2017-18 HSC Section 3 Green Book

J.E.

Strychowsky

et al.

/ International

Journal

of Pediatric Otorhinolaryngology 79

(2015)

959–964

1. Introduction

Search

results were

limited

to

the English

language and

there were

restrictions

for

year

of

publication.

no

injury among pediatric patients

is uncommon due

to

Laryngeal pliability

of

their

laryngeal

cartilages

and

anterior–superior

the

3. Results

of

the

larynx,

which

results

in

protection

by

the

positioning mandible

[1] . Motor vehicle accidents are

the most common cause

Patient

presentation

3.1.

laryngeal

injury;

however,

it

is

much

less

common

in

the

of

population.

Vocal (TVF)

fold

(VF)

avulsion,

a

condition where endolaryngeal

pediatric

sustained blunt

laryngeal

trauma after

falling

A 5-year-old boy the metal bar of

true

vocal

fold

is

avulsed

from

the

the

a piece of fitness

equipment and

striking his

onto

is

even more

rare.

framework,

reported

immediate breathy dysphonia without

anterior neck. He

review of

the National Trauma Data Bank

from 2002

to 2006

A

or

airway

compromise. He was

brought

to

the

emergency

stridor

69

pediatric

patients with

laryngeal

trauma

[2] .

Blunt

identified

for

evaluation

several

hours

after

injury.

Upon

department assessment,

trauma accounted

for 83% of

injuries and was associated with

force

he

was

breathing tenderness

comfortably

without

respiratory

trauma

in

77%

of

patients.

They

reported

an

overall

multisystem

There was

and

crepitus

on

palpation

of

his

distress. anterior fiberoptic edema of

rate

of

9%.

According

to

a

retrospective

review

of

the

mortality national

neck

but

no

ecchymosis

or

notable

edema.

Flexible marked

Kids’

Inpatient

Database

(KID),

106

pediatric

patients Seventy- (SD 0.45 operative

laryngoscopy

was

performed including

and

there

was

admitted with

laryngotracheal

trauma

in 2009

[3] .

were

the

right

supraglottis

the

false vocal

fold

(FVF),

the mean age was 15.9 years

nine percent were male and

mostly

obstructed

the

view

of

the

TVF.

There

was

also

which edema

Laryngoscopy

was

performed

in

54

patients,

years).

of

the

aryepiglottic

fold

and

arytenoid, true vocal

with

possible

the

larynx

and/or

trachea

in 32 patients,

and

tracheosto- utilization

repair of

integrity of

the

fold

(TVF) could

mucosal disruption. The

in

30

patients.

The cost

authors

reported

high

resource and mean

my

be

assessed.

There

was

symmetric

movement

of

the

not

a mean

total

per

patient

of

$90,879

length

of

with stay

The

airway was

patent

and

there was

no

hematoma.

arytenoids. This allowed

of

8.4

days

(SD

1.1

days).

for consideration of

imaging. The C-spine was cleared

avulsion

can

occur

as

a

result

of

either

external

or

internal

VF

on

plain scan

film was

neck X-rays.

based

[4] .

Blunt

trauma

to

the

anterior

neck

forces

the

larynx

trauma against

CT

obtained

and

was

concerning

for

contour

A

the

vertebral

bodies where

this

force

is

absorbed

into

the

the right TVF and possible VF avulsion, edema of the

irregularity of

pediatric

laryngeal

framework.

The

thyroid

alae

are

forced

pliant apart these

FVF

and

paraglottic

space,

and

suspicion

for

laryngeal

adjacent fracture definitive

and

the

cricoid

plate

is

displaced. Owing

to

the

elasticity

of

given

the

subcutaneous

emphysema,

however,

no

cartilages,

the

thyroid

cartilage

then

springs

back

into

fracture was

noted

( Fig.

1 ).

which

abruptly

increases

the

tension

on

the

vocal

position,

arranged

in

the

intensive

care

unit

for

airway

Admission was

result

in VF or arytenoid avulsion

[1] .

Internal

ligaments. This may

He

was

treated

with

intravenous

corticosteroids,

monitoring. antibiotics,

is most commonly associated with

traumatic

intubation or

trauma airway

anti-reflux medication,

and humidification. Due

to his

instrumentation. There have been very literature. We present a

airway, we decided

to wait until

the next morning

to

go

to

stable

few case

reports of pediatric VF avulsion in of a pediatric patient who presented the

operating

room

for

further

evaluation.

the

obtained

to

undergo

an

evaluation endoscopic

of

his

airway

Consent was

a

VF

avulsion

secondary

to

blunt

laryngeal

trauma

who

with

possible

tracheotomy

and

possible

versus

open

with

successful

endoscopic

repair.

We

summarize

the

underwent published

the

following day. Prior

to

induction,

there was a discussion

repair

literature

and

discuss

clinical

pearls

and

controversies

emergent

airway

management

with

the

anesthesia

regarding

the

evaluation

and management

of

pediatric VF

avulsion.

in

Positive

pressure would

not

be

used

because forcing

of

the

likely

team.

laryngeal

fracture

and

risk

of

additional

air

nondisplaced

2. Material

and methods

the

subcutaneous

tissue/mediastinum with

resultant

pneu-

into

If the patient developed hypoxia

or became

apneic, we

mothorax.

relevant

case

of

a

pediatric

patient

with

a

VF

avulsion

to

use

intermittent

intubation.

General

anesthesia

was

agreed induced

A

to

blunt

laryngeal

trauma who

underwent search was

successful conducted database

using infusion. Direct microlaryngoscopy with a propofol

secondary endoscopic

repair

is presented. A publications

literature

bronchoscopy was

performed

peer-reviewed

using

the

online

search

spontaneous ventilation. Topical xylocaine

(4%)

for

while maintaining

on

January

25,

2015.

Search

terms

included:

vocal

fold

applied

to

the

endolarynx.

The

0-degree

4 mm

Hopkins

PubMed avulsion,

was

vocal

cord

avulsion,

and

pediatric

laryngeal

trauma.

used

to

evaluate

the

airway.

There was

avulsion

of

telescope was

Fig.

1.

CT

imaging

(A,

axial;

B,

coronal).

36