Laryngeal Fracture Repair
The purpose of this surgery is to reapproximate the epithelium of the endolarynx and to reduce any cricoid or thyroid cartilage fractures. Failure to repair superstructural changes to the laryngeal “framework” also risks “resultant” stenosis, dysphonia, and dysphagia.
Indications/Contraindications
Displaced fracture of the laryngeal skeleton (cricoid or thyroid cartilages) with or without endolaryngeal mucosal disruption.
Even in patients with polytrauma with hemodynamic instability, every effort should be made to perform early repair (48 hours after injury) since unrepaired epithelial and superstructural defects will quickly lead to refractory laryngeal stenosis.
Laryngeal repair could be performed at the time of other operations that the patient might be undergoing for polytrauma (e.g., craniotomy).
In the Clinical Setting
Key Points
Securing the airway is the first priority in cases of airway distress. Tracheotomy is the preferred method in most cases; transoral intubation may be problematic due to edema, concerns for cervical spine injury, and cricotracheal separation.
All exposed cartilage in the endolarynx should be covered with epithelium. Epithelial disruption can be seen on a careful transnasal flexible endoscopy. Simple repair of epithelial tears is usually possible. The use of buccal mucosa in cases of epithelial loss is an option.
Endolaryngeal stenting may be required to maintain a patent lumen while repaired epithelium fully heals.
If a stent is used, it should not be left in place for more than 2 weeks or there is an increased risk of granulation tissue.
When the vocal folds are disrupted at the anterior commissure, every effort should be made to stabilize the thyroid cartilage fracture and restore the anterior commissure to its native site on the interior of the thyroid cartilage. Often a near mid-line laryngofissure exists in these cases, making it possible to reattach the anterior vocal fold to the external thyroid ala perichondrium. If the anterior commissure is displaced posteriorly, the patient will have permanent dysphonia due to loss of tension on the vocal folds.
Pitfall
Laryngeal cartilage may be poorly calcified and therefore challenging to wire or plate into a stable three-dimensional conformation. In these cases, a titanium mesh plate can be used to recreate the contour of the thyroid cartilage and the thyroid cartilage segments can be sewn to the plate. A resorbable miniplate is also an option if titanium is not desired. Reabsorbable miniplates are also an option.
From a Technical Perspective
Key Points
All exposed cartilage in the endolarynx should be covered with epithelium. After a laryngofissure, this can be simulated in the laboratory by making lacerations with a scalpel and practicing reapproximation with interrupted chromic suture.
An oscillating saw can be used to create cricoid and thyroid cartilage “fractures” in as simple or complex way as desired.
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