Laryngeal injuries: causes, symptoms, diagnosis, treatment

Laryngeal injuries are among the most life-threatening injuries, which, if not fatal, most often condemn the victim to permanent cannula use, disability and a significant deterioration in quality of life.

Laryngeal injuries, especially penetrating wounds, are aggravated by the proximity of large blood vessels, the damage to which in most cases leads to the rapid death of the victim. The presence of large nerve trunks nearby is also a factor that greatly aggravates the clinical course of laryngeal injuries, since their injury leads to severe shock conditions with a pronounced dysfunction of vital nerve centers. Combined injuries to the larynx, laryngopharynx and cervical esophagus cause the occurrence of nutritional disorders in a natural way, which requires a number of difficult measures to ensure this vital function. Thus, laryngeal injuries can entail either changes in the entire organism that are incompatible with life (asphyxia, bleeding, shock), or conditions that require immediate medical care for vital indications, which is not always and not everywhere possible to undertake. If the victim can be saved, other problems arise, namely, ensuring proper breathing, an acceptable method of nutrition, preventing infection and post-traumatic stenosis of the larynx, and subsequently a number of long-term rehabilitation measures aimed at restoring the natural functions of the injured organs (larynx, esophagus, nerve trunks).

Laryngeal injuries are divided into external and internal. External injuries include blunt trauma and wounds, internal injuries include thermal and chemical burns, internal wounds of the larynx with piercing and cutting foreign bodies and foreign bodies themselves, which cause, in addition to obstruction, bedsores, necrosis, and secondary infection. Internal injuries also include the consequences of prolonged tracheal intubation (intubation granulomas, cysts, bedsores) and iatrogenic injuries (forced or accidentally occurring during one or another endolaryngeal surgical intervention).

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Pathogenesis and pathological anatomy of laryngeal injuries

Blunt external injuries of the larynx may cause bruises, contusions, soft tissue ruptures, fractures and varying degrees of crushing of the laryngeal cartilages, dislocations in the joints, as well as combined injuries to the anatomical structures surrounding the larynx. Bruises cause a state of shock, while contusions, fractures, dislocations, crushing disrupt the morphological and anatomical structure and integrity of the larynx, causing bleeding and damage to its nervous apparatus. Dislocations in the joints and ruptures of their bags, hemorrhages disrupt the mobility of the epiglottis, arytenoid cartilages, as a result of which the obturator, respiratory and vocal functions suffer, and the presence of bleeding leads to aspiration of blood and, depending on its intensity, to various complications - from aspiration pneumonia to asphyxia. In the immediate period after the injury, interstitial edema of the larynx occurs, especially pronounced in the area of the aryepiglottic folds and arytenoid cartilages. As a rule, dislocations in the laryngeal joints are combined with fractures of its cartilages, and in an isolated form are extremely rare. In children and young people, when the process of calcification of cartilages has not yet begun, due to their elasticity and mobility of the larynx relative to the spine, these injuries occur less often than in people over 40-50 years old.

The thyroid cartilage is most often subject to fracture, with the destruction occurring along the midline connecting the lateral plates; fractures of the horns of the thyroid cartilage also often occur. In hanging, fractures of the upper horns and the hyoid bone most often occur. A fracture of the cricoid cartilage occurs in the area of its arch or closer to the plate in front of the cricoarytenoid joint, as a rule, combined with a fracture of the lower horns of the thyroid cartilage and a rupture of the upper and lower cricoarytenoid ligaments. Simultaneously with these injuries, dislocations of the arytenoid cartilages in the cricoarytenoid joints also occur.

The nature of cartilage fractures depends on the point of application, direction and magnitude of the traumatic force. They can be open (with a violation of the integrity of the mucous membrane) and closed - without the latter. Displaced fragments of cartilage injure the mucous membrane, perforate it, which causes internal bleeding (threat of aspiration asphyxia) and emphysema of the intertissue spaces surrounding the larynx (threat of compression asphyxia). The most massive emphysemas occur when damage to the cartilaginous framework and mucous membrane is localized in the subglottic space due to the fact that in this case a peculiar valve is formed, the mechanism of which is that the exhaled air, encountering an obstacle at the level of the glottis, closed as a result of impaired mobility of the arytenoid cartilages, rushes under pressure through ruptures in the mucous membrane into the surrounding tissues, while there is no return stroke due to the valve mechanism formed by the floating parts of the torn mucous membrane. With such traumatic injuries to the larynx, emphysema can reach the mediastinum, preventing diastole of the heart. Of the secondary complications, it is necessary to note abscesses and phlegmon, perichondritis, cicatricial deformations of the larynx, mediastinitis, sepsis.

In penetrating wounds of the larynx (stab, cut, gunshot wounds), the laryngeal cavity can be open in various directions, communicating with the esophagus, mediastinum, prevertebral space, and in especially severe cases - with large veins and arteries of the neck. Incised wounds, the origin of which is due to an attempt at murder or suicide, have a transverse direction, are located above the anterior edge of the thyroid cartilage, capture the median thyroid and hyoid-epiglottic ligaments, as well as the epiglottis. When the muscles fixing the larynx to the hyoid bone are cut, in particular, the thyrohyoid muscle, the larynx, under the action of the sternothyroid muscles, moves down and moves forward, which makes its cavity visible through the wound opening. This configuration of the wound provides the victim with relatively free breathing through the wound and emergency care at the scene by spreading its edges for free access of air. If a cutting object (knife, razor) hits the dense thyroid cartilage, it slides down and cuts the cricothyroid ligament (membrane) that begins at the cricoid cartilage arch and attaches to the lower edge of the thyroid cartilage. In this case, the laryngeal cavity becomes visible from below, and the initial sections of the trachea - from above. This circumstance also allows for emergency measures to ensure breathing, for example, by inserting a tracheotomy cannula into the trachea through the wound channel.

In wounds located between the cricoid cartilage and the trachea, completely separating them, the trachea collapses into the mediastinum; at the same time, severe bleeding occurs from the damaged thyroid gland. Due to the fact that large vessels cover powerful sternocleidomastoid muscles, and due to the fact that usually when an injury is inflicted, the head reflexively deviates backwards, and with it the large vessels of the neck are displaced backwards, the latter are rarely subject to injury, which, as a rule, saves the life of the victim.

Gunshot wounds to the larynx are the most severe and are often incompatible with life due to damage to adjacent vital organs (carotid arteries, spinal cord, large nerves). The damaging objects in these wounds are fragments (grenades, mines, shells, etc.), bullets and secondary damaging objects (stones, glass, etc.). The most extensive damage to the larynx occurs with shrapnel wounds, since the zone of destruction significantly extends beyond the larynx itself.

In external injuries, the nerves of the larynx may also be damaged, either directly from the wounding instrument, or secondarily - from compression by edema, hematoma, or a fragment of cartilage. Thus, damage to the recurrent nerve by the above factors leads to its paralysis and bringing the vocal fold to the medial line, which significantly worsens the respiratory function of the larynx, taking into account the rapidly developing interstitial edema.

External injuries of the larynx

The larynx, due to its topographic anatomical position, can be recognized as an organ that is fairly well protected from external mechanical impact. It is protected from above and in front by the lower jaw and thyroid gland, from below and in front by the manubrium of the sternum, from the sides by the strong sternocleidomastoid muscles, and from behind by the bodies of the cervical vertebrae. In addition, the larynx is a mobile organ that easily absorbs mechanical impact (impact, pressure), and moves both en masse and in parts due to its articular apparatus. However, with excessive mechanical force (blunt trauma) or with stabbing and cutting gunshot wounds, the degree of damage to the larynx can vary from mild to severe and even incompatible with life.

The most common causes of external laryngeal injuries are:

1. impacts with the front surface of the neck against protruding hard objects (steering wheel or handlebars of a motorcycle, bicycle, stair railings, the back of a chair, the edge of a table, a stretched cable or wire, etc.);
2. direct blows to the larynx (with a palm, fist, foot, horse's hoof, sports equipment, an object thrown or torn off during rotation of the unit, etc.);
3. suicide attempts by hanging;
4. knife, stabbing, cutting, bullet and shrapnel wounds.

External injuries of the larynx can be classified according to criteria that have a certain practical significance both for establishing the appropriate morphological and anatomical diagnosis and for determining the severity of the injury and making an adequate decision on providing assistance to the victim.

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Classification of external laryngeal injuries

Situational criteria

1. household:
   1. as a result of an accident;
   2. for killing;
   3. for suicide.
2. production:
   1. as a result of an accident;
   2. as a result of non-compliance with safety regulations.
   3. wartime injuries.

By severity

1. Mild (non-penetrating) - injuries in the form of bruises or tangential wounds without damaging the integrity of the walls of the larynx and its anatomical structure, not causing immediate disruption of its functions.
2. Moderate severity (penetrating) - injuries in the form of fractures of the laryngeal cartilage or penetrating wounds of a tangential nature without significant destruction and rupture of individual anatomical structures of the larynx with immediate, mild impairment of its functions that do not require emergency care for vital indications.
3. Severe and extremely severe - extensive fractures and crushing of the laryngeal cartilages, cut-chopped or gunshot wounds that completely block its respiratory and phonatory functions, incompatible (severe) and combined (extremely severe and incompatible with life) with injury to the main arteries of the neck.

According to anatomical and topographic-anatomical criteria

Isolated injuries of the larynx.

• In case of blunt trauma:
  • rupture of the mucous membrane, internal submucous hemorrhage without damage to cartilage and dislocations in the joints;
  • fracture of one or more laryngeal cartilages without their dislocation and damage to the integrity of the joints;
  • fractures and ruptures (separation) of one or more cartilages of the larynx with ruptures of the joint capsules and dislocations of the joints.
• For gunshot wounds:
  • tangential injury to one or more cartilages of the larynx without penetration into its cavity or into one of its anatomical sections (vestibule, glottis, subglottic space) without significant impairment of respiratory function;
  • penetrating blind or through wound of the larynx with varying degrees of impairment of respiratory and vocal functions without associated damage to surrounding anatomical structures;
  • penetrating blind or through wound of the larynx with varying degrees of impairment of respiratory and vocal functions with the presence of damage to surrounding anatomical structures (esophagus, vascular-nerve bundle, spine, etc.).

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Internal injuries of the larynx

Internal laryngeal injuries are less traumatic injuries to the larynx compared to its external injuries. They may be limited to damage to the mucous membrane, but they may be deeper, damaging the submucosal layer and even the perichondrium, depending on the cause of the injury. An important cause complicating internal laryngeal injuries is secondary infection, which can provoke the occurrence of abscesses, phlegmon and chondroperichondritis with subsequent cicatricial stenosis of the larynx to varying degrees.

Classification of internal laryngeal injuries

Acute laryngeal injuries:

• iatrogenic: intubation; as a result of invasive interventions (galvanocautery, diathermocoagulation, endolaryngeal traditional and laser surgical interventions);
• damage by foreign bodies (piercing, cutting);
• burns of the larynx (thermal, chemical).

Chronic laryngeal injuries:

• pressure ulcers resulting from prolonged tracheal intubation or the presence of a foreign body;
• intubation granulomas.

The criteria for the classification of external laryngeal injuries may also be applicable to a certain extent to this classification.

Chronic laryngeal injuries most often occur in individuals weakened by long-term illnesses or acute infections (typhoid, typhus, etc.), in which the general immunity decreases and saprophytic microbiota is activated. Acute laryngeal injuries can occur during esophagoscopy, and chronic ones - during a long stay of the probe in the esophagus (during tube feeding of the patient). During intubation anesthesia, laryngeal edema often occurs, especially often in the subglottic space in children. In some cases, acute internal laryngeal injuries occur during forced screaming, singing, coughing, sneezing, and chronic ones - during long-term professional vocal load (singer's nodules, ventricular prolapse of the larynx, contact granuloma).

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Symptoms of laryngeal injuries

Symptoms of laryngeal trauma depend on many factors: the type of trauma (bruise, compression, injury) and its severity. The main and first symptoms of external mechanical trauma are shock, respiratory obstruction and asphyxia, as well as bleeding - external or internal, depending on the damaged vessels. In case of internal bleeding, mechanical obstruction of the respiratory tract is accompanied by aspiration asphyxia.

Laryngeal contusions

In case of laryngeal contusions, even if no external signs of damage are detected, a pronounced state of shock occurs, which can lead to rapid reflex death of the victim due to respiratory arrest and cardiac dysfunction. The starting points of this fatal reflex are the sensory nerve endings of the laryngeal nerves, the carotid sinus and the perivascular plexuses of the vagus nerve. The state of shock is usually accompanied by loss of consciousness; upon recovery from this state, the patient feels pain in the larynx, which intensifies when trying to swallow and talk, radiating to the ear (ears) and the occipital region.

Hanging

A special clinical case is hanging, which is the compression of the neck with a noose under the weight of one's own body, leading to mechanical asphyxia and, as a rule, to death. The immediate cause of death may be asphyxia itself, cerebrovascular accident due to compression of the jugular veins and carotid arteries, cardiac arrest due to compression of the vagus and superior laryngeal nerves due to their compression, damage to the medulla oblongata by the tooth of the second cervical vertebra during its dislocation. Hanging may cause laryngeal injuries of various types and localizations, depending on the position of the strangulation instrument. Most often, these are fractures of the laryngeal cartilage and dislocations in the joints, the clinical manifestations of which are detected only with timely rescue of the victim, even in cases of clinical death, but without subsequent decortication syndrome.

Laryngeal injuries

Laryngeal wounds, as noted above, are divided into incised, stab and gunshot wounds. The most common are incised wounds to the anterior surface of the neck, among which are wounds with damage to the thyrohyoid membrane, thyroid cartilage, wounds localized above and below the cricoid cartilage, transcricoid and laryngeal tracheal wounds. In addition, wounds in the anterior surface of the neck are divided into wounds without damage to the laryngeal cartilages, with their damage (penetrating and non-penetrating) and combined wounds of the larynx and pharynx, larynx and vascular-nerve bundle, larynx and cervical vertebral bodies. According to A.I. Yunina (1972), laryngeal wounds, in accordance with clinical and anatomical appropriateness, should be divided into:

• for wounds of the supra- and sublingual region;
• areas of the vestibular and vocal folds;
• subglottic space and trachea with or without damage to the esophagus.

In the first group of injuries, the pharynx and laryngopharynx are inevitably damaged, which significantly aggravates the injury, complicates the surgical intervention and significantly prolongs the postoperative period. Injury to the thyroid cartilage invariably leads to injuries to the vocal folds, piriform sinuses and often to the arytenoid cartilages. This type of injury most often leads to obstruction of the larynx and the occurrence of suffocation. The same phenomena occur with injuries to the subglottic space.

Laryngeal injuries due to cut wounds

Damage to the larynx from cut wounds can be of varying severity - from barely penetrating to complete transection of the larynx with damage to the esophagus and even the spine. Injury to the thyroid gland leads to difficult-to-stop parenchymatous bleeding, and injury to large vessels, which are much less common for the reasons noted above, often leads to profuse bleeding, which, if it does not immediately result in the death of the victim from blood loss and hypoxia of the brain, carries the danger of death of the patient from asphyxia caused by blood flowing into the respiratory tract and the formation of clots in the trachea and bronchi.

The severity and extent of the laryngeal injury do not always correspond to the size of the external wound, especially with stab wounds and bullet wounds. Relatively small skin lesions may conceal deeply penetrating laryngeal wounds, combined with wounds to the esophagus, vascular-nerve bundle, and vertebral bodies.

A penetrating cut, stab or gunshot wound has a characteristic appearance: when exhaling, air bubbles with bloody foam, and when inhaling, air is sucked into the wound with a characteristic hissing sound. Aphonia and coughing fits are noted, increasing the emphysema of the neck that begins "before our eyes", spreading to the chest and face. Respiratory failure can be caused by both blood flowing into the trachea and bronchi, and destructive phenomena in the larynx itself.

A victim with a laryngeal injury may be in a state of traumatic shock in a twilight state or with complete loss of consciousness. In this case, the dynamics of the general condition may acquire a tendency to move towards a terminal state with a violation of the rhythm of the respiratory cycles and heart contractions. Pathological breathing is manifested by a change in its depth, frequency and rhythm.

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Respiratory failure

Increased respiratory rate (tachypnea) and decreased respiratory rate (bradypnea) occur when the excitability of the respiratory center is impaired. After forced breathing, apnea, or a prolonged absence of respiratory movements, may occur due to weakened excitation of the respiratory center caused by a decrease in the content of carbon dioxide in the alveolar air and blood. With a sharp depression of the respiratory center, with severe obstructive or restrictive respiratory failure, oligopnea is observed - rare shallow breathing. Periodic types of pathological breathing that occur due to an imbalance between excitation and inhibition in the central nervous system include periodic Cheyne-Stokes breathing, Biot and Kussmaul breathing. With shallow Cheyne-Stokes breathing, superficial and rare respiratory movements become more frequent and deeper and after reaching a certain maximum they again weaken and become rarer, then there is a pause of 10-30 s, and breathing resumes in the same sequence. This type of breathing is observed in severe pathological processes: cerebrovascular accident, traumatic brain injury, various diseases of the brain with damage to the respiratory center, various intoxications, etc. Biot's breathing occurs when the sensitivity of the respiratory center decreases - alternation of deep breaths with deep pauses of up to 2 minutes. It is typical for terminal conditions, often precedes respiratory arrest and cardiac activity. It occurs in meningitis, brain tumors and hemorrhages in it, as well as in uremia and diabetic coma. Kussmaul's big breathing (Kussmaul's symptom) - gusts of convulsive, deep breaths, audible at a distance - occurs in comatose states, in particular in diabetic coma, renal failure.

Shock

Shock is a severe generalized syndrome that develops acutely as a result of the action of extremely strong pathogenic factors on the body (severe mechanical trauma, extensive burns, anaphylaxis, etc.).

The main pathogenetic mechanism is a sharp circulatory disorder and hypoxia of the body's organs and tissues, primarily the central nervous system, as well as secondary metabolic disorders as a result of a disorder of the nervous and humoral regulation of vital centers. Among the many types of shock caused by various pathogenic factors (burn, myocardial infarction, transfusion of incompatible blood, infection, poisoning, etc.), the most common is traumatic shock, which occurs with extensive wounds, fractures with damage to nerves and brain tissue. The most typical shock condition in its clinical picture occurs with trauma to the larynx, which can combine four main shockogenic factors: pain due to injury to the sensitive laryngeal nerves, discoordination of autonomic regulation due to damage to the vagus nerve and its branches, obstruction of the respiratory tract and blood loss. The combination of these factors greatly increases the risk of severe traumatic shock, often leading to death at the scene of the incident.

The main patterns and manifestations of traumatic shock are the initial generalized excitation of the nervous system caused by the release of catecholamines and corticosteroids into the blood as a result of the stress reaction, which leads to some increase in cardiac output, vascular spasm, tissue hypoxia and the emergence of the so-called oxygen debt. This period is called the erectile phase. It is short-term and cannot always be observed in the victim. It is characterized by excitement, sometimes screaming, motor restlessness, increased blood pressure, increased heart rate and respiration. The erectile phase is followed by a torpid phase caused by worsening hypoxia, the emergence of foci of inhibition in the central nervous system, especially in the subcortical regions of the brain. Circulatory disorders and metabolic disorders are observed; part of the blood is deposited in the venous vessels, the blood supply to most organs and tissues decreases, characteristic changes in microcirculation develop, the oxygen capacity of the blood decreases, acidosis and other changes in the body develop. Clinical signs of the torpid phase are manifested by the victim's inhibition, limited mobility, weakened response to external and internal stimuli or the absence of these reactions, a significant decrease in blood pressure, rapid pulse and shallow breathing of the Cheyne-Stokes type, pallor or cyanosis of the skin and mucous membrane, oliguria, hypothermia. These disorders, as shock develops, especially in the absence of therapeutic measures, gradually, and in severe shock quite quickly, worsen and lead to the death of the organism.

There are three degrees of traumatic shock: degree I (mild shock), degree II (moderate shock) and degree III (severe shock). In degree I (in the torpid stage), consciousness is preserved but clouded, the victim answers questions in monosyllables in a muffled voice (in case of laryngeal trauma, which has led to even a mild form of shock, vocal communication with the patient is excluded), pulse is 90-100 beats/min, blood pressure (100-90)/60 mm Hg. In degree II shock, consciousness is confused, lethargy, skin is cold, pale, pulse is 10-130 beats/min, blood pressure (85-75)/50 mm Hg, breathing is rapid, there is a decrease in urination, pupils are moderately dilated and sluggishly react to light. In stage III shock - clouding of consciousness, lack of response to stimuli, pupils dilated and not reacting to light, pallor and cyanosis of the skin covered with cold sticky sweat, frequent shallow arrhythmic breathing, threadlike pulse of 120-150 beats/min, blood pressure of 70/30 mm Hg and below, sharp decrease in urination, up to anuria.

In mild shock, under the influence of the body's adaptive reactions, and in moderate shock, additionally under the influence of therapeutic measures, a gradual normalization of functions and subsequent recovery from shock is observed. Severe shock, even with the most intensive treatment, often becomes irreversible and ends in death.

Diagnosis of laryngeal injuries

Diagnosis of external laryngeal injuries is not as simple as it may seem at first glance: it is quite easy to establish the fact of laryngeal injury and its type, but it is very difficult at first to assess the severity and establish the nature of internal injuries both in wounds and in blunt injuries. First of all, at the scene of the incident, the health worker assesses the viability of the respiratory function of the larynx and excludes the presence of bleeding. In the first case, attention is paid to the frequency, rhythm and depth of respiratory movements and chest excursions, as well as to the signs, if present, of expiratory or inspiratory dyspnea, manifested respectively by bulging or retraction of the pliable surfaces of the chest, cyanosis, impaired cardiac activity and anxiety of the victim, as well as increasing emphysema, indicating a rupture of the mucous membrane and the formation of an obstruction of the larynx, preventing exhalation. In the second case, external bleeding is easily detected, unlike intralaryngeal bleeding, which may be hidden, but is given away by coughing and splashes of scarlet blood released with the air stream through the mouth. A penetrating injury to the larynx is manifested by a noisy exhalation through the wound opening and bloody foam released through it along with the air. In all cases of laryngeal trauma, there are symptoms such as respiratory failure, dys- or aphonia, and very often dysphagia, especially with damage to the upper parts of the larynx and laryngopharynx. Cartilage fractures are determined by palpation of the anterior surface of the larynx (crepitus, dislocation).

At the scene of the incident, "urgent" diagnostics of laryngeal trauma is designed to establish indications for emergency medical care for vital indications, consisting of ensuring breathing, stopping bleeding and combating shock (see below). In a hospital setting, the victim undergoes an in-depth examination to assess the general condition and determine the nature of the injury. As a rule, victims with severe laryngeal trauma are placed in the intensive care unit or directly in the operating room for emergency surgical care (final stopping of bleeding by ligating blood vessels, applying a tracheostomy and, if possible, providing specialized or qualified surgical care). If the victim's condition allows, an X-ray examination of the larynx is performed, which reveals fragments of cartilage, dislocation of parts of the larynx, dislocations in the joints and other signs of damage to its integrity, the presence of hematomas and emphysema. The X-ray examination should also cover the hyoid bone, trachea, lungs and chest. If there is a suspicion of damage to the esophagus, it is also examined using fibroscopy and radiography with contrast.

Endoscopic examination of the larynx is advisable to perform immediately after radiography, which gives an idea of the nature of the laryngeal injury. Direct microlaryngoscopy is mainly performed, allowing for a detailed examination of the damaged areas of the larynx and determining their localization and prevalence.

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Treatment of laryngeal injuries

In case of external injuries of the larynx, the nature and extent of first aid and subsequent treatment, as well as indications for transporting the victim are determined by his general condition (absence of shock, presence of compensated or decompensated shock), the nature of the injury (bruise, cartilage fractures, cut, stab or gunshot wound, combined wound, etc.), the presence of life-threatening conditions (respiratory obstruction, bleeding), etc.

First aid for all types of external laryngeal injuries consists of emergency provision of adequate breathing volume either by tracheal intubation, or by using a wound channel communicating with the tracheal lumen, or by conicotomy or tracheotomy. A specialized surgical emergency team usually performs these procedures at the scene of the incident. To insert a tracheotomy or rubber tube of sufficient diameter into the wound, a Killian nasal speculum (with long branches) can be used, since the length of the branches of the Trousseau dilator included in the tracheotomy set may be insufficient to penetrate the lumen of the larynx or trachea. In this case, to suppress the cough reflex and pain syndrome, promedol with atropine and diphenhydramine are administered to the victim. The list of priority measures for providing emergency care to the victim also includes combating shock, and the treatment should be comprehensive and carried out in the intensive care unit or intensive care ward after providing emergency care to prevent asphyxia or bleeding or simultaneously with it. In case of traumatic shock, hypertensive agents (dopamine, adrenaline), glucocorticoids (Betamethasone, Hydrocortisone, Dexamethasone, etc.), metabolites, plasma substitutes and other blood substitutes, fibrinolysis inhibitors (Aprotinin, Gordox), neuroleptics (droperidol), parenteral and enteral nutrition agents (Albumin), enzymes and antienzymes (Aprotinin) are prescribed. Each of the above drugs is prescribed according to the relevant indications in agreement with the resuscitation physician.

The patient is transported from the scene of the incident only after the bleeding has been temporarily stopped (ligation of a vessel in a wound, pressing a large vessel with a finger, etc.) and breathing has been established (intubation of the trachea, conicotomy). The victim is transported in a semi-sitting position, while simultaneously being given oxygen or carbogen. During transportation of an unconscious victim, measures must be taken to prevent the tongue from sinking by fixing it outside the oral cavity.

In the surgical department, traumatic damage to the larynx and other respiratory organs is carefully examined to determine the priority measures for providing assistance and treatment to the victim. When the trachea is torn, its lower end is displaced into the chest cavity. In these cases, a bronchoscope is inserted into the distal section of the trachea, the blood that has entered it is sucked out through it, and artificial ventilation is performed.

Every practicing physician of any medical specialty should be familiar with artificial ventilation methods, even the simplest ones. Artificial ventilation is a therapeutic technique aimed at maintaining gas exchange in the absence or severe suppression of one's own breathing. Artificial ventilation is part of a complex of resuscitation measures in case of circulatory and respiratory arrest, respiratory depression due to various diseases, poisoning, blood loss, injuries, etc. When providing first aid, the so-called expiratory artificial ventilation is most often used, such as mouth-to-mouth or mouth-to-nose. Before starting artificial ventilation, it is necessary to restore the patency of the airways. To do this, the sunken tongue is pulled out with a tongue depressor and fixed with stitches outside the oral cavity, or the victim is laid on his back, his head is thrown back, one hand is placed under his neck, and the other is placed on his forehead. In this position, the root of the tongue moves away from the back wall of the pharynx, and free access of air to the larynx and trachea is ensured. To restore airway patency, an S-shaped airway or an intubation tube can be used. If external airway patency cannot be restored, a tracheotomy is performed.

The technique of artificial ventilation of the victim's airways is as follows. In the above position of the victim, the person providing assistance pinches his nose with his fingers, takes a deep breath and, tightly covering the victim's mouth with his lips, makes a vigorous exhalation, blowing air into his lungs; after this, the victim's lower jaw is pulled down, the mouth opens and spontaneous exhalation occurs due to the elasticity of the chest. During the first and second stages of artificial ventilation, the person providing assistance monitors the chest excursion - its rise when blowing air and its descent during its passive exhalation. If air was blown through the victim's nose, then to facilitate exhalation, the mouth should be slightly opened. To avoid touching the patient's mouth or nose with your lips, you can put a gauze napkin or handkerchief on them. It is more convenient to insert a nasopharyngeal cannula or a rubber tube through a nostril to a depth of 6-8 cm and blow air through it, holding the mouth and the other nostril of the victim.

The frequency of insufflations depends on the speed of passive exhalation of air and in an adult should be within 10-20 per 1 min, and the volume of air insufflated each time should be within 0.5-1 l.

Intensive artificial ventilation is continued until cyanosis disappears and the patient begins to breathe adequately. If the heart stops, artificial ventilation is alternated with indirect cardiac massage.

Once the victim has recovered from the state of shock, the thoracic surgeon provides the patient with surgical assistance aimed at restoring the integrity of the trachea.

In case of closed fractures of the laryngeal cartilages with their displacement, the position is restored using a tracheoscopic tube and fixed with a tamponade around the intubation tube inserted into the larynx. In case of open fractures of the larynx, laryngotomy and reposition of its viable fragments using a rubber tube are indicated. Free fragments of cartilage that cannot be used for plastic restoration of the laryngeal lumen are removed.

To prevent post-traumatic stenosis of the larynx, early bougienage of its lumen is used.

What is the prognosis for laryngeal injuries?

Laryngeal injuries have a very serious prognosis, since the victim’s life is threatened by shock, suffocation, bleeding, and secondary purulent complications.