Cricotracheal separation after gunshot to the neck: report of a survivor with recovery of bilateral vocal fold function.

BACKGROUND: Traumatic tracheal injury via blunt or penetrating mechanism comes with a grave prognosis. Cricotracheal separation is a rare entity among these injuries and even more infrequent by means of penetrating trauma. Resultant airway discontinuity subsequent to these insults causes immense global hypoxia and tends to be uniformly fatal. OBJECTIVE: Our aim was to discuss emergent and surgical management of traumatic airway injury. CASE REPORT: We report the case of a 28-year-old male who sustained a gunshot wound to the neck resulting in laryngeal fracture and cricotracheal separation. We review the initial stabilization of his airway and detail the successive surgical management of his injury in the context of the current available literature, with an emphasis on timely airway stabilization when high suspicion for cricotracheal separation exists based on traumatic mechanism. CONCLUSIONS: Emergent management and stabilization of the airway is critical to survival in the context of trauma involving the neck and airway structures.

Hyperbaric oxygen treatment (HBOT) in a case of traumatic chondronecrosis of the cricoid cartilage.

Cricoid chondronecrosis is a rare entity and is scarcely reported in the literature. Its prevalence is increasing in the form of chondroradionecrosis among the survivorship of head and neck carcinoma patients treated with radiotherapy. We have reported a case of cricoid chondronecroisis caused by trauma from repeated tracheostomy. The patient presented with hoarseness and dyspnoea. Radiological findings in multidetector computed tomography showed disintegration of the cricoid and confirmed the diagnosis. Conservative treatment was given in the form of antibiotics, steroids and nebulised anticholinergics and bronchodilators. However, the patient did not improve and his condition worsened throughout two months of hospitalisation. He was referred for hyperbaric oxygen treatment, which was given over 30 sessions. This was associated with improvement in his condition and he was able to be decannulated from tracheostomy. Six monthly follow up of the patient showed a well-healed tracheostomy scar.

[The clinical treatment of laryngotracheal rupture injury].

Objective:To investigate the therapeutic effect of laryngotracheal rupture injury and management of related complications. Methods:A retrospective analysis was conducted on 10 patients with laryngotracheal rupture injury caused by trauma, admitted between October 2014 and October 2022. Results:Anti-shock treatment, local debridement, tracheal-cricoid cartilage or tracheal-tracheal anastomosis, laryngeal cartilage reduction and fixation, local transposition flaps repair and phase-Ⅱ airway reconstruction were performed respectively on 10 patients. Nine patients underwent operations of tracheal-cricoid cartilage or tracheal-tracheal anastomosis, with five of these were performed by cartilage broken reduction and fixation, placed with intraluminal stents of iodoform gauze fingerstalls for （8.2±1.6） days. Tracheal reconstruction surgery was performed on 2 cases during phase-Ⅱ and both were placed with T-shaped silicone tube to support for 3 months. Two cases required tracheoesophageal fistula surgical repair, and vocal cord suturing was conducted for three vocal fold injuries. Anti-shock treatment was given to one emergency case and closed thoracic drainage treatment was given to another one. We removed the tracheal cannula from 10 patients after surgery and one case was diagnosed with Ⅰ-level swallowing function of sub-water test. All cases recovered to take food per-orally. Conclusion:Maintenance of circulation and respiration functions is the major target during early treatment of laryngotracheal rupture. It should strive to complete the reconstruction of airway structure on phase-Ⅰ, among which end-to-end anastomosis to reconstruct airway and broken laryngeal cartilage reduction and fixation are the vital methods for airway structure reconstruction to achieve good results. It is suggested that the reconstruction of trachea and esophagus structures should be performed simultaneously to patients with tracheoesophageal fistula.

High-force simulated intubation fails to dislocate cricoarytenoid joint in ex vivo human larynges.

OBJECTIVES: We assessed the likelihood of arytenoid dislocation during intubation through the application of controlled force. METHODS: Six cadaveric human larynges were mounted in an apparatus for simulating forcible collision with the arytenoid complexes. An endotracheal tube tip probe (ETTP) was used to push one arytenoid complex, and a non-slip probe (NSP) was tested on the other. Increasing pressure was applied until the probes either slipped or reached 5 kg of force. Dissection was then performed to assess the integrity of the cricoarytenoid ligament. The forces obtained by pushing an endotracheal tube against an electronic balance were measured to estimate the maximal possible intubating force. RESULTS: None of the ETTP or NSP trials disrupted the cricoarytenoid joint ligaments, and the joint never appeared to be dislocated. The mean maximal forces were 1.8 kg for the ETTP (after which, slippage consistently occurred) and 4.7 kg for the NSP. The mean maximal forces from an endotracheal tube pushed against a scale were 1.5 kg (without stylet) and 4.6 kg (with stylet). CONCLUSIONS: Arytenoid dislocation did not happen, and gross disruption of the joint capsule or ligament did not occur, even when the testing approximated the maximum force achievable under extreme conditions. Endotracheal tube insertion thus seems unlikely to cause arytenoid dislocation.

Fracture of the cricoid as a potential pointer to homicide. A 6-year retrospective study of neck structures fractures in hanging victims.

The distinction of a suicidal hanging from a simulated hanging following a homicidal strangulation is highly challenging. The present study evaluates the fracture of the cricoid cartilage as a potential pointer toward homicide. Despite the numerous studies on neck structures fractures in hanging, this is the first study to concentrate on the cricoid cartilage. Neck structures fractures in all cases of suicidal hanging over a 6-year period were retrospectively reviewed (231 cases) and a comparison with homicidal hangings (4 cases) and homicidal no-hanging strangulations cases (52 cases) was performed. Overall, neck structures fractures were found in 23.4% of suicidal cases (54 cases). The cricoid cartilage was intact in all suicidal hangings. The general incidence of fractures in homicidal no-hanging strangulation was 65.4% (34 cases),with an incidence of fracture of the cricoid cartilage of 20.6%. By compiling studies from the literature, only one cricoid cartilage over 2700 suidical hanging cases was found, whereas an incidence of 5 to 20% is found for homicidal strangulation. It is therefore proposed that the presence of a fracture of the cricoid in an apparent suicidal hanging should be considered highly suspicious.

Habitual non-traumatic cricothyroid joint dislocation: a rare case of rotated larynx.

A case of a 21 year old gentleman is described, with no history of preceding trauma, presenting with intermittent dysphagia to solids and fluids for 4 years. Neck examination at rest was normal. However on deep inspiration, the right thyroid lamina protrudes or becomes more prominent. The patient is able to return the larynx to its normal position with manual manipulation. Laryngeal examination with fibreoptic scope during rest and deep breath shows gross rotation of the laryngeal structures for more than 60 degrees on deep breath, with the vocal cords axis rotated to the left side. Management was conservative.

Cricoid chondronecrosis: a complication of endotracheal intubation.

Stenosis of the subglottic area is a common complication of endotracheal intubation and external blunt trauma. Chondronecrosis of the cricoid cartilage is a rare but known complication of neck radiotherapy for laryngeal carcinoma. It has also been reported as a complication of prolonged endotracheal intubation. The clinical and bronchoscopic findings are non-specific and the diagnosis can not be accurately established without surgical evidence or computed tomographic (CT) findings. In addition to technical issues related intubation, multiple anatomic and host factors can contribute to the pathogenesis of this uncommon entity. In this report, we describe the clinical and radiographic findings of a recent case and review the literature. To our knowledge, this is the second case of cricoid chondronecrosis in an adult patient occurring after only a few hours of intubation.

Reconstruction of tracheal wall defect with a mesh patch of nickel-titanium shape-memory alloy.

OBJECTIVES: We explored the feasibility of reconstructing tracheal wall defects with a mesh patch fashioned from a nickel-titanium shape-memory alloy. METHODS: A tracheal wall defect was first constructed surgically by resecting the anterior half of the tracheal wall between the second and sixth tracheal rings. The defect was reconstructed in 8 experimental animals by replacing the resected tracheal mucosa and tracheal cartilage with a pedicle skin flap, which was then enclosed in the mesh patch. In 4 control animals, only a pedicle skin flap with strap muscles was used in the reconstruction procedure. The performance of the animals was observed after surgery. At the end of the experiments, the reconstructed segment was harvested for anatomic evaluation. RESULTS: In the experimental group, 1 animal died 5 days after the operation. Endoscopic and anatomic examination of the 7 animals that survived the observation period showed that the reconstructed trachea was stable, with sufficient airway space for breathing. All 4 control animals died after the operation. After observing successful completion of this operation in animals, we successfully used this method to repair a tracheal wall defect in a human victim of a traffic accident. CONCLUSIONS: Tracheal defects can be successfully reconstructed by use of a mesh patch of nickel-titanium shape-memory alloy as an extraluminal stent--a method that avoids complications associated with intraluminal stents.

Cricotracheal separation: a case of delayed diagnosis and treatment.

A motorcyclist was involved in a motor vehicle accident and presented with respiratory distress and neck swelling with surgical emphysema. He sustained gross tracheal injury, severe pneumothoraces and lung contusions. As intubation was successful, the tracheal injury was not addressed immediately in view of the other severe respiratory problems. Evidence of aspiration lead to further investigations which confirmed the diagnosis 22 days post trauma. Thyrotracheal anastomosis was carried out without stenting. A complete cricotracheal separation is a rare event and can be easily overlooked in the emergency department.

Postmortem Computed Tomography and Magnetic Resonance Imaging of Gunshot Wounds to the Neck.

Postmortem magnetic resonance imaging (MRI) is rarely used for the radiologic assessment of gunshot injuries, although it has clear advantages over postmortem computed tomography (CT) with regard to the imaging of soft tissue injuries. Another benefit in using MRI is that lodged projectiles composed of nonferromagnetic material such as lead present only marginal metal artifacts compared with severe artifacts on CT. This case report presents CT and MRI findings in a case with two gunshot wounds to the neck: a perforating wound and a nonperforating wound with a lead bullet lodged in the cervical spine. The decedent underwent CT and MRI before the scheduled autopsy. A ring of radiopaque material under the dermis in the fatty tissue was identified at both entrance wounds on CT, which was indicative of contact shots. The perforating gunshot was clearly indicated on CT by bullet fragments along the wound channel through the perforated 6th cervical vertebra and the fractured cricoid cartilage at the exit wound. The second trajectory, however, was only assumed based on the presence of gunshot residues at the entrance wound and the position of the lodged bullet. The radiologic assessment was severely impeded by the metal artifacts on CT. Barely noticeable metal artifacts on MRI allowed for clear visualization of the soft tissue injuries and the ruptured medulla oblongata. Only MRI clarified the soft tissue injuries of the brainstem noninvasively, which could provide specific and graphic information on the rapidity of death and the incapacitation of the victim.

Stridor is not a scientifically valid outcome measure for assessing airway injury.

Since about a decade cuffed intubation is becoming more popular in pediatric anesthesia. Studies supporting cuffed intubation compared cuffed and uncuffed intubation by using stridor as main outcome measure after extubation. No differentiations were made between benign (oedema) and severe (ulceration of mucosa) lesions. Stridor was considered to represent all relevant injuries. Far reaching conclusions for daily practice were drawn from these studies. Pediatric endoscopists and - ENT-surgeons with extensive experience in this field have warned against this opinion because significant injury of the airway is not always accompanied by stridor! The symptom of stridor might develop weeks and months after injury when silent ulcerations of the mucosa retract to significant stenosis. Only endoscopy can evidently detect all airway injuries. Studies describing airway injury by endoscopic control are urgently needed to find the best way of preventing airway injury by intubation.

An uncommon cause of throat pain.

Throat pain is a common presenting complaint in the pediatric emergency department and often occurs secondary to non-life-threatening conditions. Certain etiologies may initially appear benign, but if not recognized and treated, may result in airway compromise. Patients with blunt trauma to the neck may present with throat pain. This is an uncommon pediatric injury usually due to a sharp blow to the anterior neck. This injury is rarely seen in isolation. We present a case of laryngeal injury due to blunt trauma to the neck. This case illustrates the potentially serious consequence after an apparently minor traumatic injury.

On the development of idiopathic subglottic stenosis.

Idiopathic subglottic stenosis is a fibrotic narrowing of the airway at the level of the cricoid cartilage, which can result in severe dyspnea. There is an overwhelming female preponderance, and treatment usually involves dilation, tracheostomy or resection with reconstruction of the involved portion of the airway. The exact mechanism of action is unknown. Estrogen has been thought to play a role in the pathogenesis of this disease, but estrogen receptors have not been found in tissue specimens taken from afflicted individuals. A careful history taken from the patient often reveals a severe episode of coughing prior to the development of symptoms, and intraoperative examination can reveal impaction of the first tracheal ring within the lumen of the cricoid cartilage. Based on these observations, we surmise that an intermittent telescoping effect of the first tracheal ring within the lumen of the cricoid cartilage can lead to disruption of the local blood supply and trauma to the cricoid mucosa, with consequent mucosal edema, ischemia, and ultimately fibrosis. While estrogen has been shown to play a beneficial role in wound healing, abnormal wound healing may be potentiated by variations in estrogen receptor expression, and could also explain the female preponderance seen in this disease.

Suspicion of cricohyoidopexy line rupture after supracricoid partial laryngectomy and the value of computed tomography to exclude this complication.

We presented a 48-year-old man who underwent supracricoid partial laryngectomy with cricohyoidoepiglottopexy. He developed diffuse subcutaneous emphysema and saliva aspiration on the first postoperative day, arousing suspicion of a pexy line rupture. Palpation of the cricohyoid suture line and a lateral cervical X-ray were not helpful. Laryngeal computed tomography (CT) obtained demonstrated an undisturbed cricohyoidoepiglottopexy suture line. Some of the neck sutures were removed, a drain was placed under the neck flap, a tight dressing was applied, and surgical exploration was not necessary. Subcutaneous emphysema regressed in the following days and no other problem was seen. Subcutaneous emphysema was attributed to the air escape from the cricohyoid approximation line. Following supracricoid partial laryngectomy, rupture of the cricohyoidopexy line is a rare but serious complication that needs urgent exploration. Therefore, when there is suspicion, laryngeal CT is very important to rule out this condition. Moreover, a close cooperation is necessary with the radiologist who may not be familiar with disturbed anatomy by previous surgery.

Effects of supramaximal balloon dilatation pressures on adult cricoid and tracheal cartilage: A cadaveric study.

OBJECTIVES/HYPOTHESIS: Cricoid fracture is a serious concern for balloon dilatation in airway stenosis. Furthermore, there are no studies examining tracheal rupture in balloon dilatation of stenotic segments. The aim of this study was to evaluate the effect of supramaximal pressures of balloons on the cricoid and tracheal rings. STUDY DESIGN: Prospective cadaveric study. METHODS: Seven cadaveric laryngotracheal complexes of normal adults with intact cricothyroid membranes were acquired. Noncompliant vascular angioplasty balloons (BARD-VIDA) were used for dilatation. The subglottis and trachea were subjected to supramaximal dilatation pressures graduated to nominal burst pressure (NBP) and, if necessary, rated burst pressure (RBP). Larger-diameter balloons, starting from 18 mm size to 24 mm, were used. Dilatations were maintained for 3 minutes. RESULTS: The cricoid ring was disrupted by larger-diameter balloons (22 mm and 24 mm) even at lower pressures (less than NBP) in six cases. Tracheal cartilages were very distensible, and external examination after supramaximal dilatation (24 mm close to RBP) revealed no obvious cartilage fractures or trachealis tears. Histopathological examination revealed sloughing of mucosa in the areas corresponding to balloon placement, but no microfractures or disruption of the perichondrium of tracheal ring cartilages. CONCLUSIONS: These results indicate that the cricoid is vulnerable to injury from larger balloons even at lower dilatation pressures. The tracheal cartilages and the membranous wall of the trachea remained resilient to supramaximal dilatation and larger balloons. LEVEL OF EVIDENCE: NA. Laryngoscope, 128:1304-1309, 2018.

Endoscopic Posterior Cricoid Split With Graft in an Adult With Posterior Cricoid Fracture.

A 45-year-old man presented with bilateral vocal fold immobility (BVFI) following a remote history of assault. He was found to have a comminuted, telescoped, and ossified posterior cricoid fracture on imaging. Electromyography revealed normal cricothyroid and thyroarytenoid muscle function, but moderate chronic denervation of bilateral posterior cricoarytenoid muscles. The patient underwent endoscopic posterior cricoid split with rib graft (EPCS/RG), and he regained moderate vocal abduction and full vocal adduction, resolution of dysphonia, and was decannulated. This report describes the only case of an adult with BVFI due to a posterior cricoid fracture that was successfully treated with EPCS/RG. Laryngoscope, 128:2864-2866, 2018.

Airway Management of Near-Complete Tracheal Transection by Through-the-Wound Intubation: A Case Report.

We present an approach to airway management in a patient with machete injuries culminating in near-complete cricotracheal transection, in addition to a gunshot wound to the neck. Initial airway was established by direct intubation through the cricotracheal wound. Once the airway was secured, a bronchoscopy-guided orotracheal intubation was performed with simultaneous retraction of the cricotracheal airway to optimize the surgical field. This case offers insight into a rarely performed approach to airway management. Furthermore, our case report demonstrates that, in select airway injuries, performing through-the-wound intubation engenders a multitude of benefits.

The Role of Postmortem Computed Tomography in the Evaluation of Strangulation Deaths.

We explored the value of postmortem computed tomography (PMCT) to augment autopsy in evaluating strangulation fatalities. A literature search identified 16 studies describing autopsy findings in 576 deaths and two studies describing autopsy and PMCT findings in six deaths. Similar cases were identified from our institution, yielding 130 deaths with autopsy findings and 14 deaths with both autopsy and PMCT findings. The presence of laryngohyoid fracture and soft tissue hemorrhage was compared from autopsy and autopsy+PMCT cases. The detection rates of fractures in autopsy and autopsy+PMCT cases were not significantly different. PMCT identified all fractures observed at autopsy and five fractures not identified. While PMCT may not detect soft tissue injuries in decomposed remains or subtle internal hemorrhages in neck injury, it is equally able to detect bony injuries as autopsy and might surpass autopsy in detecting subtle fractures. We conclude PMCT is useful to supplement autopsy in strangulation cases.

Isolated cricoid fracture associated with blunt neck trauma.

A 32-year-old woman without a remarkable history presented at the emergency department with strangulation of the neck. CT scans of the neck revealed a displaced cricoid fracture. Six days after admission to hospital, hoarseness and dyspnoea disappeared. On the 10th day, the patient was discharged without complications. The traditional treatment guidelines for laryngeal trauma have recommended an early surgical intervention after immediate tracheotomy in cases of displaced fractures of the cricoid cartilage. The patient could be treated successfully through continuous monitoring of airway obstruction without surgical management.