2017-18 HSC Section 3 Green Book

J.E.

Strychowsky

et

al.

/ International

Journal

of Pediatric Otorhinolaryngology 79

(2015)

959–964

Table 2 Internal

laryngeal

trauma.

Author,

year

Age/Gender

Mechanism

of

injury

Injury

Management

Outcome

presentation

Acute

and

intubation

Right

TVF

avulsion

from

performed

at

age

1

for

Tracheotomy with placement of ETT to bypass tracheal tear; open repair with laryngoplasty and resuspension of right TVF to anterior commissure 12 days later

LTR

6wo/M

Traumatic

Quesnel

commissure,

decannulated;

on

Hartnick (2009)

anterior

SGS;

[7]

edema

of

feeds;

bilateral

significant epiglottis arytenoid; posterior

thickened

and

right

VFs;

voice

outcomes

mobile

grade

III

SGS,

reported

not

tracheal wall

tear

Normal

(1996)

[11]

Newborn/M

Traumatic

intubation

Gouge

injury

involving

the

and

voice

and age

VF

Wohl

Tissue manipulated

portion

of

the

left

back

into

position

at

18m

posterior

placed

movement

TVF

blunt

probe;

size

membranous

with

uncuffed

ETT

placed

for

3.0

then

extubated; granuloma

72 h

reparative

CO 2

laser

at

removed with

4wks

Delayed

presentation

16yo/F

Suspected prolonged

et

al.

injury

from

vocal

process

avulsion Endoscopic

repair, reapproximation;

complete

resolution

of

Near

Harris

Right

[4]

intubation at age

botulinum TA muscle

at

3m;

complete

(2011)

dysphonia

5 u

to

right

closure

and

equal

vocal

14

toxin

VF

heights

process

Neonate,

Suspected intubation,

et

al.

diagnosis

injury

from

right

TVF

at

age

1y Voice

therapy

Mild with

to moderate

dysphonia

Bray

Absent

[12]

age

1y/M

ventilated

for

harsh,

breathy

voice

(2010)

at

6m

quality

in

cardiac

ICU,

at

age

3

placed

at

that

tracheotomy

time

Single grade

neonate,

injury

from

ragged,

scarred and

stage

LTR

for

repair

of

thickened

Ex24 wk diagnosis

Suspected intubation,

Right TVF atrophic

Breathy dysphonia,

at

ventilated

for

and

right

III

SGS

at

age

3;

voice

for

laryngeal

liquids

10y/M

prior

to

tracheotomy

joint

fixed

at

age

7m

cricoarytenoid

therapy

penetration

10y

age

neonate,

injury

from

laryngeal mucosal ulcer

therapy, may

consider

dysphonia with

Ex23 wk presented

Suspected prolonged previous

Large

Voice

Breathy

noted when

medialization

harshness

at

intubation;

young;

absent

procedure

exacerbated

by

13/F

anterior

cricoid

VF

and

aryepiglottic

fold

or

stress

age

left

fatigue

scar

tissue,

incomplete

split

with

closure

glottis

Absent middle

neonate,

injury

from

third

of

right

Voice

therapy

Moderate dysphonia

to

severe

Ex28 wk presented

Suspected prolonged

at

intubation

TVF

4/M

age

presented

injury

from

absence

of

the

therapy

Normal

voice

at

age

3y

Ex26 wk,

Complete anterior

Voice

Suspected prolonged intubated

at

age

5m/F

intubation,

two-thirds of

the

left

for 1m after birth

grade

I

SGS

TVF;

endotracheal

tube;

F,

female;

FVF,

false SGS,

vocal

fold; h, hours;

LTR,

laryngotracheal thyroarytenoid;

reconstruction; M, male; m, month; MVA, motor

vehicle

accident; NR, not

reported;

ETT, POD,

post-operative

day;

pts,

patients;

subglottic

stenosis;

TA,

TVF,

true

vocal

fold;

VF,

vocal

fold; wks, weeks;

yo,

year

old.

Firstly, follow

et al. endoscopically repaired a right vocal process avulsion

in a 16-

airway

management

is

critical

and

assessment

should

female; botulinum

toxin was also used as a postoperative there was near complete resolution of her

the advanced

trauma

life

support

(ATLS)

training protocol. A

year-old adjunct

[4] . At 3 months,

the mechanism of Flexible fiberoptic

injury

and

current

symptoms

brief history with

Bray

et

al.

reported

a

case

series

of five

neonates who

sought.

laryngeal

examination

should airway cursory

dysphonia.

should be

found

to

have

partial

or

complete

absence

of

a

vocal

fold

performed

to

assess

the

airway

if

feasible.

Ensuring

were when

be

they

presented

between

the

ages

of

5 months

to

13

years voice

is paramount

and fiberoptic examination

allows

a

patency

all managed non-operatively with

of

the

supraglottis,

glottis,

and

sometimes

subglottis

[12] . These patients were

evaluation

however, many

continue

to

be

dysphonic.

airway obstruction or narrowing, blood

therapy;

for presence of hematoma,

of mucosal

disruption

or

laceration, VF movement,

and

suggestive possibility

4. Discussion

of video laryngoscopy and video strobolaryngoscopymay provide additional diagnostics not afforded by conventional fiberoptic laryngoscopy [7] . Direct microlaryngoscopy remains the gold standard for diagnosis. With adequate suspicion, an airway evaluation under anesthesia may be warranted. Two approaches exist to the evaluation of laryngeal trauma: evaluation in the operating room versus imaging. This decision may depend on the severity of injury and has been previously described according to the Schaefer–Fuhrman classification system [13,14] . The utility of radiography, specifically CT scan imaging, is controversial. The pediatric laryngeal cartilages are very pliable and elastic due to the lack of calcification that is usually deposited with age. It is this lack of calcification that makes it difficult to delineate the cartilages in general and to appreciate the presence of VF avulsion. The use of enhanced chip tip

fold

avulsion

in

the

pediatric

population

as

a

result

of of

Vocal

trauma

remains

uncommon. We

presented

a

case

laryngeal

laryngeal

trauma

causing

a

midmembranous

vocal

fold

blunt

in

a

5-year-old

boy

that

was managed

successfully

by

avulsion

repair without

the need

for

a perioperative

tracheoto-

endoscopic my. Given minimally endoscopic

the

rarity

of

this

clinical

entity

and

emerging

trend

for the

invasive

surgical

approaches,

we

report

that

repair

of

vocal

fold

avulsion

is

both

safe

and

feasible

in the pediatric patient and may

lead

to good voice outcomes. This

is

supported

by

two

previous

reports

in

the

literature

technique

also

utilized

an

endoscopic

approach

without

the

need

for

that

tracheotomy.

perioperative

are

several

controversies

regarding

the

evaluation

and

There

laryngeal

trauma

that warrant discussion.

management of pediatric

39