2017-18 HSC Section 3 Green Book

J.E.

Strychowsky

et al.

/ International

Journal

of Pediatric Otorhinolaryngology 79

(2015)

959–964

of

fracture

lines.

In our patient, we elected

to perform a CT scan given

intubation

in

a

newborn

[11] , we would

hesitate

to

follow

this

the

patient

had

a

stable

airway

and

had

significant

crepitus

attempt

to place

a suture endoscopically

if possible.

that

approach and

concerning

for

an

upper

aerodigestive

tract

injury. After

to

our

case,

Bloom

et

al.

used

an

endotracheal

tube

to

that was

Similar

review

of

our

patient’s

imaging with

the

senior

attending

their

patient’s

airway

for

a

few

days

prior

to

extubation

careful

stent

an

irregularity

to

the

right

VF

was

only

Appropriate

sedation

during

this

period

of

intubation

is

neuroradiologist,

[9] .

however,

this

is

a

challenging

diagnosis

to make

on

to

limit

coughing

so

as

to

not

stress

the

repair.

In

an

suspected;

important

In addition,

there was no obvious

laryngeal

fracture,

it may

be

reasonable

to wake

the patient

and

abide

imaging alone.

older patient,

a nondisplaced

fracture

of

the the

thyroid pattern

cartilage

at

the

level

of

strict

voice

rest.

but the

by

TVFs was

suspected

given

of

free

air

in

the

neck.

the

use

of

botulinum

toxin

in

otolaryngology

and

Although

information helped us

intraoperatively

to

identify

the

location

laryngology

is well

reported, only

two studies

reported

This

specifically

fractures, which

can be quite difficult given

the

use

as

an

intraoperative

adjunct

to

the management

of

vocal

of potential occult

its

edema

in

the

acute

trauma

setting.

Our

patient

[6]

and this use

process possible

[4]

avulsion.

Further

studies

are

needed

to

significant tolerated

fold

the

CT

scan

without

sedation;

we

would airway

hesitate

to

role.

explore

sedation

to

a

young

child

due

to

possible

concern. As

of

perioperative

antibiotics,

corticosteroids,

and

give

The

injuries

may

be

associated

with

concomitant

C-spine

medication

should

be

considered.

Appropriate

vocal

laryngeal injuries,

antireflux

imaging

(plain film X-ray or CT scan) to

rule out a possible

therapy, and

long-term

follow-up outcomes.

should be

sought

hygiene, voice

injury

should

be

considered

and

the

possibility

of

such

ensure

adequate

patient-centered

C-spine

to

should

not

be

overlooked.

injury

is another consideration.

In a patient with

Timing of evaluation

5. Conclusion

airway,

the decision

to

intubate, perform

a DLB

in

the

an unstable

room,

or

perform

tracheotomy

needs

to

be

made

operating

Pediatric

vocal

fold

avulsion

is

a

rare

clinical

entity.

Accurate sedation

In our

case,

the patient presented

late

in

the

evening.

emergently.

timely

diagnosis considered

is

paramount.

CT

imaging without

and

stable with a patent airway, we

Because he was hemodynamically

be

in

stable during

patients

to

identify

occult

lesions

should

to

add This

the

case

urgently

to

our morning

operative

room

elected

areas

to

focus

on

endolaryngeal

examination. repair when

The

and

ensured

that

we

had

two

experienced

pediatric

schedule.

approach

is

the

preferred method

of

it

is

endoscopic amenable

and pediatric

anesthesiologists

available

for

the

otolaryngologists

to

the extent of

injury and availability of

expertise

from

case. a stable patient cannot be generalized, but should be made on a case- by-case basis. Things to consider include having an experienced anesthesiologist, operating room personnel familiar with both open and endoscopic airway equipment, and appropriate assis- tance in the event of an emergency. If the decision is made to delay surgery for any reason, then the patient should be admitted to an intensive care unit for close monitoring. The surgical approach should also be considered. This decision will likely depend on the individual patient, physician preference, and presence of associated laryngotracheal injuries. A few patients presented in the literature review had associated thyroid cartilage fractures that nearly resulted in the creation of a traumatic laryngofissure. In this clinical scenario, an external approach is most appropriate. For patients with isolated avulsion or minimal injuries amenable to endoscopic repair, endoscopic management is reasonable to consider. Adequate exposure via suspension laryngoscopy is important to achieve in this setting and may preclude endoscopic repair. Two other case reports in the literature have used endoscopic techniques to repair laryngeal trauma in the pediatric population. Daniel and colleague endoscopically repaired a displaced cricoid fracture with balloon dilation [15] ; Elmaraghy et al. managed an endolaryngeal hematoma and mucosal lacera- tions with exposed cartilage [16] . Timing of surgical repair of the avulsed VF has not been well studied. Our patient’s vocal fold was repaired within 24 h of injury. It is our opinion that early operative intervention should be considered if feasible. Given the suggested possibility of successful delayed repair, one should also consider repair if patient presentation and subsequent diagnosis is delayed. Although Wohl reported a case of successful healing of an avulsed VF with gentle tissue manipulation to approximate the tissues followed by 3 days The decision regarding timing of operative evaluation in

surgeon

and

anesthesiologist.

both

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