頚部・縦隔気腫の増悪にて緊急挿管された喉頭外傷例

Abstract

A 35-year-old man was involved in an automobile collision and was brought to the emergency room of our hospital by ambulance. He had cuts on his forehead and left knee, and complained of dyspnea and hoarseness. Since swelling and crepitation were palpable on his anterior neck without any other external injury, he was suspected of having sustained a laryngeal trauma caused by the seatbelt pressing on his neck. A CT scan indicated a slight disruption of the lower part of the laryngeal framework, which appeared to cause emphysema extending from the neck to the mediastinum. Examination with a flexible endoscope was tried, resulting in an unexpected exacerbation of the emphysema into a respiratory crisis possibly due to increased subglottic pressure. An immediate oral intubation relieved this crisis.After his general condition was observed for two days in the ICU, we studied his larynx and hypopharynx using endoscopes under general anesthesia by tracheostomal intubation and found a mucosal disruption in the subglottic area. Under sequential open reduction, we also found fractures of the antero-lateral cricoid arch and the lower thyroid cartilage with disruptions of the sternohyoid muscle and the crico-thyroid muscle and ligament. The injuries healed well under repairs by suturing and wiring. We observed no sign of subglottic stenosis without a stent for a period of 5 weeks, and then repaired the tracheostome. Presently, the patient's vocal cords are mobile, and the vibratory patterns observed with a stroboscope appear normal. However, he has continued to demonstrate limitations in high-pitched phonation for 2 months.We discuss in detail the effects of the laryngeal injuries in this case regarding postoperative phonatory function using 3D images reconstructed with a helical CT. In addition, we also discuss the usefulness of so-called endoscopic 3D-CT images in cases of laryngeal trauma with mucosal disruption as a non-invasive examination in place of endoscopy.