Cricotracheal Separation with Esophageal Laceration in Blunt Neck Trauma: A Case Report

Abstract

Survival from laryngotracheal separation injuries depends on appropriate airway treatment, these injuries are uncommon but dangerous. consequently, expert opinion and brief case studies have served as the foundation for managerial recommendations. In the present case, the airway was first obtained by awake tracheostomy followed by urgent neck exploration and repair of cricotracheal defect and esophageal laceration under general anaesthesia. at four months after surgery, patient had an occluded tracheostomy with cords in paramedian position, eating a regular diet, and had a decent voice quality. patients can regain a patent airway, a functional voice, and normal swallowing with a high index of suspicion and prompt reconstruction that restores the laryngotracheal framework and mucosal integrity.

Introduction

Laryngeal trauma is a rare but potentially fatal disorder [1]. The most severe type of laryngeal trauma is complete laryngotracheal separation, which falls into the fifth grade of the schaefer-fuhrman classification [2]. For the patient’s survival in these situations, early appropriate airway treatment within the first several hours after trauma is essential. Less than 1% of all traumas admitted to the emergency room are laryngeal traumas, thus some doctors may not be knowledgeable on how to diagnose and treat these. Patients are at risk for poor outcomes due to delayed diagnosis and incorrect care [3].

Case

An 18 year old boy presented with difficulty in breathing immediately after a blunt trauma to neck due to accidental strangulation by a rope while riding a two-wheeler vehicle. He was fully conscious, oriented, normotensive, tachycardic and tachypnoeic with a respiratory rate of 28/min, aphonic and stridor was absent. The peripheral saturation was 90% on room air in sitting position and dropped to 70% in supine position. There were multiple superficial graze abrasions seen over anterior and lateral aspects of neck with underlying subcutaneous emphysema. The laryngeal framework could not be assessed due to emphysema and tenderness in the region. The patient was given intravenous hydrocortisone 100 mg and put on oxygen support. Cervical spine injury was ruled out and chest and pelvic compression tests were negative.

The patient underwent a non-contrast computed tomography of neck and thorax which revealed airway discontinuity at level of subglottis and cervical tracheav (Figure 1 a, b), no rib fracture and opacification in lower and middle lobes of right lung due to contusion or aspiration. The patient was counseled for emergency tracheostomy under local anaesthesia followed by emergency neck exploration under general anaesthesia with consent for airway repair with oesophageal repair, change in voice, permanent tracheostoma, oesophageal repair/neck stoma, Ryle’s tube insertion, need for post-operative ventilation and need for revision procedure/surgery.

Fig. 1.

a Axial section of CT Neck showing disrupted cricoid ring (white arrow) with intact great vessels and subcutaneous emphysema (white star) b Sagittal section of CT Neck showing cricotracheal disruption (white arrow)

First, a tracheostomy was done under local anaesthesia with head end of the patient raised 45 degrees, as he was not able to lie in a completely supine position. After securing the airway, the patient was laid supine with neck extension and given general anaesthesia. The tracheostomy incision was extended laterally and subplatysmal flaps elevated till hyoid superiorly, lacerated thyroid isthmus was encountered with underlying complete cricotracheal transection and esophageal transection of 270 degrees (Figure 2 a). The posterior wall of esophagus was intact. Ryle’s tube 16 FG was inserted guided by the operating surgeon into the esophagus. The anterior rim of cricoid was found fractured with posterior lamina intact. Bilateral recurrent laryngeal nerves could not be identified. The esophagus was closed primarily over the Ryle’s tube(RT) by extramucosal watertight suturing using vicryl 3 − 0. As the patient could not afford a Montgomery T-tube, the patient was nasotracheally intubated with an endotracheal tube(ET) 6.5 mm which was used as a stent. Cricotracheal repair was done with PDS 3 − 0 in a manner to keep the knot outside the lumen, over the nasotracheal tube after locally applying dexamethasone (Figure 2 b). The neck extension was removed at the time of tying knots. A drain was placed in subplatysmal plane and wound was closed in layers. Neck flexion and a chin stitch to prevent postoperative hyperextension of the neck were used. The patient was kept on ventilatory support, sedated and paralyzed for 12 h with the neck in a flexed position and was weaned off the next day.

Fig. 2.

a Intraoperative image showing transection at the level of lower border of cricoid cartilage and lacerated esophagus b Intraoperative image showing esophageal closure and cricotracheal repair (Black stars - lobes of thyroid gland White star– cricoid Solid black arrow - ruptured trachea - anterior wall Dotted black arrow– tracheostoma White solid arrow - anterior wall of cervical esophagus with Ryle’s tube in situ)

Ryle’s tube feed was started and the patient was not allowed to swallow saliva for 2 days. Subplatysmal drains did not show signs of saliva and were removed on post op day 4. Chest condition improved by day 5. The nasotracheal tube placed as a stent for 14 days following which it was removed. Fibre-optic tracheoscopy showed bilateral abductor palsy with a glottal gap at rest and slight gaping seen at the anterior subglottic wedge. Oral sips of water started on the same day. No sign of aspiration noted. Aspiration was noted on starting a semi-solid diet on day 18 following which a swallow study was performed. Video fluoroscopic swallow study revealed aspiration to liquids (Figure 3). So patient is discharged on Ryle’s tube feed, with a tracheostomy tube size 7.00 mm internal diameter in-situ on day 23. On 15-day follow up patient had airway edema, the tracheostomy tube was corked and RT was removed. The patient tolerated feeds well with swallowing maneuver (supraglottic maneuver). On 4 months follow up the grade two subglottic stenosis is present, and patient tolerated tube closure with cords in paramedian position (Figure 4 a, b). 4 months post operative X ray neck shows the stenosis length extending to upper trachea (Figure 5).Voice was husky but patient was satisfied with the vocal outcome. Patient is on regular follow-up to assess the progression of subglottic stenosis and cord palsy.

Fig. 3.

Video fluoroscopic picture showing minimal aspiration (blue arrow)

Fig. 4.

a 4 months post operative vocal cord status in paramedian position(star) b 4 months post operative grade II subglottic stenosis.(star)

Fig. 5.

4 months Xray neck with stenotic segment (blue arrow)

Discussion

Cricotracheal separation is categorized as a grade 5 injury, the most severe kind of laryngeal trauma, in the Schaefer-Fuhrman classification [2]. Only 1% of all trauma cases have laryngeal injuries, making them rare [4]. Cricotracheal separation with esophageal injury is an even less common subtype of laryngeal injury. Clinicians have little experience managing it because it is not commonly observed. Even though cricoid fractures and cricotracheal separation are uncommon, they can be difficult for doctors to treat since they can cause airway blockage and severe bleeding that needs to be identified early and treated effectively. On the outside, the neck may appear to be unharmed or to have only little bruises and surprisingly little airway trouble. The various phases of patient treatment may present a number of challenges.

Because laryngeal injuries can be fatal, they should be treated very carefully. Patients who appear with subcutaneous neck emphysema should be treated with a high degree of suspicion. The standard of therapy for cricotracheal separation is swift assessment, emergency tracheostomy followed by neck exploration and repair [5]. Creating a safe airway is the main goal. Endotracheal intubation carries the risk of further aggravating the injuries by avulsion of mucosa and disruption of fractured laryngeal framework. Blind endotracheal intubation should never be performed in a partially transected airway because it can result in total cricotracheal separation [6, 7]. Endotracheal tube in a false tract in the setting of cricotracheal separation may increase subcutaneous emphysema and airway distress. Early tracheostomy under local anaesthesia is the safest way to secure airway. This also allows for further workup and definitive management Better voice and airway results result from early treatment of laryngeal lesions.

Generally speaking, surgical exploration ought to be carried out within twenty-four hours of the damage [6].

A flexible laryngoscopy can be used to evaluate the larynx’s integrity, vocal fold movement, and airway patency in stable patients. Nevertheless, there is a poor correlation between these results and the extent of the injury [7]. As with flexible laryngoscopy, neck imaging should only be done after airway stabilization. When it is difficult to see the continuity of the endolarynx and trachea due to edema or hematoma, Computed tomography imaging can be helpful [5]. These processes provide extra data to support managerial choices.

First, the anastomosis is made between the posterior cricoid and tracheal ring using simple, interrupted PDS/prolene spaced 3 mm apart and 3 to 4 mm from the cut edge. The posterior-wall stitches span the posterior cricoid cartilage to the distal trachea’s membranous trachea. The remaining anterior and lateral anastomotic sutures are tied with knots outside the lumen over the stent. Stents are used to stabilise and support the laryngotracheal framework following repair. According to various studies, the length of stenting might range from three days to a year, contingent on the severity of the trauma. A silicone T tube is the most commonly used stent, but in our case nasotracheal ET tube was placed as stent due to non-availability and non-affordability.

Esophageal repair preferably should be done in two layers over a Ryle’s tube but single layer repairs have been documented to have a successful outcome if closure is done with extra mucosal, inverted absorbable sutures and is watertight.

There is a 60% risk of recurrent laryngeal nerve injury in cases of cricotracheal separation [8].

Recurrent laryngeal nerve was not looked for in this case and the patient had bilateral abductor palsy in postoperative period. There are chances of recovery of recurrent laryngeal nerve palsy in cases of blunt trauma so any definitive surgery for abductor palsy should be deferred for a minimum of 6 months [9]. Procedures to increase the airway diameter, such as arytenoidectomy and laser cordotomy, are taken into consideration when bilateral recurrent laryngeal nerve paralysis is found to be permanent. Suture lateralization of vocal fold or arytenoid abduction are also used. Suture lateralization has the benefit of being reversible and can be used where recovery is anticipated. Laser release and endoscopic dilatation of subglottic stenosis may be done in mild to moderate cases of subglottic stenosis. An inner, continuous, absorbable suture and an outer, interrupted, non-absorbable suture should be used to reapproximate the esophagus in two layers. Local tissue and muscle flaps should be used to buttress repairs, particularly if they are postponed to prevent trachea-esophageal fistula. If there are no clinical indications of leaking, contrast swallow assessments should be performed five to seven days following primary esophageal reconstruction.

Reduced lung function, infection, vocal cord paralysis, and strictures are possible side effects even with early detection and proper treatment [10].

In conclusion, because laryngeal injuries have the potential to be lethal, they should be treated very carefully. Patients who appear with subcutaneous neck emphysema should be treated with a high degree of suspicion. Creating a safe airway is the main goal. Blind endotracheal intubation should never be performed in a partially transected airway because it can result in total cricotracheal separation.

Author Contributions

Conceptualization- AS, DK Data curation-PK, DK Formal analysis-AS, AKG Funding acquisition-NA Investigation- AS, PK, DK Methodology- AS, PK, DK Project administration- AS, AKG Resources- AS, PK, DK Software-AKG, AS Supervision-AKG, AS Writing– original draft- AS, DK Writing– review and editing- AKG, PK.

Funding

Non funded.

Data Availability

All data pertaining to the case can be made available on request.

Declarations

Conflict of Interests

None.