Abstract
Laryngeal fractures are though uncommon they can be potentially life threatening. Comminuted laryngeal cartilage fractures are difficult to manage and various fixation techniques have been described in literature. Outcome results of fixation with different materials can be varied. We report a case of 27 years old male who sustained laryngeal cartilage fracture following accidental fall. Patient underwent emergency tracheostomy and early surgical repair of fractured laryngeal thyroid cartilage with one of the newest techniques “titanium mesh fixation”. After a month of surgery tracheostomy tube was removed and patient recovered with good laryngeal function. Titanium mesh fixation gave immediate effective fixation and stability to laryngeal fracture leading to good surgical outcome.
Keywords: Laryngeal trauma, Titanium mesh, Cartilage fracture
Introduction
Laryngeal fractures are rare however they can cause significant morbidity and may even be fatal if not addressed promptly. Incidence of laryngeal trauma varies from 1 in 5000 to 1 in 137,000 in emergency room attendees [1, 2]. The infrequency of laryngeal injury is likely due to factors such as mobility and elasticity of the larynx and its protection by the mandible, sternum and spine. The laryngeal injuries can cause enormous morbidities in the form of loss of airway, phonatory and swallowing dysfunctions and may even be life threatening. It is fortunate for mankind that these injuries are rare however due to their rarity clinicians have very little or no experience in managing these cases especially the severe injuries which involve fracture of laryngeal cartilage.
Various techniques have been described in literature regarding management of laryngeal fractures. Open surgical repair by reduction and fixation of laryngeal cartilage have been done using thread, steel wires, and titanium miniplates [3–5]. Recently there has been a trend towards fixation of fractured laryngeal cartilage with titanium alloy mesh which provides a framework for the rigid fixation and also bridges large defects [6, 7].
Here we report a rare case of fractured laryngeal cartilage managed with titanium mesh fixation.
Case Report
27-year-old male with no known co-morbidities presented with history of accidental fall from a height of 15 feet. He was initially taken to a nearby hospital, where he underwent emergency tracheostomy due to respiratory distress. He was diagnosed to have laryngeal injury and mandibular fracture on right side. He underwent open reduction and fixation of mandible fracture at that center. Subsequently he was referred to our center on day 11 post injury. Examination of the neck revealed presence of tracheostomy tube with no traumatic emphysema. There was loss of prominence and widening of the laryngeal framework. Fiberoptic flexible video laryngoscopy (Fig. 1a) showed compromised laryngeal inlet, edematous endolarynx with well-preserved anterior commissure and restricted mobility of both true vocal cords. Computed tomography (CT) scan showed displaced fracture of thyroid cartilage on both sides (Fig. 2). After taking informed written consent patient underwent open reduction and fixation of laryngeal Cartilage on 17th day post injury.
Fig. 1.
Preoperative and intraoperative picture: a Preoperative fibreoptic laryngoscopy: white arrow—shows grossly compromised laryngeal inlet, black arrow—shows denuded mucosa on arytenoids and interarytenoid, b Intraoperative picture: Fixation of fractured thyroid cartilage segments with Titanium mesh (white arrow) using 0.9 mm screws (grey arrow)
Fig. 2.
CT scan of neck: a Axial cut showing fractured thyroid cartilage in midline and on right lamina of thyroid cartilage (white arrow) and surgical emphysema in neck on left side (small white arrow), b Coronal cut showing fractured left lamina of thyroid cartilage (white arrow) where there is communication between larynx and neck leading to surgical emphysema
Horizontal skin crease incision was given along margin of tracheostoma and after elevating subplatysmal flap and division of strap muscle fracture site was exposed. We gently elevated subperichondrial flaps over the thyroid cartilage lamina laterally on both sides. The thyroid cartilage was fractured and split completely in midline along with undisplaced linear fracture present on the (R) lamina and multiple displaced linear fracture of (L) lamina of thyroid cartilage. The paraglottic tissue was herniating into neck from the fractured lamina of thyroid cartilage on left side. The fractured cartilage fragments were reduced. The reduced cartilage fragments were then stabilized by using titanium alloy mesh (Leibinger) which was molded in shape as per curvature of cartilage (Fig. 1b). The mesh was fixed to cartilage fragments with screws 0.9 mm in diameter. Screw holes were made using 0.5 mm drill burrs. Post fixation microlaryngoscopy was done which showed denuded area of mucosa and exposed cartilage over vocal process and superior pole of (L) arytenoid and also in the left paraglottic region edges of fractured thyroid cartilage were exposed. He was given injectable antibiotics to prevent perichondritis. On first postoperative day he aspirated oral feed and developed surgical emphysema of neck and turbid drain fluid. This was managed conservatively. He was placed on ryle’s tube feed to prevent aspiration and subsequent infection of the fracture site which was exposed in endolaryngeal part.
Serial fiberoptic flexible laryngoscopies were done subsequently in post-operative period which revealed left true vocal cord palsy with mobile and compensating right true vocal cord. Endolaryngeal mucosa also healed well. Gradually oral feeds were started and on 20th postoperative day his ryle’s tube was removed. Tracheostomy tube was removed on post operative day 33. Post-operatively patient’s voice improved in quality, loudness, and breathiness. At six months post surgery his left vocal cord palsy is persisting though he has a fairly good preservation of laryngeal functions.
3. Discussion
Laryngeal fractures result in destruction of the laryngeal architecture. If untreated they lead to chronic stenosis with reduction of airway and phonatory dysfunctions. Thus, severe laryngeal fractures must be reduced and stabilized to preserve its anteroposterior and transverse dimensions maximum laryngeal function.
Suture and steel wire fixation, provide non-rigid, unstable fixation which are inferior to miniplate fixation in preserving alignment of reduced fractured segments during swallowing and other neck movements [8]. Intraluminal laryngeal stents may also be required for a few weeks to preserve stability when sutures and wires are used and they can be detrimental to laryngeal mucosal healing [3].
Woo reviewed 12 cases of laryngeal reconstruction with miniplate and similarly de Mello-Filho and Carrau carried out the same type of study with 20 cases [5, 7]. These studies concluded that fixation with miniplate/mesh is effective, well tolerated and easy to apply. Miniplate/mesh is advantageous over other materials because after precise reduction, they are conformed to the laryngeal framework to restore the pre-injury architecture of the laryngeal framework. Titanium mesh can also cover defects of laryngeal cartilages in comminuted fractures where some fragments of fractured cartilage may have to be removed. In our case also the mesh covered defect on the left lamina of thyroid cartilage.
Placing plates/mesh in the larynx is similar to the way they are placed in the reconstruction of facial bones. However, less resistance is felt as the screw tightens in cartilage as compared to facial bones. This can be overcome by use of a drill bit that is one size smaller than that appropriate for the screw size. This will increase the “pull out strength” and screw-cartilage contact [9]. The screws will then hold well.
Titanium mesh fixation of laryngeal fractures provides immediate rigid stabilization, restores laryngeal architecture and function.
Conclusion
In cases of laryngeal trauma correct and timely evaluation and intervention is of utmost importance to prevent long term complications of laryngeal stenosis and loss of airway. During surgery correct identification of fracture segments is important to bring the fractured segments together and fix them optimally for good results. Titanium mesh is an excellent material to fix the fractured segments and provide a framework for soft tissues in the regions where there is loss of cartilage as seen in our case.
Funding
None.
Compliance with Ethical Standards
Conflict of interest
The authors have none to declare.
Ethical Approval
The research involved a human participant.
Informed Consent
Written informed consent was obtained from the individual participating in the study
Footnotes
Publisher's Note
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References
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