23 Treatment of Injuries of the Larynx, Pharynx, Trachea, Esophagus, and Soft Tissues of the Neck Any injury involving more than the superficial skin or mucosal layers in the pharynx, larynx, or soft tissues of the neck demands surgical management. Surgical treatment eliminates a potential gateway for deep soft tissue infection (Table 23.1). The most important associated operative measure in patients with these injuries is securing the airways with intubation or tracheotomy, if necessary. Injuries of the larynx should be managed according to degree of severity (Table 23.2).
Flowchart and Checklist Injuries of the Neck, Chapter 3, p. 25.
Diagnosing Injuries of the Neck, Chapter 13, p. 120.
Antibiotic Therapy, Chapter 24, p. 210.
Indications
| Absolute indications | Relative indications |
Pharynx | Penetrating injuries |
|
Larynx | Penetrating injuries | Intubation damage (e. g., arytenoid dislocation) |
| Soft tissue injuries with hemorrhage or submucosal bleeding | Intubation trauma (e. g., thermal burns, caustic injuries) |
| Unstable laryngeal fracture |
|
Esophagus/trachea | Penetrating injuries |
|
| Tracheal rupture > 4 cm with clinical symptoms | Tracheal rupture < 4 cm without clinical symptoms |
| Laryngotracheal separation |
|
Degree | Type of injury | Treatment |
I | Visible endolaryngeal hematoma without swelling |
|
| Fracture of the hyoid bone | In-patient observation |
| No fracture of the cricoid or thyroid cartilage |
|
II | Visible endolaryngeal hematoma or swelling |
|
| Vocal cord dysfunction | In-patient observation (intensive care) |
| Detectable, immobile fracture of the cricoid or thyroid cartilage |
|
III | Free endolaryngeal cartilage | |
| Unstable fracture of the cricoid or thyroid cartilage | Intubation, possibly tracheotomy, interval treatment possible |
IV | Open laryngeal injury | |
| Laryngotracheal separation | Immediate surgical management |
Conservative Treatment
The following treatment measures should be used for blunt trauma to the neck with endolaryngeal or hypopharyngeal swelling (grade I, II):
i. v. administration of 1000 mg prednisolone (children: 500 mg), possibly in step-down doses over 3 days;
inhalation of micronephrine;
inpatient observation, possibly intensive care observation;
always consider early intubation before complications occur.
Chemical/Alkali Injuries
In nonpenetrating acid/alkali injuries, stenting with a gastric tube must be done as soon as possible following flexible endoscopy (and irrigation/neutralization of the mucosal surface) to prevent stenosis and stricturing. Concurrent antiedema and antibiotic treatment are imperative (cf. Fig. 15.3, p. 134).
Surgical Therapy
Approaches
Penetrating Injuries
In penetrating injuries, exploration of the injury is dictated by injury pattern. Treatment is always “from the inside out.”
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