx without disturbing the integrity of the mucous membrane.

The depth of the wound in the larynx can vary depending on the shape and speed of the wounding projectile. High-velocity wounding projectiles, even with tangential wounds of the larynx, lead to contusion of surrounding tissues, manifested by hematoma, edema and often cartilage fractures.

At the moment of a gunshot wound to the larynx, the victim experiences a sensation of impact without pain. In this case, loss of consciousness may occur due to damage to the vagus and sympathetic nerves. A constant symptom of wounds to the larynx is respiratory distress. A great danger for a wounded person, especially one in an unconscious state, is the flow of blood into the trachea and bronchi and their tamponade with blood clots.

Emphysema of the subcutaneous tissue develops only in cases where the wound opening is small and its edges quickly stick together. Difficulty breathing is more pronounced when injured in the area of ​​the vocal folds, and especially in the subglottic space, which is explained by the narrowness of the lumen and the abundance of loose submucosal tissue. Respiratory disorder can also occur when the larynx itself is intact if the recurrent nerves or the main trunk of the vagus nerve are damaged. When the entrance to the larynx is damaged, its protective function is primarily affected. Swallowing is usually impaired and accompanied by severe pain. Food enters the respiratory tract, causing choking and coughing, and with open wounds it can come out.

In the first time after injury to the larynx, the use of laryngoscopy is impossible. And in the future, direct laryngoscopy should be performed with extreme caution so as not to cause blood clots to break off in damaged vessels and subsequent bleeding. Retrograde examination of the larynx through a tracheostomy is possible.

If laryngoscopy is possible, swelling of certain areas of the larynx is determined, for example, the area of ​​the arytenoid cartilages, the entrance to the larynx, and the subglottic space. Hematomas, ruptures of the mucous membrane, damage to cartilage, and sometimes a wounding projectile are also found. With injuries to the vagus nerve, along with the immobility of the corresponding half of the larynx, on the same side, in the piriform sinus, there is an accumulation of saliva - a “salivary lake”. When the sympathetic nerve is injured, Horner's symptom occurs (narrowing of the palpebral fissure, enophthalmos, constriction of the pupil), as well as a decrease in the tone of the vocal muscles, which causes rapid fatigue when speaking and a change in the timbre of the voice.

X-ray examination allows you to determine the condition of the cartilaginous skeleton and the presence of a foreign body. Pictures are taken in frontal and lateral projections. To determine the localization of a foreign body, the radiography method proposed by V.I. Voyachek is used with the introduction of a metal probe into the wound canal. In later periods of treatment, before X-ray examination, a contrast mass is injected into the fistulous tract (fistulography). The task of topographic diagnosis is greatly facilitated by the use of CT and MRI.

Complications of laryngeal injuries. Quite often, suppuration occurs along the wound canal and chondroperichondritis of the cartilage of the larynx. The latter can develop several weeks and even months after injury. As a result of blood aspiration, pneumonia occurs, which can be asymptomatic in exhausted wounded people. A severe complication of wounds of the larynx combined with damage to the pharynx or esophagus is purulent mediastinitis.

Therapeutic measures Injuries of the larynx can be divided into three groups:

1) provision of emergency assistance;

2) primary surgical treatment;

3) subsequent specialized treatment.

The measures of the first group include eliminating asphyxia, stopping bleeding, combating shock and providing nutrition to the patient.

For restoration of breathing in urgent cases, it is possible to perform an “atypical” tracheotomy, laryngotomy or dissection of the conical ligament. If there is a wide enough wound that penetrates the lumen of the larynx and allows breathing air to pass through, it can be used to insert a tracheotomy tube. It is advisable to do this before transporting the victim from the scene of the accident, since airway obstruction may occur suddenly.

Stop bleeding, if it does not come from the main vessel and does not pose an immediate danger to life, it can easily be carried out by pressing the vessel, followed by the application of a hemostatic clamp and ligation of the vessel. If large trunks are damaged, the external or common carotid artery is ligated.

Fighting shock is carried out according to the general rules: administration of morphine or omnopon, blood transfusion, cardiac stimulants, external or intrapharyngeal vagosympathetic novocaine blockade.

Primary surgical treatment in case of injury to the larynx, in addition to stopping bleeding, it consists of economical excision of crushed tissue and suturing of the wound. If there is significant damage to the cartilage, a laryngofissure with reduction of displaced fragments is indicated. A T-shaped tube is inserted into the larynx or, if there is a tracheostomy, the laryngeal cavity is tamponed.

Injuring foreign bodies, if they are in the accessible zone, they are removed immediately, while paying attention to the possibility of a large blood vessel adjacent to them. The issue of removing deep-seated metallic foreign bodies is handled with caution. They are removed immediately in cases where they cause insurmountable respiratory distress, severe pain, or, being located near large vessels, pose a threat of damage to them.

To reduce pain, novocaine blockade of the wounded area is performed. The wounded, for whom oral intake is excluded, are prescribed nutrition through a gastric or duodenal tube inserted through the nose or mouth. If there is a wound on the neck, then as a temporary measure it is permissible to insert a probe into the esophagus and stomach through this wound. It is not recommended to leave a probe inserted through the nose, mouth or wound for more than 7-10 days, as complications such as bedsores and secondary infections may occur. Sometimes they resort to gastrostomy. Nutrition can be provided by parenteral administration of protein hydrolysates.

Fish and meat bones, dentures, small objects, as well as living creatures: leeches, worms can get into the larynx. Thin fish bones and metal needles are usually pierced directly into the mucous membrane of the entrance to the larynx.

Small foreign bodies slip through the glottis into the trachea and bronchi. Foreign objects of a larger size can be fixed in the vestibule of the larynx, in the lumen of the glottis, or entrapped in the subglottic space.

Most often, laryngeal foreign bodies occur in young children. Their getting stuck in the larynx is explained by the narrowness of the children's larynx. Unlike adults, whose narrowest place in the larynx is the glottis, in children the foreign body encounters the greatest obstacle under the vocal folds. Due to the presence of a loose submucosal layer, when a foreign body is localized in this area, swelling quickly occurs under the inner space, which pinches the foreign body and creates an additional obstacle to breathing.

Symptoms depend on the size and location of fixation of the foreign body. When the glottis is completely closed, clinical death occurs within 5 minutes. With small foreign bodies pinched between the vocal folds, the voice is lost and a sharp cough occurs. After some time, the cough may stop. When leeches enter the hypopharynx or larynx, bleeding or hemoptysis is observed.

In the diagnosis of a foreign body in the larynx, anamnesis is of great importance. In non-emergency cases, foreign bodies are removed by indirect or direct laryngoscopy. In emergency cases, when there is no time left to attempt removal, a tracheotomy is performed and the foreign body is removed through an incision in the trachea. It may also happen that removal of a foreign body is only possible through the laryngofissure.

Otorhinolaryngology. IN AND. Babiyak, M.I. Govorun, Ya.A. Nakatis, A.N. Pashchinin

Laryngeal injuries are a violation of the integrity of the tissues of this organ under the influence of one or another traumatic agent.

The larynx is a part of the upper respiratory tract, so traumatizing it can be fraught with the normal act of breathing.

In addition, trauma to the larynx can lead to disruption of voice formation, and this state of affairs is catastrophic for representatives of some professions whose voice is the main working instrument - actors, singers, entertainers, hosts of events.

Table of contents: 1. General data 2. Causes 3. Development of pathology 4. Symptoms of laryngeal injury 5. Diagnosis 6. Differential diagnosis 7. Complications 8. Treatment of laryngeal injuries 9. Prevention 10. Prognosis

The larynx is part of the upper respiratory tract. Its upper section borders the pharynx, and the lower section borders the trachea. The spaces of all three mentioned organs merge into each other, forming the respiratory tract.

The area of ​​the larynx is an important strategic location of the body, as it contains a number of vital organs. So, in the vicinity of the larynx, in addition to the pharynx and trachea, there are such structures as:

• esophagus;
• thyroid;
• cervical spine;
• large vessels of the neck;
• recurrent nerves;
• parasympathetic nerve trunks.

Therefore, when the larynx is injured, there is a risk of injury to these structures with subsequent disruption of their vital functions. Most often, laryngeal injuries are combined with injuries to the pharynx and trachea. Such combined disorders lead to severe and dangerous conditions - these are:

• severe breathing difficulties;
• profuse (severe) bleeding, which leads to massive blood loss, and this, in turn, can provoke the development of hemorrhagic shock - a shock (critical) disorder of microcirculation;
• disruption of innervation (nervous supply) of vital structures.

The described disorders are often observed simultaneously and the final result can lead to one consequence - death.

Traumatization of the larynx is observed in almost all the same cases as trauma to the pharynx, but the larynx contains cartilage, which means that it is to some extent more durable than the pharynx.

Laryngeal injuries, depending on the traumatic agent, are:

• mechanical;
• thermal;
• chemical.

Laryngeal injuries can occur when:

• medical intervention;
• as a result of trauma not related to medical actions.

A separate case is laryngeal injuries, which are observed with a sharp increase in intralaryngeal pressure. This can happen during:

• hacking cough;
• strong scream.

The circumstances surrounding the occurrence of such injuries are:

• vocal strain;
• deterioration of blood supply to the vocal cords;
• gastroesophageal reflux.

The larynx can be injured during medical procedures:

• diagnostic;
• medicinal.

Most often, the larynx is injured during diagnostic procedures such as:

• laryngoscopy - examination of the larynx using a laryngoscope (a type of endoscopic equipment);
• tracheal intubation - insertion of a special tube for the purpose of connecting to an Ambu bag used for artificial ventilation of the lungs, or to a ventilator. The insertion of the tube itself is not a traumatic procedure, but during intubation a laryngoscope is used, which can damage the larynx;
• biopsy of the larynx - sampling of a section of its soft tissue for subsequent examination under a microscope;
• bronchoscopy - examination of the bronchi using a bronchoscope (a type of endoscope), which is inserted through the larynx.

Therapeutic measures during which there is a risk of damage to the larynx most often are:

• incorrect bougienage of the esophagus - insertion of expanding metal rods into it, while the bougie can be mistakenly inserted into the laryngeal cavity and injure its walls;
• removal of a foreign body from the larynx, trachea or esophagus;
• conicotomy - the formation of an artificial hole in the wall of the larynx during asphyxia;
• any operations on the pharynx, trachea, esophagus and other structures of the neck.

Injuries to the larynx not related to medical manipulations on it can occur as a result of the following actions:

• unintentional;
• deliberate.

In the first case it is most often:

• road traffic accidents;
• man-made disasters - the formation of landslides as a result of explosions in production;
• natural disasters - the formation of the same landslides as a result of earthquakes.

Injuries to the larynx due to intentional traumatization are more common than others. This:

• closed blunt injuries when struck in the neck with a fist;
• fractures of the cartilage of the larynx during attempted strangulation or hanging;
• injuries caused by sharp objects - knives, stilettos;
• less often - bullet wounds (more common in wartime). Moreover, about 80% of bullet wounds of the larynx are through and through.

Cases of injury to the larynx are also common in sports traumatology - this is associated with such power sports as:

• boxing;
• various types of struggle;
• hockey

and a number of others.

According to the mechanism of origin, laryngeal injuries are divided into:

• internal - occur when exposed to a traumatic agent from the inside - if it enters the lumen of the larynx;
• external - occur when the soft tissues of the neck are damaged, when a traumatic factor, passing through tissue masses, reaches the wall of the larynx and violates its integrity.

Internal injuries to the larynx are often isolated - that is, only the larynx is affected. The explanation is simple: a small traumatic agent can enter the lumen of the larynx, which is not capable of causing massive tissue damage; moreover, it literally has nowhere to “turn around”.

note

External injuries of the larynx in most cases are combined, with damage to other anatomical structures in addition to the larynx.

Depending on the nature of the wounding factor, laryngeal injuries can be:

• bruised (dull, even with severe damage they are called contusions);
• cut;
• torn;
• bitten;
• chopped;
• firearms (bullets).

According to the degree of violation of the integrity of the laryngeal wall, injuries are divided into:

• non-penetrating - the cartilage of the larynx, ligaments and muscles are damaged, but there is no through hole in them;
• penetrating - the impact of a traumatic agent on the structures of the larynx leads to the formation of a through defect in them, through which the laryngeal cavity communicates with the surrounding tissues (and if there is an open nature of the injury, then with the external environment).

Even if non-penetrating, laryngeal trauma can be significant. So, with blunt injuries of the larynx, the following are possible:

• fracture of the cartilage of the larynx;
• fracture of the hyoid bone;
• laryngeal separation;
• rupture of one (less often) or both (more often) vocal cords.

Depending on the circumstances in which the larynx injuries were sustained, they may be:

• household;
• production;
• sports;
• military.

Signs of laryngeal injuries depend on characteristics of the injury, such as:

• localization;
• character;
• vastness;
• retraction of neighboring structures.

The clinical picture of laryngeal injuries consists of symptoms such as:

• respiratory dysfunction;
• voice disorder;
• pain syndrome;
• cough;
• bleeding;
• swallowing disorder;
• subcutaneous emphysema.

Impaired respiratory function is the leading sign of laryngeal injuries and develops in almost all cases of this pathology. This disorder is manifested by respiratory failure. In some cases, it may be absent immediately after the injury, but then develops due to:

• increased inflammatory infiltration (thickening and compaction of tissues);
• swelling of the soft tissues of the neck;
• formation of a hematoma (blood clot).

• dysphonia – changes in the timbre and strength of the voice;
• aphonia - complete absence of voice.

The severity of the pain syndrome depends on the degree of damage received and can manifest itself from a feeling of discomfort to intense pain, often requiring the use of narcotic analgesics.

note

Cough does not occur in all cases of laryngeal injuries. In the vast majority of cases, it appears under such circumstances as a foreign body entering the larynx naturally or through a wound.

External bleeding is observed with external injuries of the larynx. Internal bleeding is not visualized, but it may manifest as hemoptysis. If there is a hard foreign object in the wound, you should be wary of the fact that it can damage the large vessels of the neck at any time, causing massive bleeding.

Swallowing disorder occurs when there is damage to the entrance to the larynx.

Subcutaneous emphysema is the entry of air into tissue masses, causing them to swell and change the shape of the neck. Its presence indicates the penetrating nature of the laryngeal injury. Emphysema can spread quite quickly to the mediastinum and further to the subcutaneous tissue in the chest area.

If you suspect an internal injury to the larynx, you should contact an otolaryngologist, and if you suspect an external injury, contact a traumatologist. In critical cases, laryngeal injuries require the intervention of a resuscitator.

The diagnosis is made based on the victim’s complaints and medical history (the fact of exposure to a traumatic agent is important). Additional diagnostic methods (physical, instrumental, laboratory) are necessary in order to assess the severity of the pathology and possible complications.

A physical examination reveals the following:

• during a general examination - in case of severe trauma associated with respiratory failure, it is revealed that the victim is breathing heavily, breathing can be shallow and frequent, while the skin and visible mucous membranes are pale, in case of severe respiratory failure - with a bluish tint. During a general examination, the severity of the patient’s condition is assessed;
• upon local examination, in the case of an external injury to the larynx, the surface of the wound is visualized on the anterior surface of the neck; with a significant injury, the presence of bleeding; with subcutaneous emphysema, swelling of the soft tissues of the neck. During a local inspection, the nature of the damage is assessed;
• upon palpation (palpation) - in the case of emphysema, swelling of the soft tissues and crepitus (a small crunching sound, as if small bubbles are bursting) are palpated in its place.

The following instrumental examination methods are used in the diagnosis of laryngeal injuries:

• probing the wound - a medical probe (metal rod) is used to carefully examine the wound, determining its depth and the presence of foreign bodies;
• laryngoscopy - using a laryngoscope (a type of endoscopic equipment) to study the inner surface of the larynx. During the examination, scratches and tears in the laryngeal mucosa, hemorrhages in the submucosal layer, foreign bodies are detected, and perforation of the laryngeal wall is confirmed or excluded. If there is a separation of the larynx from the hyoid bone, it is detected by such signs as elongation of the epiglottis, increased mobility of its free edge, lower location of the glottis;
• X-ray of the larynx - helps to clarify the nature of the damage and the size of the wound;
• multislice computed tomography of the larynx (MSCT) - with the help of computer slices you can obtain more information than with an x-ray examination.

A number of instrumental methods are also used to help determine whether there has been damage to structures adjacent to the larynx. These are diagnostic methods such as:

• pharyngoscopy - examination of the pharynx using a spatula. Used to identify associated laryngopharynx trauma:
• X-ray of the cervical spine;
• X-ray of the esophagus with contrast;
• Ultrasound examination of the thyroid gland (ultrasound);
• Ultrasound of neck tissues;
• magnetic resonance imaging of neck tissue (MRI);
• X-ray of the lungs;
• spirometry - used to assess external respiration.

If the patient's condition is not critical, methods for assessing voice formation are used:

• phonetography – during it, voice analysis is carried out using a special computer program;
• stroboscopy - during this method, the oscillatory ability of the vocal cords is studied using a strobe;
• electroglottography – assesses the mobility of the larynx and vocal cords. To do this, the electrical resistance of the larynx is measured.

Laboratory research techniques used in the diagnosis of laryngeal injuries are as follows:

• general blood test - a decrease in the number of red blood cells and hemoglobin will help assess the degree of bleeding;
• blood gas analysis - determine the amount of oxygen and carbon dioxide, using these indicators to assess the degree of development of respiratory failure;
• determination of the acid-base state of the blood - helps to judge the degree of gas exchange disturbance in the body;
• bacterioscopic examination - a smear from the wound is examined under a microscope, the pathogen that can cause an infectious process in the wound is determined;
• bacteriological examination - a smear from the wound is inoculated onto nutrient media, the pathogen is determined.

Differential diagnosis should be made between isolated and combined injuries of the larynx.

Most often, with laryngeal injuries, regardless of their characteristics, the following complications develop:

• traumatic shock - a violation of tissue microcirculation as a result of severe pain, which not only causes suffering to a person, but also triggers a number of pathological mechanisms (narrowing of blood vessels, disruption of blood flow through them, and so on);
• chondroperichondritis of the larynx - inflammatory lesion of the perichondrium of the larynx - a thin connective tissue film that covers the cartilage of the larynx;
• phlegmon of the neck is its diffuse purulent lesion. In this case, pus can spread very actively in the soft tissues of the neck;
• purulent mediastinitis - purulent-inflammatory lesion of the mediastinum (mediastinum) - a complex of organs that is located between the lungs;
• getting into the swelling of a foreign body - these can be parts of a wounding weapon (shell fragments, bullets, cutting part of a knife), scraps of clothing, soil, sand, and so on;
• post-traumatic swelling of the neck - swelling of its soft tissues;
• aspiration pneumonia - inflammation of the lungs that develops due to blood entering the lungs in the presence of severe bleeding;
• the formation of a hematoma - because of it, the lumen of the larynx may decrease;
• acute laryngeal stenosis. Develops as a result of a reflex spasm - it is a reaction of the soft tissues of the larynx to the fact of damage;
• respiratory failure - a violation of the flow of air through the larynx from the external environment into the lungs;
• asphyxia (or suffocation) is a complete cessation of air flow into the lungs due to obstruction of the larynx resulting from injury. It can occur both with acute stenosis of the larynx and with the presence of a foreign body in its lumen.

Most complications of laryngeal injuries can sooner or later lead to the death of the victim.

Treatment of laryngeal injuries

The most important measure for laryngeal injuries is first aid. His tasks:

• stopping bleeding;
• restoration of airway patency and resumption of normal breathing;
• anti-shock measures.

Based on the appointments:

• in case of an external injury or a penetrating wound, treat it and apply a sterile bandage;
• placing the victim on the bed in such a position that his head is elevated;
• immobilization (immobilization) of the neck;
• mask ventilation and oxygen therapy;
• complete motor and vocal rest;
• nutrition - through a nasogastric tube;
• drug treatment.

The basis of drug therapy is the following:

• antibacterial drugs;
• anti-inflammatory drugs;
• painkillers;
• decongestants;
• hemostatic agents;
• infusion therapy - to restore blood volume during bleeding and for detoxification purposes. Saline solutions, electrolytes, protein solutions, glucose, blood serum, fresh frozen plasma are administered intravenously;
• blood components - in case of severe bleeding. Red blood cells, platelets, blood serum and others are injected intravenously.

For severe injuries to the larynx, surgical intervention is performed.

Indications for performing the operation are as follows:

• fracture of the laryngeal cartilage with displacement;
• increasing emphysema of the neck;
• severe bleeding;
• violation of the skeleton (framework) of the larynx;
• massive wound surface;
• the presence of a foreign body in the tissues that cannot be removed non-surgically without the risk of damaging adjacent structures.

Depending on the type of violation, the following manipulations are performed during the operation:

• primary surgical treatment of the wound;
• removal of a foreign body;
• removal of hematoma;
• tracheostomy - the formation of an artificial opening in the anterior wall of the trachea for normal air flow into the respiratory tract;
• ligation of the external carotid artery - in case of unstoppable bleeding, if there is a threat of massive blood loss;
• Chordectomy – removal of the vocal fold;
• laryngopexy – suturing the larynx to the hyoid bone;
• reconstructive manipulations - restoration of the normal shape of the larynx from its damaged but viable tissues;
• prosthetics and plastic surgery of the larynx (including artificial implants);
• resection of the larynx (if it is severely damaged, when reconstructive actions do not make sense).

During the postoperative recovery period, such patients attend special classes conducted by a phoniatrist (a doctor who deals with voice problems).

To prevent injury to the larynx, it is necessary to avoid any situations and circumstances associated with the risk of such injuries. If it is necessary to find yourself in such situations, it is necessary to use personal protective equipment.

The prognosis for laryngeal injuries is completely different, as it depends on the degree of damage, aggravating circumstances and the development of complications. In general, with prompt first aid, stopping bleeding and re-opening the airway, the prognosis is favorable. You should beware of combined injuries, in which damage to structures adjacent to the larynx is even more dangerous than damage to the larynx itself.

Kovtonyuk Oksana Vladimirovna, medical observer, surgeon, consultant doctor

Due to its location, the human larynx is protected from various external influences. The articular apparatus controls the larynx, allowing it to cushion the organ from pressure or bruise. With injuries to the larynx, especially penetrating wounds, the person’s condition is aggravated if large vessels are damaged. We are talking about dangerous lesions that lead to the death of the victim or entail a deterioration in the victim’s health, and sometimes disability. The danger of laryngeal injuries is that the consequences tend to appear months and even years later: a person’s breathing is constantly impaired, his voice changes, and he has difficulty swallowing food. In such cases, specialists perform surgical operations that help restore the functions of the organ.

Laryngeal injuries are various injuries caused by the influence of one or another factor. This influence can be external and internal. Trauma to the larynx can be internal or external.

Internal injuries include burns with chemicals, internal injuries with cutting objects, as well as penetration of a foreign body, which leads to bedsores, re-infection, and necrosis. These also include forced and accidental injuries (consequences of unsuccessful surgery), the consequences of intubation that occurs with the trachea (the presence of cysts or bedsores).

External injuries are considered to be wounds and blunt injuries. They are often combined with lesions of nearby structures that can affect the trachea and pharynx.

CLOSED INJURIES

Injuries to the larynx are relatively rare in peacetime.

Laryngeal injuries are divided into closedAndopen. Closed ones, in turn, are divided into internal and external. If closed injuries are often isolated, then open injuries are usually combined. They damage not only the integument, but also the organs of the neck.

In case of internal injuries, the area of ​​the entrance to the larynx is mainly affected: the epiglottis, arytenoid cartilages, aryepiglottic folds and pyriform sinuses.

Depending on the operating factor, injuries can be chemical, thermal and mechanical.

Chemical burns of the larynx are caused by strong alkalis (caustic soda) and acids (sulfuric, hydrochloric, nitric). They are often combined with burns of the oral cavity, pharynx and esophagus, the clinical manifestations of which are much more severe than in the larynx.

Thermal burns of the larynx caused by hot liquids, vapors or gases are generally rare. There are no major changes with them, and no measures other than those taken for burns of the pharynx with which they are combined are required. The development of edema complicates the course of the burn.

Mechanical internal injuries are applied by foreign bodies entering the larynx, such as fish and meat bones, as well as by instruments due to careless lubrication, during direct laryngoscopy, tracheo-bronchoscopy or intubation, and during intratracheal anesthesia. They are usually small and do not cause serious functional impairment. At the site of injury, hemorrhage and disruption of the integrity of the mucous membrane are detected. Sometimes swelling appears at the site of the injury and around it. The swelling may be limited to a small area, but it can increase and threaten serious respiratory distress, dictating the need for appropriate treatment measures, up to and including tracheotomy. When the damaged area becomes infected, an infiltrate forms, and then an abscess on the lingual surface of the epiglottis or in the pyriform fossa. The possibility of developing phlegmon and chondroperichondritis cannot be ruled out. Prediction in such cases becomes serious.

Are of great importance external injuries. External closed injuries include bruises, compression, fractures of the laryngeal cartilage and hyoid bone, and separation of the larynx from the trachea.

Closed external damage is caused by a blunt instrument. They usually occur accidentally as a result of hitting the back of a chair, the handlebars of a bicycle, or the rotating handle of a car; A person can receive such damage if he stumbles upon a wire in the dark, or in a fight. Depending on the force with which the injury is caused, a bruise or fracture of the cartilage of the larynx occurs.

With closed injuries to the larynx, the victim often immediately loses consciousness (reflex laryngeal shock) from irritation of the cervical neurovascular bundle. The general condition is disturbed. Hemoptysis and subcutaneous emphysema, pain when swallowing and when palpating the neck appear, which intensify during talking and coughing. Breathing is usually difficult.

On external examination, hemorrhages are found on the skin of the anterior surface of the neck. If there is subcutaneous emphysema, then the contours of the neck are smoothed out and it thickens significantly. Emphysema can spread to the chest and back, face, and mediastinum. The characteristic crepitation is determined by palpation.

In case of cartilage fractures, their deformation and crunching at the fracture site are determined. Most often the thyroid cartilage is affected, then the cricoid and, finally, the arytenoids. Retraction or depression of one or another section of cartilage can be recognized only a few days after the injury, when the emphysema decreases.

Laryngoscopically, with bruises of the larynx, hemorrhages and hematomas are determined.

The mucous membrane takes on a bluish tint, and blue-purple bubbles form under it. In cases of violation of the integrity of the cartilage of the larynx, fragments protruding into its lumen can be seen. The lumen of the larynx is narrowed by these fragments, as well as as a result of edema or emphysema of the area of ​​the arytenoid cartilages. Sometimes, in the absence of these changes, one half of the larynx becomes motionless, which is explained by damage to the inferior laryngeal nerve.

If a laryngeal injury is combined with a fracture of the hyoid bone, then the described picture is accompanied by retraction of the tongue, pain when protruding it, and immobility of the epiglottis (V.K. Trutnev).

In addition to the listed signs, X-ray data are of great importance for diagnosis. X-rays can reveal a narrowing of the lumen of the larynx and a violation of the integrity of its skeleton. Sometimes, during such a study, gas bubbles are detected under the skin of the neck. Gas may also be in the pleural cavity.

The prognosis for bruises and especially for fractures of the larynx is always serious. Death can occur either at the moment of injury or at any other moment. The victim is at risk of suffocation due to displacement of cartilage, development of laryngeal edema, and mediastinal emphysema. Danger to life is also associated with the flow of blood into the bronchi and their tamponing with coagulated blood. The possibility of complications such as sepsis or mediastinitis cannot be ruled out. Therefore, the victim must be under constant medical supervision.

Treatment. Anyone who suffers a laryngeal injury must be hospitalized without fail. To reduce cough and pain, subcutaneous injection of morphine is prescribed. The hospital must be provided with round-the-clock supervision by a qualified doctor who is ready to perform a tracheotomy, since suffocation can occur at any time.

Turning off the larynx from breathing is the moment to stop bleeding; therefore, tracheotomy is indicated in cases where blood from the wound flows into the trachea and bronchi: after tracheotomy, the larynx can be plugged. If even after laryngeal tamponade the bleeding does not stop completely, then the blood will pour out and enter the trachea in much smaller quantities. Through a tracheotomy wound, blood clots can be removed from the bronchi.

Simultaneously with these measures or immediately after them, in case of severe injuries, anti-shock measures should be carried out (blood transfusion, vagosympathetic novocaine blockade, stimulants).

If a significant displacement of cartilage fragments is determined, it is necessary to open the larynx (laryngofissure or laryngostomy), remove crushed areas, straighten the displaced fragments and hold them in place by suturing the perichondrium or tamponing the lumen of the larynx.

For fractures of the hyoid bone, reduction of the fragments is done with fingers inserted into the mouth.

In the absence of difficulty breathing and bleeding or after they have been eliminated, the patient is prescribed a regime of silence; codeine or dionine is prescribed to reduce cough; In the first hours after injury, swallowing pieces of ice is recommended. Liquid and mushy food is allowed. Prescription of antibiotics and sulfonamides in the first days after injury is mandatory.

Open injuries (or wounds) of the larynx can be cuts, stabs or gunshots.

Depending on the level of the incision, there are: 1) wounds under the hyoid bone, when the sublingual-thyroid membrane is crossed, and 2) wounds of the subglottic space, passing through the conical ligament. With injuries of the first kind, due to contraction of the cut muscles, the wounds gape widely, the larynx, pharynx, and sometimes the entrance to the esophagus become clearly visible. The epiglottis can move upward in whole or in part. The voice in such patients is preserved, but speech disappears, since the larynx and articulatory apparatus are disconnected. However, as soon as the patient lowers his head and thus narrows the wound, speech appears.

Saliva flows through the gaping wound and food falls out.

When the wound is located high (above the entrance to the larynx), breathing is often not impaired, air freely enters and exits through the wound. With injuries at the level of the vocal cords and especially in the subglottic space, breathing is usually difficult.

The general condition of patients, especially immediately after injury, is greatly impaired. Shock symptoms are often present. Blood pressure drops, pulse quickens, temperature rises. Bleeding can be significant if the thyroid gland is injured. With injuries to the carotid arteries, death occurs immediately. However, the carotid arteries are rarely crossed by suicides; when they throw their head back strongly, then with their neck protruded, the carotid arteries are hidden under the sternocleidomastial muscles and do not fall under the knife.

Forecast. Wounds inflicted with intent to kill usually result in instant death from severe bleeding or shock. If injury to large vessels does not occur, then the victims remain alive, but the prognosis should be made with caution, since severe complications may occur. In the near future, secondary bleeding may occur, aspiration pneumonia, mediastinitis, sepsis, and meningitis may develop.

Treatment. Sutures are applied in layers: on the mucous membrane, muscles, skin. Rubber or gauze drains are placed in the corners of the wound. To reduce tissue tension and bring the edges of the wound closer together, the patient’s head is tilted forward during suturing. It should remain in this position in the postoperative period.

Puncture wounds have small external dimensions, but go deep, forming a narrow channel. With them, large vessels are often damaged, large bleeding occurs and shock develops, which lead to a sad outcome. These wounds are characterized by bloody sputum and emphysema. For puncture wounds, tracheotomy is certainly indicated, since emphysema spreads quickly. Sometimes, to eliminate it, in addition to tracheotomy, it is necessary to cut the wound channel.

• Thyroid cartilage fracture the most serious traumatic injury to the larynx and hypopharynx.
• Blunt trauma (eg, car accident, punch, strangulation, fall)
• A fracture of the cartilage of the larynx is often accompanied by the formation of a hematoma, bleeding and swelling of the soft tissues of the larynx
• Rupture of the mucosa can lead to the formation of soft tissue emphysema.

Clinical manifestations

Typical symptoms:

• Subcutaneous hematoma at the level of the larynx
• Acute shortness of breath
• Dysphagia
• Stridor
• Hemoptysis
• Dysphonia
• Pain when swallowing.

Signs of a thyroid cartilage fracture on CT and MRI images with contrast

Selection method

• CT with contrast.

What will CT scans of the neck show for a cartilage fracture?

• Fracture line (usually on the anterior surface)
• Hematoma of the periglottic tissue (fresh hemorrhage is hyperintense) can cause displacement of the trachea
• Sometimes there is extravasation of contrast material due to ongoing bleeding.
• With soft tissue emphysema, subcutaneous air accumulation is usually observed.

Possible displacement of the arytenoid cartilage: Non-physiological position or rotation of the arytenoid cartilage

• Edema of the aryepiglottic fold
• Fixation of the vocal cords when pronouncing the letter “i” or performing the Valsalva maneuver.

In what cases is an MRI of the neck necessary for a fracture of the thyroid cartilage?

• Fracture line
• Depending on the time elapsed since hematoma formation, it may be hyper-, iso-, or hypointense to muscle tissue on T1- and T2-weighted images
• There is no signal enhancement after gadolinium administration.

Features

• CT scan shows discontinuity of the thyroid cartilage (fracture line)
• Presence of hematoma
• Expansion of the shadow of the larynx and peritracheal soft tissues during a conventional x-ray examination (roentgenogram of the cervical spine in a lateral projection).

What the attending physician would like to know

• Presence of offset
• Exact location
• Complications

What diseases can be confused with a fracture of the thyroid cartilage?

Tumor infiltration (stage T4)

CT: cortical discontinuity, moderate enhancement after administration of contrast agent

MRI: high signal intensity on T2-weighted image, unclear edges

Ossification

CT scan: negative density values ​​in the center (fat tissue)

MRI: high signal intensity on T1-weighted image

Treatment

Fracture of the thyroid cartilage without displacement:

• Antibacterial therapy
• Glucocorticoids
• Intravenous administration of calcium supplements

Fracture of the thyroid cartilage with displacement:

• Open reduction
• If the integrity of the laryngeal skeleton is compromised, a tracheotomy is performed and a plastic stent is installed in the lumen of the larynx.

What specialties do doctors diagnose and treat thyroid cartilage fractures?

ENT doctor (definition of defect)

Surgeon (reposition of fragments, installation of a stent)

Forecast

• With timely treatment, the prognosis is usually favorable

Possible complications and consequences

• With delayed treatment, chronic stenosis of the larynx or trachea may develop
• Postoperative dysphonia is common after severe displaced fractures.

CT scan in horizontal projection: traumatic fracture of the posterior part of the thyroid cartilage on the right (without displacement). There is also predominantly left-sided emphysema of soft tissues near the larynx.

CT scan in frontal and horizontal projections: old fracture of the anterior commissure of the thyroid cartilage.

Damage to the larynx as a result of a closed neck injury should be suspected if the wounded person experiences hoarseness, wheezing, soft tissue emphysema, swelling or hematomas of the neck. Laryngeal injuries are divided into bruises, dislocations and cartilage fractures (closed or open). In many cases there is a combination of these injuries.
Symptoms of a bruise usually consist of pain and discomfort in the larynx; coughing, dysphonia, swelling, hematomas and ecchymosis may occur. The development of respiratory disorders after a contusion of the larynx is possible with intralaryngeal hematomas, reactive or inflammatory edema that develops later after the injury. With severe bruises of the anterior sections of the neck, multiple injuries to various cervical organs are often observed - the vagus nerve and its branches, the esophagus, the thyroid gland, etc. Post-traumatic injuries to the recurrent nerves can cause laryngeal stenosis.
Dislocations of the cartilages of the larynx, as a rule, occur in combination with wounds of the larynx or fractures of its cartilages
Among laryngeal cartilage fractures, the most common are thyroid cartilage fractures. Typical fractures of the thyroid cartilage are a horizontal transverse fracture of both plates at once, a comminuted fracture with vertical and horizontal cracks.
Fractures of the cartilage of the larynx can be either closed (without damage to the mucous membrane) or open. With open cartilage fractures immediately after the injury, the wounded person may lose consciousness due to respiratory arrest from suffocation. He experiences shortness of breath with strained breathing, sputum mixed with blood, dysphonia or aphonia, pain spontaneously and when swallowing, and cough.
An external examination reveals swelling, bruising, and sometimes subcutaneous emphysema, the increase of which is stimulated by coughing to a large extent; deformation of the external contours of the larynx; pathological mobility of cartilage can be detected by palpation. During laryngoscopy, if it is successful, edema, ecchymoses, hematomas, immobility of half of the larynx, narrowing of its lumen due to edema or hematoma, and ruptures of the mucous membrane are detected.

Trauma to the anterior surface of the neck may result in separation of the larynx from the hyoid bone. Complete avulsions are rare; partial avulsions occur quite often. With complete separation, if the pharyngeal muscles are torn, the clinical picture is very severe. Many such wounded people die from dislocation-aspiration asphyxia before receiving medical care. The larynx goes down, and the hyoid bone, on the contrary, moves up and anteriorly. There is continuous aspiration of mucus and blood, and swallowing is usually impossible. Already upon examination, retraction at the site of the hyoid bone is visible, and the angle between the chin and the front surface of the neck becomes acute. X-ray examination reveals a high position of the root of the tongue and hyoid bone, an increase in the distance between them and the larynx. Fluoroscopy can reveal how the contrast agent enters mainly the larynx, and not the esophagus, and spreads through ruptures in the pharynx. If the larynx is separated from the hyoid bone partially in front or on the side, then it still moves downward to one degree or another. The separation of the larynx from the side also leads to its partial rotation around the vertical axis. In case of laryngeal injuries, it is very important to have a correct understanding of the volume and severity of the damage received.
The most severe injury to the larynx is the complete separation of the cricoid cartilage from the trachea. Immediately after the injury, extensive emphysema of the neck, chest, and head develops, a cough with bloody sputum, hemoptysis appears, and threatening shortness of breath and asphyxia quickly increases. An accurate diagnosis is always difficult to establish, especially when it is very often combined with injuries to other organs.
Diagnosis of closed injuries of the larynx is based on data from a study of the general condition of the wounded person and local phenomena. Indirect laryngoscopy often fails due to the patient's severe condition. External examination and palpation help determine the location and nature of the damage, however, with emphysema of the cervical subcutaneous tissue, determining a fracture of the laryngeal cartilage by palpation is extremely difficult. Diagnosis of damage to the cartilaginous skeleton, as well as deep emphysema, is facilitated by radiographic (and especially tomographic) examination. If a simultaneous rupture of the laryngopharyngeal wall is suspected in stable wounded patients, it is advisable to perform fluoroscopy with water-soluble contrast.

Gunshot wounds of the larynx, located in the anterior part of the neck, are often accompanied by damage to neighboring organs - the pharynx, esophagus, large vessels and nerves, and the spine. The wound channel in the neck has a tortuous nature and is often interrupted by displaced muscle-fascial layers, the so-called “scenes”. In this case, closed spaces are formed, filled with both spilled blood and crushed non-viable tissues, and the remnants of brought clothing.
With injuries to the larynx, disorders of the vocal, respiratory and protective functions, as well as swallowing, often occur.
Voice and breathing disorders can become persistent. Stenosis of the larynx and trachea is one of the most common causes of long-term disability.
Respiratory disorders most often develop immediately after injury or in the first days after it, usually due to traumatic deformation of cartilage and (or) swelling of the laryngeal mucosa. With the development of acute stenosis, breathing in the wounded usually becomes stridorous, with inspiratory dyspnea. The wounded try to take a sitting position, holding the edges of the bed or stretcher with their hands. Asphyxia most often develops with wounds of the larynx in the vocal cords and subglottic space. If the larynx above the vocal cords is damaged, most of the wounded continue to breathe freely. Respiratory disorders are also observed when the larynx itself is intact, but with damage (especially bilateral) to the recurrent nerves, which causes immobility of the vocal cords and their shift to the midline.
Bleeding is one of the most severe consequences of a wound to the larynx, along with breathing disorders. Bleeding from injuries to the larynx itself is rarely intense due to the small diameter of the laryngeal vessels, but even they can be dangerous due to the possibility of aspiration of blood into the lower respiratory tract. In this case, a blood clot forms in the trachea and bronchi, like a cast of their lumen. In most cases, intense bleeding develops with simultaneous damage to the large vessels of the neck. In cases where the amount of aspirated blood is not so significant that respiratory failure develops, the blood poured into the bronchi often causes aspiration pneumonia. Bleeding is divided into external (from a wound on the neck) and internal. Internal bleeding - into the lumen of the larynx and
tracheobronchial tract - usually manifested by the release of blood out through the mouth or nose. A characteristic feature of respiratory tract injuries is the so-called throat bleeding or hemoptysis. Endoscopic examination quite often reveals submucosal accumulations of blood (hematomas), which have the appearance of a bluish-purple swelling, visible through the intact mucosa, with a gradual transition into unchanged tissue.
Emphysema of the tissues of the neck is of no small importance in the diagnosis and course of penetrating wounds of the larynx. Starting from a small wound hole in the wall of the larynx, emphysematous impregnation of tissue with air can quickly spread throughout the subcutaneous tissue. The appearance of emphysema indicates a penetrating injury to the respiratory tract. With the development of subcutaneous tissue emphysema, the contours of the neck first become smooth. The swelling, gradually spreading, can involve the torso and even the upper and lower extremities. Emphysema increases gradually and reaches its greatest development usually on the second day after injury. Subsequently, mutually opposite processes are observed - the resorption of air permeating the tissue and a new intake of air from the lumen of the respiratory tract. The subsequent course depends on the predominance of one of these processes.
Voice changes develop with injuries to the larynx above the vocal cords (in the area of ​​the epiglottis, aryepiglottic ligaments or in the upper parts of the thyroid cartilage) mainly due to reactive phenomena in the area of ​​the true vocal cords, accompanied by hoarseness of the voice, and in some cases - complete aphonia, which can be explained the desire of the wounded to spare the larynx. Complete aphonia develops more often with injuries to the larynx in the area of ​​the vocal cords due to severe deformation of this part of the larynx. However, in some cases, the vocal function is still preserved, which can be explained by the compensatory participation of neighboring intact formations in the process of voice formation. Damage to the larynx in the subglottic space most severely affects the voice-forming function, in which in almost all cases complete aphonia is detected.
Swallowing disorders manifest as pain when swallowing (dysphagia), mechanical difficulties in swallowing food, and the entry of food masses and liquids into the external wound.
or into the respiratory tract (choking). These disorders are often accompanied by drooling and increased pharyngeal reflex (especially in the first days after injury). Subsequently, a wound infection develops, emphysema of the subcutaneous tissue, and secondary bleeding occur. Laryngeal injuries are characterized by complications such as perichondritis of the laryngeal cartilage, aspiration pneumonia and mediastinitis. Swallowing disorders due to wounds of the larynx in a significant number of cases are explained by pain that occurs when muscles contract during swallowing, as well as from irritation of the injured larynx by a lump of passing food. In addition, when the larynx is injured, damage to the laryngeal part of the pharynx often occurs, because these two organs have common walls. If the separation mechanism at the entrance to the larynx is disrupted due to injuries to this area, food masses and liquids can penetrate into the respiratory tract, causing aspiration complications. The latter are accompanied by a cough, which further irritates the damaged larynx.
To recognize the characteristics of a wound to the larynx, the use of the following diagnostic methods is required: external examination, internal methods (endoscopy) and additional techniques (including x-ray). External research methods include inspection, palpation, probing and observation of laryngeal function.