Abstract
Objectives
Pediatric blunt laryngeal trauma is a rare and potentially life-threatening entity. External injuries can be misleading, and a high index of suspicion, as well as early intervention, is essential to achieve the best possible outcome. The authors of this report review the management of blunt laryngeal trauma in the pediatric population and describe the endoscopic management of posttraumatic supraglottic stenosis.
Methods
Methods used were case report from a tertiary referral institution and review of the literature.
Results
We describe the case of a 13-year-old girl whom developed supraglottic stenosis following blunt laryngeal trauma. Innovative endoscopic techniques were used in the successful management of this exceedingly rare entity.
Conclusion
Early recognition and intervention are of paramount importance if successful endoscopic management of blunt laryngeal trauma is to be considered.
1
Introduction
Blunt laryngotracheal trauma in the pediatric population is uncommon. The incidence in the adult population is reportedly between 1/14 000 and 1/30 000 of patients presenting to the emergency department . This is believed to be much lower in the pediatric age group because of behavioral and anatomic differences . External injuries in these cases can often be misleading , and therefore, a high index of suspicion is required in managing patients with a history of blunt trauma to the neck, if the serious and potentially life-threatening complications of these injuries are to be avoided. This case report is, to the knowledge of the author, the first described case of posttraumatic supraglottic stenosis in the pediatric population. Innovative endoscopic techniques were used in the successful management of this rare entity.
2
Case report
A 13-year-old female patient presented with dysphonia that had been present since she sustained a blow to the anterior neck with a hockey stick 2 days earlier. On initial clinical examination, no stridor or clinical abnormalities were noted, and flexible nasendoscopy revealed supraglottic as well as paraglottic edema with normal vocal cord function. Further evaluation included a computed tomography scan of the neck with intravenous contrast, which confirmed edema of the laryngeal tissues and raised the possibility of hematoma formation. There was no evidence of any laryngeal fractures. Owing to the above findings, it was decided to treat the patient conservatively. However, on review a week later, she was complaining of exertional dyspnea and ongoing dysphonia. Repeat flexible nasendocopy at this stage revealed a large amount of slough in the supraglottis and laryngeal inlet. The patient was started on a course of intravenous antibiotics, steroids, and humidified air with dramatic effect on the appearance of her larynx; however, the quality of her voice remained unchanged. On review 2 weeks later, marked supraglottic stenosis was noted during flexible nasendoscopy, and the patient was referred to our institution for further management.
After initial evaluation, the patient was admitted for an elective microlaryngoscopy and bronchoscopy. This confirmed the diagnosis of supraglottic stenosis with marked airway narrowing due to scar tissue formation in the midline ( Fig. 1 ) with normal vocal cords and subglottis. During the same procedure, a combination of carbon dioxide laser, microdebridement (Xomed, Medtronic—microdebrider @500cylces, USA), and endoscopic cold steel dissection was used to divide the scar tissue and Mitomycin C (MMC; 0.25 mg/mL; Kyowa Hakko Kirin UK Ltd, United Kingdom) was applied for 5 minutes, followed by irrigation with normal saline, to prevent recurrence. The patient was monitored overnight and discharged the following day. Following the procedure, there was improvement in exercise tolerance and mild improvement in dysphonia. She was returned to theater a month later, and at that stage, a significant improvement was noted ( Fig. 2 ). However, there was still an element of supraglottic stenosis present, and therefore, the above procedure was repeated. Following this procedure, there was a marked improvement in the patient’s dysphonia. A final laryngoscopy was performed a month later, which revealed no residual adhesions, minimal scar tissue formation in the supraglottic region ( Fig. 3 ) again with normal vocal cords and subglottis ( Fig. 4 ). The patient no longer complains of dysphonia and has returned to full activity with no exercise intolerance.
2
Case report
A 13-year-old female patient presented with dysphonia that had been present since she sustained a blow to the anterior neck with a hockey stick 2 days earlier. On initial clinical examination, no stridor or clinical abnormalities were noted, and flexible nasendoscopy revealed supraglottic as well as paraglottic edema with normal vocal cord function. Further evaluation included a computed tomography scan of the neck with intravenous contrast, which confirmed edema of the laryngeal tissues and raised the possibility of hematoma formation. There was no evidence of any laryngeal fractures. Owing to the above findings, it was decided to treat the patient conservatively. However, on review a week later, she was complaining of exertional dyspnea and ongoing dysphonia. Repeat flexible nasendocopy at this stage revealed a large amount of slough in the supraglottis and laryngeal inlet. The patient was started on a course of intravenous antibiotics, steroids, and humidified air with dramatic effect on the appearance of her larynx; however, the quality of her voice remained unchanged. On review 2 weeks later, marked supraglottic stenosis was noted during flexible nasendoscopy, and the patient was referred to our institution for further management.
After initial evaluation, the patient was admitted for an elective microlaryngoscopy and bronchoscopy. This confirmed the diagnosis of supraglottic stenosis with marked airway narrowing due to scar tissue formation in the midline ( Fig. 1 ) with normal vocal cords and subglottis. During the same procedure, a combination of carbon dioxide laser, microdebridement (Xomed, Medtronic—microdebrider @500cylces, USA), and endoscopic cold steel dissection was used to divide the scar tissue and Mitomycin C (MMC; 0.25 mg/mL; Kyowa Hakko Kirin UK Ltd, United Kingdom) was applied for 5 minutes, followed by irrigation with normal saline, to prevent recurrence. The patient was monitored overnight and discharged the following day. Following the procedure, there was improvement in exercise tolerance and mild improvement in dysphonia. She was returned to theater a month later, and at that stage, a significant improvement was noted ( Fig. 2 ). However, there was still an element of supraglottic stenosis present, and therefore, the above procedure was repeated. Following this procedure, there was a marked improvement in the patient’s dysphonia. A final laryngoscopy was performed a month later, which revealed no residual adhesions, minimal scar tissue formation in the supraglottic region ( Fig. 3 ) again with normal vocal cords and subglottis ( Fig. 4 ). The patient no longer complains of dysphonia and has returned to full activity with no exercise intolerance.
