Total Laryngectomy Following Severe Laryngeal Trauma: A Case of Surgical Dilemma

Abstract

External laryngeal trauma is a rather rare occurrence, and comprises a varying severity of injuries. Every laryngeal injury is unique and the management can be invariably complex. For the most severe forms of external laryngeal trauma, reparative procedures and laryngeal stenting (after control of the airway) are considered standard treatment. We present a case of a complex laryngeal trauma with extensive loss of tracheal cartilage and soft tissues which was treated with total laryngectomy.

Introduction

External laryngeal trauma is a rather rare occurrence, and comprises a varying severity of injuries. Every laryngeal injury is unique and the management can be invariably complex, the immediate goal will be achieving emergency airway control, and subsequently in performing the best treatment procedures aimed at limiting the possible respiratory and vocal impact. For the most severe forms of external laryngeal trauma, scrupulous reparative procedures and laryngeal stenting are considered standard treatment, after airway control [1]. The purpose of this report is to highlight and present a rare option of a total laryngectomy due to complications of the trauma, rather than an attempted laryngeal repair.

Case Report

We had a 44-years old gentleman, brought to the Emergency & Trauma Department by co-workers with an alleged cut by a huge industrial blade that broke off from a machine while sharpening a knife at work. He presented with difficulty breathing, active bleeding and aspiration of blood from the neck wound. Patients vitals was stable and was put on high flow mask oxygen to maintain his oxygen saturation. Neck examination revealed a deep laceration wound over centre of neck extending to the left, active bleeding and gurgling sound from wound site. A compression gauze placed over wound site.

Patient was pushed to operation theatre immediately. The comminuted fracture wound of the thyroid cartilage enabled an insertion of size 7.5 mm, cuffed endotracheal tube to secure the airway followed by a formal tracheostomy. Intraoperatively, we found that there is a deep laceration wound from left mandible extending inferiorly to midline of neck with laceration of strap muscles and soft tissue, chip fracture of ramus of left mandible, comminuted displaced fracture of thyroid cartilage with loss of cartilage. Anterior commisure was found to be separated from thyroid cartilage. Left false cord and true cord lacerated and macerated with loss of mucosa. Cricoid cartilage and tracheal cartilage was found to be normal and intact and the thyroid gland was normal as well (Fig. 1). No vessel injury found. An attempt at repair of the traumatized larynx proofed futile. However, remaining thyroid cartilage was approximated and sutured with absorbable 4–0 sutures. Visualization of upper airway with direct laryngoscopy reveled oedematous epiglottis and supracricoid structures with no much appreciation to structures. Flexible fibreoptic bronchoscopy revealed trachea and bilateral primary bronchuses normal.

Fig. 1.

Comminuted thyroid cartilage fracture

Following his recovery, computed tomography (CT) of neck was done. There was fracture through the left superior horn of the thyroid cartilage with lateroinferior displacement obliterating left vocal cord. Right vocal cord appears to be thickened. Some fractured fragments are seen displaced medially at the left side of hypopharyngeal region at level of C5. Another fractured fragment is seen anterior to hypopharynx at the level C6. Mild luminal narrowing is noted at this region measuring 8.5 mm in AP diameter. Cricoid cartilage is not fractured. The right arytenoids cartilage has a normal appearance. Left arytenoids cartilage appears to have an abnormal configuration. No hyoid bone fracture. Mild asymmetry of pyriform sinus (Fig. 2).

Fig. 2.

Axial non contrasted CT of neck showing fractured displaced segments of thyroid cartilage

Flexible nasopharyngolaryngoscopy assessment revealed a distorted left vocal cord, aryepiglottic fold and arytenoid configuration. However the right vocal cord, aryepiglottic fold and arytenoid mucosa was normal. The epiglottis above and subglottic below was normal as well. The left vocal cord movement was restricted, positoned at the paramedian, giving rise to incomplete glottic closure and a significant glottal gap. Fiberoptic Endoscopic Evaluation swallowing assessment was done 1 month post operative and there is evidence of aspiration to fluid and saliva.

Patient was offered partial vertical laryngectomy. However, patient refused in view of prolonged healing, the need to be on nasogastric tube feeding and the risk of aspiration. Decision was taken for total laryngectomy with thyroid preservation. Post operation, patient healed well. He is taking orally well and voice rehabilitation with electro larynx was initiated.

Disccussion

Laryngotracheal trauma is a rare entity. The injury mechanism of laryngeal fracture can be classified as either penetrating trauma or blunt trauma. In the literature, blunt traumas has been reported widely to be the most frequent cause of laryngeal fracture. Penetrating injuries are far less common. Nevertheless, the proportion of penetrating laryngeal injury is on the rise now, and is believed to be the result of increased trauma caused by urbanization and industrialization. Gunshots, stabbing injury, or injuries caused by machines, and other similar types of injury have been perpetrated to be the important causes of penetrating neck traumas. In penetrating trauma, it was observed that nondisplacement fractures to the widest area of the thyroid cartilage were abundant [2]. The type of injury was pertinent with the literature but the presentation was very exceptional.

The most severe forms of laryngotracheal trauma can be life-threatening due to the risk of respiratory failure and in most cases, these patients die before reaching the hospital because of severe airway injury or succumbing to occurrence of severe organ injury in association with laryngeal fracture. The handling of the airway is an absolute priority if they do survive. On the other hand, the possible outcome of scarring and impaired motor function may have a negative impact on both respiratory and speech functions, and might require further intervention.

In regards to treatment options, laryngeal fractures which are displaced or which involves more extensive damages will require surgical repair. According to literatures, a reparative procedure performed within 24–48 h has a greater probability of success and fewer complications, compared to a delayed intervention. The available surgical procedures must be tailored to each individual case that include accurate mucosal, cartilaginous and ligamentous sutures, and, if needed, mucosal flaps or grafts.

In severe trauma cases, it is commonly believed that surgical repair must be followed by the placement of a stent for stenosis prevention and internal stability. However, the presence of such a stent has some disadvantages, such as the risk of granulations, pressure necrosis, ulcers and subsequently infection. Additionally, there is lacking of general consensus as to the best type of device to be used and, optimum duration of stenting. [3–5]

Most studies have classified outcomes of both blunt and penetrating laryngeal trauma into airway obstructions, voice outcome and swallowing difficulty. The airway could be compromised in about 7–17%, whilst voice compromised in 21–25% and swallowing normal about 99% of the time. [5] In one of the case that patient went through with supracricoid laryngectomy, post-operatively, no airway stenoses occurred, voice was breathy but functional and swallowing was normal. [4]

In our patient, the complexity of the injuries sustained would have proven any attempt to restore the laryngeal integrity tremendously difficult, and we were mindful that a conservative treatment would have led to a less than ideal functional results with patient already on long term tracheostomy tube and nasogastric tube feeding. The larynx was deemed non-functional with the inability to protect the airway with intractable aspiration and the loss of voice. There was loss of arytenoid on one side and the stability of the laryngeal framework was questionable with the extensive loss of thyroid cartilage and mucosa. The option of partial vertical laryngectomy holds its own complications and the long term healing process involved. These considerations led us to choose total laryngectomy as the primary treatment of choice, which would at least allow for a single, acceptable surgical intervention with stable end result.

This management must be considered exception rather than the general rule. The occurrence of severe laryngeal destruction not followed by instant death is a very rare event. Therefore, recontructive procedures should be preferred when and where the skeleton and the soft tissues of the larynx are sufficiently preserved.

Nevertheless, in this circumstances, this one-off surgical intervention enables a stable result for a continuous livelihood.

Funding

No funding required for this study.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interests.

Ethical Approval

Research was conducted in accordance with the 1964 Helsinki Declaration.

Informed Consent

Verbal informed consent was obtained from patient.