An Algorithm for the Management of Concomitant Maxillofacial, Laryngeal, and Cervical Spine Trauma

Abstract

Concomitant maxillofacial, laryngeal and cervical spine injuries may occur after high-energy accidents. Although this presentation is uncommon, the multiple injuries may compromise airway, breathing, circulation, and neurologic function. We identified 8 adult trauma patients admitted to the National University Hospital with the concomitant injuries. We reviewed the patient data and existing literature to identify the important factors that must be considered for management. Seven resulted from high velocity accidents, whereas 1 was assaulted. An algorithm that prioritizes in-tandem diagnosis and acute management of the adult trauma patient with maxillofacial, laryngeal, and cervical spine trauma was developed. The first priority is to assess airway, breathing, and circulation with cervical spine immobilization. Early diagnosis of patients with severe laryngeal injury, confirmation by video endoscopy, and establishing a surgical airway prevents airway obstruction or even a laryngotracheal dissociation. Urgent computed tomography scans of the head and neck are essential for definitive diagnosis and surgical planning for the 3 injuries. Prudent sequencing of surgery is important to avoid complications and to achieve better functional outcomes.

Damage Control of Laryngotracheal Trauma: The Golden Day

“…The clinical features of laryngotracheal trauma are variable and have been reported from asymptomatic presentations to patients presenting with dyspnea, stridor and hoarseness; the latter is known as the laryngeal trauma triad 15,16 . Other symptoms such as dysphonia, neck pain, and hemoptysis have been described.…”

ACR Appropriateness Criteria® Imaging of Facial Trauma Following Primary Survey

“…Overall, the most common structures involved in facial fractures, in order of frequency, are nasal bones, orbital floor, zygomaticomaxillary complex, maxillary sinuses, and mandibular ramus [6]. Before evaluating facial trauma, an emergency or trauma physician must perform a primary survey being mindful of the "airway, breathing, and circulation" for patient stabilization [12][13][14][15]. Maxillofacial trauma can lead to airway compromise secondary to hemorrhage, soft-tissue edema, and loss of facial architecture from fractures.…”

“…Maxillofacial trauma can lead to airway compromise secondary to hemorrhage, soft-tissue edema, and loss of facial architecture from fractures. Depending upon the mechanism of injury and severity of the maxillofacial fractures, associated injuries to the brain, cervical spine, and cerebrovascular structures may be present [12,[16][17][18][19][20][21]. Once life-threatening injuries have been managed successfully, a secondary survey of the face includes palpation, visual inspection, full visual acuity interrogation, cranial nerve evaluation, detection of a cerebrospinal leak, and dental occlusion assessment.…”

“…As such, orbital trauma, although falling under the umbrella of facial trauma, will not be discussed in this document. As stated above, maxillofacial trauma may coexist with injuries to the brain, cervical spine, and cerebrovascular structures [12,[16][17][18][19][20][21]. However, this document should not replace or supersede the imaging recommendations in the ACR Appropriateness Criteria Ò topics on "Head Trauma" [25], "Penetrating Neck Injury" [26], "Cerebrovascular Disease" [27], "Cerebrovascular Diseases-Aneurysm, Vascular Malformation, and Subarachnoid Hemorrhage" [28], and "Suspected Spine Trauma" [29].…”

Securing the Airway in Maxillofacial Trauma Patients: A Systematic Review of Techniques

“…1 Stabilization of these patients requires a multifaceted approach and begins with the basic tenets of securing stable airway, breathing, and circulation. 2 Successfully establishing an airway in cases of maxillofacial trauma often requires special consideration of bony and soft tissue damage as well as mechanism of injury. Airway mismanagement can lead to hypoxia, aspiration, further oropharyngeal or laryngeal trauma, and death.…”