Page 1156 - Cote clinical veterinary advisor dogs and cats 4th

Laryngeal Trauma 577

• Trauma (e.g., bite wounds, projectile missiles, • ± Laryngeal function exam (rule out laryngeal Chronic Treatment
strangulation) can cause penetrating or crush paralysis) • Intraluminal stents require a second surgery
VetBooks.ir • Airway lumen diameter can be drastically Advanced or Confirmatory Testing • Permanent tracheostomy may be required Diseases and Disorders
3-4 weeks later for removal.
injury to the cartilages or recurrent laryngeal
nerves.
• Tracheoscopy/bronchoscopy (p. 1074); exam
if severe damage to larynx has occurred.
reduced if cartilages are crushed (e.g., choke
chains) or with swelling/hemorrhage of can be performed after tracheostomy if needed. Behavior/Exercise
○ Evaluate larynx beyond the arytenoids.
surrounding soft tissues (e.g., stick foreign ○ Examine lower airways for evidence of • Exercise restriction for 3-4 weeks after trauma
bodies). trauma or foreign body. or surgical repair
• Decreased gas exchange from airway com- • Esophagoscopy (p. 1098): rule out concur- • No neck leads; harness only while leash-
promise: hypoxemia ± hypercarbia rent esophageal injury. walking
• Worsened hypoxemia (ventilation/perfusion • CT may be useful in evaluating the hyoid • Sedation as needed
mismatch) if blood is aspirated into lungs apparatus for fractures or dislocations. • Prevent hyperthermia
or with noncardiogenic pulmonary edema • Fluoroscopy: evaluate for dynamic obstruc-
from airway obstruction tion (e.g., epiglottic retroversion) Possible Complications
• Respiratory arrest
DIAGNOSIS TREATMENT • Stenosis or stricture over the ensuing
1-2 weeks, resulting in secondary airway
Diagnostic Overview Treatment Overview compromise
Laryngeal injury is suspected based on respi- Treatment consists of stabilizing the patient • Obstruction of temporary or permanent
ratory distress with upper airway noise in a (ensuring a patent airway, providing oxygen tracheostomy site
patient with a history of recent trauma to the supplementation and additional supportive • Laryngeal paralysis
cervical region or anesthesia with intubation. care), followed by surgical repair as needed. • Infection
Confirmation relies on cervical radiographs, Initial stabilization may require an emergency
laryngoscopy, and/or tracheoscopy. tracheostomy if the patient cannot be intubated Recommended Monitoring
with an orotracheal tube. • Vital signs and frequent auscultation during
Differential Diagnosis initial admission and in the perioperative
• Airway foreign body (p. 355) Acute General Treatment period
• Insect sting/bite or other allergic reaction • Oxygen supplementation (p. 1146) • Tracheostomy care
(pharyngeal swelling) • Intubation if needed • Pulse oximetry and/or arterial blood gas
• Trauma to caudal pharynx or trachea • Emergency tracheostomy (p. 1166) if unable analysis
(p. 486) to pass endotracheal tube or if prolonged • Respiratory rate and effort, respiratory noise,
• Laryngeal paralysis/collapse (p. 574) need anticipated and exercise tolerance, during and after the
• Laryngeal/pharyngeal mass (neoplasm such as • Treat cardiovascular compromise (IV catheter, recovery stage
squamous cell carcinoma, abscess, granuloma, fluids) and other life-threatening injuries.
hematoma [p. 573]) • Surgical exploration/repair or permanent PROGNOSIS & OUTCOME
• Pharyngeal/sublingual mucocele tracheostomy, if indicated.
• Epiglottic retroversion ○ Approach: midline ventral thyrotomy or • Depends on severity of trauma, concurrent
through thyroid cartilage fracture injuries, and time to diagnosis and treatment
Initial Database ■ Mucosal flaps: trim, appose edges • If severe laryngeal trauma is present and
• CBC, serum biochemistry profile, urinalysis: ■ Reduce and immobilize cartilage veterinary care can be quickly obtained,
usually unremarkable fractures to prevent stenosis permanent tracheostomy can allow for fair to
• Neurologic exam: deficits may support ■ Unilateral arytenoid lateralization good prognosis (with the exception of cats and
concurrent spinal trauma (tieback) if traumatic laryngeal paralysis very small dogs, in whom stoma obstruction
• Pulse oximetry/arterial blood gas analysis without fracture or arytenoid avulsion with mucus may be recurrent and severe).
○ Hypoxemia (common) ■ Intraluminal stents may be used to
○ Hypercarbia (severe airway obstruction) prevent adhesions, collapse, and other PEARLS & CONSIDERATIONS
• Cervical radiographs complications
○ Fractures, dislocations, or asymmetry in • Postoperative care Comments
hyoid apparatus ○ Antibiotics after obtaining cultures from • Early temporary tracheostomy: stabilizes
○ Subcutaneous emphysema contaminated wounds; continue 3-4 weeks patient and allows imaging, including
○ Concurrent vertebral trauma postoperatively. Suggested empirical treat- laryngoscopy, endoscopic exam, radiographs,
• Thoracic radiographs ment while awaiting culture results: and CT
○ Pneumomediastinum, pneumothorax, ■ Ampicillin 22 mg/kg IV q 8h and • Surgical exploration/repair must occur early,
subcutaneous emphysema enrofloxacin 10-15 mg/kg diluted and optimally within 24 hours after injury.
○ Concurrent thoracic trauma (e.g., rib given slowly IV or PO q 24h in dogs • Surgical exploration is necessary if
fractures, pulmonary contusions) (5 mg/kg q 24h in cats) or pradofloxa- ○ Airway obstruction is severe enough to
○ Noncardiogenic pulmonary edema second- cin 7.5 mg PO q 24h (cats) or require temporary tracheostomy
ary to airway obstruction ■ Clindamycin 10 mg/kg IV or PO q 8h ○ There is emphysema in the cervical region
• Laryngoscopy under general anesthesia (p. and either amoxicillin/clavulanic acid and/or pneumomediastinum
1125); exam can be performed after trache- 15 mg/kg PO q 12h, or enrofloxacin ○ There is exposed cartilage in the lumen
ostomy if patient does not have a patent as listed above of the larynx
airway, allowing for stabilization of patient ○ Glucocorticoids (dexamethasone sodium ○ The laryngeal cartilage is fractured
first. phosphate 0.1-0.2 mg/kg IV) at surgery
○ Evaluate symmetry and function of to reduce inflammation; may repeat at Prevention
laryngeal structures. 0.05-0.1 mg/kg IV q 12-24h for first • Selection of appropriate endotracheal tube
○ Look for hematomas, exposed cartilage, 24-48 hours and endoscope size along with lubrication
foreign body, or flaps of laryngeal mucosa. ○ Oxygen support as needed may prevent iatrogenic trauma.

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