List of Abbreviations
CT – computed tomography
MRI – magnetic resonance imaging
NSAIDs – non-steroidal anti-inflammatory and antirheumatic drugs
PCD – primary surgical debridement
PSD – primary surgical debridement [Note: Russian VKhO can mean secondary too depending on context, but standard is secondary/primary; keeping standard surgical terms]
IMV – invasive mechanical ventilation
EGD – esophagogastroduodenoscopy
Terms and Definitions
Injury – is the morphological substrate of a trauma (wound). It has local morphological manifestations in the form of concussions, contusions, compressions, dislocations, fractures, wounds, destructions, avulsions, burns, frostbite, as well as disorders caused by radiation, chemical, and other exposures.
Wound – a specific type of injury.
Open wound involving the larynx – is an injury to the laryngeal structures accompanied by a breach of the skin and/or mucosal integrity to their full depth, and frequently involving deeper tissues and organs.
Bleeding from the throat – escape of blood from the mouth or its entry into the respiratory or digestive tracts in the presence of a bleeding source located in the oropharynx, laryngopharynx, and/or larynx.
Levels of evidence (LoE) – ranking of study designs based primarily on their internal validity.
Note 1: this method is used to determine the persuasiveness of a study.
Note 2: various hierarchies of evidence are used to assess health technologies.
Level of clinical evidence (LCE) – the degree of certainty in the validity of the intervention's effect and in the fact that following the recommendations will bring more benefit than harm in a specific clinical situation.
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
Open wound involving the larynx – is an injury to the larynx resulting from the direct or indirect action of a traumatic factor, which can act both from the outside (external laryngeal trauma) and from the inside (internal laryngeal trauma), accompanied by a breach of the skin and mucosal integrity and leading to a disruption of the integrity and function of this organ.
Contusion of the pharynx and larynx is a closed mechanical injury to the tissues and structures of the pharynx and larynx without visible breach of the external skin and mucous membranes, resulting from the impact of a blunt object from the outside or inside, accompanied by rupture of small vessels and subsequent hemorrhage.
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
Neck trauma is a collective term encompassing open and closed injuries of the neck.
The cause of an open neck wound with laryngeal injury is the action of a traumatic factor leading to skin damage, and may occur in peacetime and wartime settings. Most commonly encountered in stab and gunshot wounds.
Causes of external blunt trauma to the pharynx and larynx may include: a blow from a blunt object or fist to the neck, a motor vehicle accident, a sports injury, an attempted strangulation, often accompanied by fracture of its cartilages and the hyoid bone, laryngeal avulsion, rupture of the vocal folds, as well as concomitant injury to anatomical structures surrounding the larynx.
Internal trauma to the larynx and pharynx accompanied by bleeding (bleeding from the throat) is more often iatrogenic in nature (intubation, mechanical ventilation) or results from foreign body ingestion (fish bone, food boluses, dentures, etc.).
Other causes of bleeding from the throat may include malignant tumors of this localization, consequences of surgical interventions and manipulations in the pharynx and larynx. Wounds of the larynx and pharynx are possible during any manipulation in this area, including endoscopic examinations and surgical interventions [68, 69].
External neck injuries are more common in combat settings and in most cases are multiple and associated. In contrast, internal injuries of the pharynx and larynx are more often isolated, occurring via internal organ damage through natural pathways.
Laryngeal trauma may be accompanied by fractures of the hyoid bone, laryngeal and tracheal cartilages, separation of the larynx from the trachea or hyoid bone, rupture of the vocal cords, dislocation of the arytenoid cartilages, and laryngeal paresis. Hemorrhages develop in the subcutaneous tissue and muscles, forming hematomas that lead to airway compression, which can cause respiratory failure.
Laryngeal injuries are among the most life-threatening traumas that, if not fatal, can lead to disability and a severe decrease in quality of life.
The anatomical structure of the larynx in children differs from that of adults. The adult larynx has a stiffer framework and is predisposed to fracture from blunt trauma. Conversely, the pediatric larynx consists of flexible cartilaginous structures resistant to fracture. Furthermore, the submucosal layer of the larynx in children is loosely attached to the underlying perichondrium. However, this loose attachment and elasticity predispose the child to more severe soft tissue injuries with a risk of massive edema and hematoma formation. Even minimal trauma can predispose children to mucosal damage and rupture of the posterior tracheal wall [1, 2].
1.3 Epidemiology of the Disease or Condition
According to literature data, the incidence of neck wounds accounts for 5 to 10% of all peacetime wounds and 0.5-4% of wartime wounds. Overall mortality from deep neck wounds is about 11%. Up to 34% of neck trauma victims in peacetime die at the scene. The main causes of death are acute massive blood loss due to injury of neck vessels (38.5%), acute cardiovascular and respiratory failure in injuries of the cervical spine and spinal cord (30.2%), severe injuries of other localizations (27.5%), and asphyxia from upper airway wounds (3.8%). The majority (80.7-90.55%) of victims, according to various authors, are men with an average age of 27–35 years, i.e., the most socially active part of the population [3-6].
The incidence of neck trauma among children is lower because they are less frequently involved in motor vehicle accidents and assaults. Laryngeal injuries are more common in school-age boys and result from bicycle accidents (striking the neck on the handlebars) and falls (striking the neck on an object), sports activities (being struck by a hockey stick/puck or ball), or strangulation. The risk of injury is highest during neck extension [7, 8]. Internal laryngeal injuries in children are more frequent than external ones and are caused by prolonged or post-intubation trauma, laryngoscopy, bronchoscopy, foreign bodies, or burns [8].
Injury to the digestive tract in victims can subsequently lead to severe purulent complications (neck phlegmon, mediastinitis, sepsis, etc.).
Neck wounds with laryngeal and tracheal injury are severe, disfiguring traumas accompanied by a high rate of disability due to the development of scarring in the larynx and trachea, and may lead to prolonged or permanent tracheostomy tube dependence.
1.4 Features of Coding the Disease or Condition
S11.0 – Open wound involving larynx and trachea.
S10.0 – Contusion of throat.
S10.1 – Other and unspecified superficial injuries of throat.
R04.1 – Hemorrhage from throat
1.5 Classification of the disease or condition
Classification of laryngeal trauma [28, 33]:
- by etiology: mechanical (including iatrogenic), gunshot, chemical, thermal;
- by the mechanism of the damaging factor, laryngeal traumas and wounds are divided into: external, internal, blunt, sharp (stab, incised);
- by the presence of a skin wound: open, closed;
- by the fact of penetration into the laryngeal lumen: penetrating, non-penetrating;
- by the presence or absence of injuries to other organs: isolated, associated.
Although each laryngeal injury is unique and requires appropriate management, dividing laryngeal injuries into a systematic classification scheme helps in treatment planning and patient management.
Schaefer classification for grading the severity of laryngeal injuries (5 groups): grade 1 – minor endolaryngeal hematomas without mucosal or cartilaginous disruption; grade 2 – edema, hematoma, minor mucosal disruption without exposed cartilage, or non-displaced cartilage fracture; grade 3 – massive edema, large mucosal lacerations, exposed cartilage, displaced cartilage fracture, or vocal fold immobility; grade 4 – same as group 3 plus severe anterior laryngeal injuries, unstable fractures, two or more fracture lines, or severe mucosal injuries; grade 5 – complete separation of the larynx from the trachea [9-11].
Gunshot wounds of the larynx are classified into: tangential wounds of one or several laryngeal cartilages without penetration into its cavity or into one of its anatomical compartments (vestibule, rima glottidis, subglottic space) without significant impairment of respiratory function; penetrating blind or through-and-through wounds of the larynx with varying degrees of respiratory and vocal function impairment without associated injury to surrounding anatomical structures; penetrating blind or through-and-through wounds of the larynx with varying degrees of respiratory and vocal function impairment accompanied by injuries to surrounding anatomical structures (esophagus, neurovascular bundle, spine).
Classification of pharyngeal injuries [28,33]:
Pharyngeal injuries are divided into: external and internal.
By etiological factor: domestic, occupational, wartime.
By traumatic agent: blunt trauma; stab and incised wounds; gunshot wounds; chemical burns; thermal burns; foreign bodies.
By pharyngeal section: injuries of the nasopharynx, oropharynx, and laryngopharynx.
By the extent of damage – isolated, associated.
1.6 Clinical presentation of the disease or condition
The severity of clinical symptoms depends on the degree of injury to the organs and structures of the neck, as well as the patient's general condition, which is influenced by the extent of exposure and the nature of the traumatic agent.
The primary symptom is respiratory impairment, which can vary in severity and may develop immediately after the trauma or after some time as a result of increasing inflammatory infiltration, edema, or hematoma formation.
Voice disorders (dysphonia, aphonia) of varying degrees occur in all laryngeal injuries and are particularly pronounced when the vocal apparatus is damaged.
Pain syndrome can vary greatly in intensity from a feeling of discomfort (foreign body) to severe pain in the projection of the larynx and pharynx.
Swallowing disorder (dysphagia) occurs as a result of impairment of the laryngeal separation function during injury to the laryngeal inlet, laryngeal paresis, or pharyngeal pathology.
Cough does not always accompany laryngeal trauma. As a rule, it occurs when a foreign body enters the larynx, during internal bleeding, or with the development of an acute inflammatory reaction.
The presence of subcutaneous emphysema in the neck region indicates a penetrating nature of the laryngeal or tracheal injury. The emphysema can rapidly spread to the neck, chest, and mediastinum.
Bleeding resulting from injury to hollow organs and soft tissues of the neck is considered life-threatening in open trauma to major vessels and the development of internal bleeding, causing blood aspiration or the formation of a hematoma that narrows the lumen of the larynx and trachea.
A penetrating cut, stab, or gunshot wound has a characteristic appearance: on expiration, air bubbling with bloody foam escapes from it, and on inspiration, air is sucked into the wound with a characteristic hissing sound.
Internal trauma to the larynx may be accompanied by bleeding (bleeding from the throat), which manifests as hemoptysis, and discharge of blood from the mouth.
Damage to the laryngeal nerves results in neuropathic laryngeal paresis.
Internal pharyngeal injuries are usually less severe than external ones. There is a characteristic medical history; patients usually indicate the site of the injury in the pharynx and its preceding cause (diagnostic and therapeutic endoscopic interventions, food intake, endotracheal intubation during anesthesia). Immediately after the injury, sore throat appears, worsening upon swallowing; swallowing is impaired; bleeding from the throat is possible in case of mucosal rupture, and breathing may be impaired due to increasing edema [28,33].
In children, respiratory symptoms from laryngeal and tracheal trauma may develop much faster or be more pronounced due to smaller airway dimensions and anatomical features [12]. At the same time, the presentation of blunt laryngeal and tracheal trauma in children may be subtle and can mimic other common pediatric respiratory conditions [13].
2. Diagnostics, medical indications and contraindications for diagnostic methods
The diagnosis/condition is established based on:
Symptoms and anamnesis data.
Physical examination.
Instrumental examination.
Criteria for establishing the diagnosis/condition:
1. An anamnesis that does not exclude an open or closed neck injury. The appearance of characteristic symptoms following the moment of injury: pain, respiratory distress, voice changes, dysphagia, bleeding, dyspnea. Stridor: inspiratory stridor implies obstruction at the supraglottic level of the larynx, which may be caused by edema or hematoma; expiratory stridor typically occurs due to obstruction of the subglottic larynx, for example, in tracheal trauma; biphasic stridor (inspiratory and expiratory) implies vocal cord injury. Identification of corresponding traumatic skin lesions: an open wound or edema and hematoma in the neck region, presence of subcutaneous emphysema. Disappearance of laryngeal crepitation: palpation of the larynx and its lateral displacement usually produce a "click". The disappearance of this "click" may occur due to laryngeal fixation or injury. Appearance of bubbling bloody foam from the wound during expiration, and blood in the saliva. Videolaryngoscopy of the larynx and laryngopharynx reveals edema, hemorrhage, hematoma, mucosal rupture, deformation of the glottic lumen, and impaired mobility of the vocal folds. According to computed tomography (CT) of the upper airway and neck, findings include deformation of neck contours, presence of emphysema, fracture of the cartilaginous laryngeal framework, changes in the laryngeal lumen, a wound tract and presence of foreign bodies in a gunshot wound, and impaired passage of a radiopaque agent (diagnostic radiopharmaceutical) in pharyngeal and esophageal injuries.
2.1 Complaints and Anamnesis
In laryngeal trauma, victims may complain of pain, soft tissue edema of the neck, respiratory distress, external bleeding, and bleeding from the throat may develop. When taking the medical history, the potential mechanism of injury and the time elapsed since its occurrence should be determined, identifying the presence or absence of symptoms and their dynamics. Given that the patient may be unconscious, the anamnesis and circumstances of the injury should preferably be clarified with relatives or accompanying persons [14, 15].
2.2 Physical Examination
The basic principles of primary assessment in Advanced Trauma Life Support (ATLS) protocols for trauma apply to neck trauma, just as they do to any other injury [16].
It is recommended to perform laryngoscopy in all patients upon admission to the hospital to detect laryngeal alterations (see section 1.6 "Clinical Presentation") [9, 15, 17-24].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
Comment: performing laryngoscopy (indirect laryngoscopy using a laryngeal mirror) is a mandatory diagnostic procedure when examining patients aged 12 years and older with laryngeal and pharyngeal trauma, as the most accessible routine method for visual assessment of the laryngeal mucosa. Examination of preschool and early school-age children using this method is often unfeasible due to patient emotional lability and a pronounced gag reflex [23, 24].
It is recommended to assess the localization, dimensions, depth, and condition of wound edges, as well as their relationship with blood vessels and nerves in all patients to rule out foreign bodies, external or throat bleeding, and airway injury [26-28].
GRL CLEL 5Grading of Recommendations Assessment, Development and Evaluation (GRADE) Level C (Level of Evidence – 5).
It is recommended to perform neck and chest palpation during the examination of all patients to rule out subcutaneous emphysema [9, 29].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
2.3 Laboratory Diagnostics
It is recommended to perform a complete blood count (CBC) in patients with blood loss or suspected blood loss to assess potential anemia and the volume of blood loss [28, 30].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
It is recommended to perform a screening coagulation test (coagulogram) in all patients to assess hemostatic disorders (and, if necessary, in preparation for surgical intervention) [28, 30].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
2.4 Instrumental Diagnostics
It is recommended to perform spiral computed tomography (SCT) of the neck and/or computed tomography (CT) of the neck with intravenous bolus contrast enhancement when vascular injury is suspected, in order to assess the extent of damage [9, 15, 16, 22, 28, 29, 31-33].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
It is recommended to perform computed tomography (CT) of the esophagus with oral contrast enhancement in all patients with neck trauma upon hospital admission when pharyngeal or esophageal injury is suspected [9, 15, 16, 22, 28, 29, 31-33].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
Comment: Performing standard radiography of the soft tissues of the neck, larynx, and trachea is of little diagnostic value, as it can only detect edema, subcutaneous emphysema, or a hyoid bone fracture, whereas computed tomography provides visualization of laryngeal fractures and soft tissue injuries [34]. These studies allow for the assessment of the anatomical structures of the neck (attention is paid to the state of the cartilaginous framework of the larynx, the hyoid bone, the presence and path of the wound tract, foreign bodies, involvement of the neck vessels, and the presence and extent of emphysema).
It is recommended that all patients undergo videolaryngoscopy using flexible and rigid endoscopes (rigid laryngopharyngoscopes, flexible videolaryngoscopes) with a 70- and 90-degree field of view [9, 20, 22, 28].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comment: videolaryngoscopy makes it possible to assess the state of the mucous membrane, the presence or absence of its damage, the presence and extent of edema in the larynx and laryngopharynx, the state of the glottis and the mobility of the vocal folds, as well as the subglottic larynx and trachea. If there is a wound opening in the larynx or trachea, a retrograde examination is possible. In children, fibrolaryngoscopy is the preferred method for visual assessment of the larynx [35].
It is recommended to perform microlaryngoscopy in all patients (Schaefer injury severity scale groups 2–5 to refine the diagnosis and select the method and extent of treatment) [9, 15, 28, 36].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comment: this study can be performed in adults and children after achieving a permanent patent airway and allows for a more detailed examination of the larynx, assessment of the cricoarytenoid joint, mucous membrane, cartilaginous framework, and aids in selecting the method and scope of reconstructive surgery.
It is recommended: in all cases of laryngeal trauma, to rule out cervical spine injury in order to prevent concomitant pathology that could worsen the patient's condition [22].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
Comment: concomitant cervical spine injuries can significantly worsen the patient's condition. Detecting a spinal injury requires an immediate consultation with a relevant specialist.
It is recommended to perform esophagoscopy in patients with penetrating wounds of the larynx or pharynx to rule out esophageal injury [9, 20, 21, 28, 36].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
Comment: concomitant esophageal injuries can significantly worsen the patient's condition.
It is recommended to perform stroboscopic laryngoscopy and laryngeal electromyography (cutaneous electromyography) in all patients with laryngeal trauma to assess vocal fold mobility (if appropriate equipment is available) [9].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comment: performed to objectify the degree of vocal fold mobility impairment.
It is recommended to perform an ultrasound examination (ultrasound) of the larynx in pediatric patients with laryngeal trauma [8, 37].
LeRR CLoE 4Level of recommendation confidence C (level of evidence – 4)
Comment: Ultrasound does not require special preparation and clearly visualizes the mobility of the vocal cords and arytenoid cartilages, asymmetric positioning of the arytenoid cartilages, thickening of the vocal cords, thyroid cartilage fractures, and hematomas in this area. Laryngeal ultrasound is recommended as a non-invasive study to complement laryngoscopy [8, 37].
It is not recommended to perform MRI in victims with shrapnel and bullet wounds due to the potential presence of metallic foreign bodies in the wound, in order to prevent their uncontrolled displacement during the procedure [67].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
2.5 Other Procedures
It is recommended to perform pulse oximetry in children with signs of upper airway stenosis to assess the severity of respiratory failure and the need for oxygen therapy [38].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
It is recommended to perform a microbiological (culture) study of purulent wound discharge for aerobic and facultatively anaerobic microorganisms, with antimicrobial susceptibility testing, in patients with wounds of the larynx or pharynx to prescribe effective therapy [33].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
The treatment of patients with laryngeal and pharyngeal trauma follows these principles regardless of the chosen management strategy:
- Restoration and maintenance of patent airways.
- Hemostasis and replacement of blood loss if necessary.
- Implementation of measures for the prevention of traumatic shock.
- Administration of anti-edematous, antibacterial, detoxifying, and anti-inflammatory therapy.
It is recommended to prioritize airway patency when caring for patients with injuries to the larynx and laryngopharynx to ensure timely diagnosis of obstruction or potential obstruction, and to prevent aspiration of oropharyngeal contents [1, 20, 28, 33].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
Comments: Treatment is proposed based on the severity of laryngeal injury according to the Schaefer classification [9]:
Group 1 (mandatory flexible laryngeal endoscopy) – mild injuries generally respond to medical management and do not require surgery. The following may be useful: systemic corticosteroids, systemic antibacterial drugs, medications for peptic ulcer disease and gastroesophageal reflux disease (GERD), humidified air, and voice rest;
Group 2 (direct laryngoscopy and esophagoscopy must additionally be performed) – watchful waiting, as injuries may worsen or progress over time. Sometimes tracheotomy may be required for such injuries. Systemic corticosteroids, broad-spectrum antibacterial drugs, medications for peptic ulcer disease and gastroesophageal reflux disease (GERD), humidified air, and voice rest may also be useful;
Group 2 (direct laryngoscopy or esophagoscopy should be performed in the operating room) – tracheotomy is frequently required; surgery is typically needed for: anterior commissure rupture, extensive lacerations of the larynx, vocal fold tears, vocal fold immobility, exposed cartilage, displaced cartilage fractures, subluxation, or dislocation of the arytenoid cartilage;
Group 3 (direct laryngoscopy and esophagoscopy are mandatory) – tracheotomy is always required; surgical treatment of these injuries will necessitate stent placement to preserve laryngeal integrity;
Group 4 (these patients present with severe respiratory failure, therefore endoscopic examination is postponed until the airway is secured) – injuries at the level of the cricoid cartilage, cricothyroid membrane, cricotracheal junction; tracheotomy is necessary to restore airway patency but may be very difficult due to altered anatomy. Laryngotracheoplasty is performed to restore the laryngotracheal region.
3.1. Conservative management
It is recommended to perform conservative treatment only for abrasions and superficial skin injuries, blunt external and internal trauma to the larynx and laryngopharynx with development of edema, abrasions, hematomas, without damage to the cartilaginous framework or with damage without displacement of cartilage fragments, in the absence of progressive respiratory failure or purulent-inflammatory changes in the neck tissues [9, 28, 39].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
Comment: in conservative management, abrasions or other superficial skin injuries should be treated with antiseptics followed by an aseptic dressing. If the patient's condition is stable, this type of injury can be managed with symptomatic therapy.
It is recommended to prescribe antiseptics and disinfectants (local antiseptic drugs) to patients with laryngeal trauma involving skin damage with signs of wound infection or a high risk of infection, to prevent the development of purulent inflammation [9, 28, 39].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
Comments: Quaternary ammonium compounds (benzyldimethyl[3-(myristoylamino)propyl]ammonium chloride monohydrate) (ATC code D08AJ), iodine preparations (povidone-iodine**(D08AG02)), and biguanides and amidines (chlorhexidine**(D08AC02)) possess pronounced antimicrobial properties. These drugs can be used in adults and children. The frequency of wound dressing depends on the severity of inflammation and the nature of the exudate. The wound is treated until the infection resolves or epithelization begins [40].
It is recommended to prescribe inhalation administration of drugs and oxygen to patients with signs of upper airway stenosis in order to reduce edema and inflammation in the laryngeal tissues and to improve blood oxygenation [9, 22, 28].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
Comments: after injury and during stages of evacuation to the hospital, it is advisable to administer cool oxygen via an oxygen inhalation mask. Inhalations of corticosteroids (ATC: R03BA): budesonide** (ATC: R03BA02) inhalation solution for adults 1.0 mg 1–2 times a day, course of 5–8 procedures; for children over 6 months, inhalation suspension 0.25–0.5 mg 1–2 times a day for a course of 5 procedures. The duration of inhalation is usually 10 minutes, and the interval between inhalations of drugs with different mechanisms of action is about 30 minutes.
It is recommended to prescribe anti-edema therapy to victims with open and closed laryngeal trauma in order to reduce post-traumatic edema in the larynx and laryngopharynx [7, 9, 22, 28].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
Comments: parenteral administration of systemic corticosteroids and diuretics is advisable [7, 9, 22, 28].
It is recommended to prescribe voice rest (no shouting, no whispering for at least 2 days) to patients with laryngeal trauma in order to reduce laryngeal edema and accelerate the resolution of reactive phenomena [22, 28].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
Comments: it is necessary to establish a protective regimen (voice rest regimen), recommending complete vocal rest for 1–2 days for patients with laryngeal trauma, followed by limitation of any vocal load. It is also necessary to stop the intake of spicy, salty, hot, cold food, alcoholic beverages, and smoking.
It is recommended to prescribe medications for the treatment of gastric and duodenal ulcers and GERD (ATC code: A02BX) for patients with wounds or inflammatory changes in the mucosa of the larynx or laryngopharynx to prevent the impact of gastric contents on the wound surface or the inflamed mucosa of the larynx and laryngopharynx [7, 5, 9, 22, 28].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
It is recommended to prescribe analgesics, non-steroidal anti-inflammatory and antirheumatic drugs to victims with trauma of the larynx and pharynx in order to reduce edema and pain syndrome [7, 28, 34, 41].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
Comments: To reduce pain intensity, preparations from the group of other analgesics and antipyretics (ATC: N02B) and the group of non-steroidal anti-inflammatory and antirheumatic drugs (ATC: M01A) are used separately or in combinations [41, 42]. It is recommended to use a combination of non-steroidal anti-inflammatory drugs (NSAIDs) (ATC: M01A) and anilides (paracetamol** (ATC: N02BE01)), as well as pyrazolones (metamizole sodium (ATC: N02BB02)) for pain management in adults and children, including in the postoperative period (Tables 1, 2) [43, 44]. In children, the use of NSAIDs (ATC: M01A) is restricted to ibuprofen** (ATC: M01AE01) starting from 3 months for rectal suppositories and oral suspension, from 6 years for tablets, and from 12 years for capsules; and ketoprofen** (ATC: M01AE03) starting from 6 years for oral granules and from 15 years for parenteral forms. In outpatient practice for the treatment of children, the use of metamizole sodium preparations (ATC: N02BB02) should be avoided, and in inpatient practice, they should be used only if other analgesics (ATC Code: N02) approved for use in children are unavailable due to the risks of serious adverse events.
Table 1. Recommended doses and regimens of analgesic and anti-edema therapy in adults with laryngeal injuries.
Drug | Single dose | Dosing interval | Maximum daily dose | Maximum duration of administration |
|---|---|---|---|---|
Paracetamol** (ATC: N02BE01) | 1 g IV infusion over 15 min. | 4h | 4 g | 5–7 days |
Diclofenac** (ATC: M01AB05 | 75 mg IM | 12 h | 150 mg | 2 days |
Ketorolac** (ATC: M01AB15 | 30 mg IV, IM | 6 h | 60–90 mg | 2 days |
Ketoprofen** (ATC: M01AE03 | 100 mg IV, IM | 12 h | 200 mg | no more than 2 days |
Lornoxicam (ATC: M01AC05 | 8 mg IV, IM | 12 h | 16 mg | 1–7 days |
Dexketoprofen** (ATC: M01AE17 | 50 mg IV, IM | 8–12 h | 150 mg | 2 days |
Metamizole sodium (ATC: N02BB02) | 500–1000 mg IV, IM | 8–12 h | 2 g | 1–5 days |
Table 2. Recommended doses i regimens application of analgesic and anti-inflammatory therapy in children with laryngeal trauma.
Drug | Single dose | Dosing interval | Maximum daily dose | Maximum duration of administration |
|---|---|---|---|---|
Paracetamol** (IV) (ATX: N02BE01) | IV infusion over 15 minutes: 10–50 kg – 15 mg/kg; <10 kg – 7.5 mg/kg >50 kg – 1000 mg Contraindicated in newborns up to 1 month! | 4 h | 33–50 kg – <60 mg/kg, but not more than 3 g; 10–50 kg – <60 mg/kg, but not more than 2 g; <10 kg – <30 mg/kg >50 kg – 4 g | 5–7 days |
Paracetamol** (per os) suspension (ATX: N02BE01) | 10–15 mg/kg | 6 h | not more than 60 mg/kg | 3–5 days |
Paracetamol** (suppositories rectally) (ATX: N02BE01) | 10-14 years – 350-500 mg 5–10 years – 250–350 mg 3–5 years – 150–200 mg 1-3 years – 100-150 mg 3-12 months – 50-100 mg | 4–6 h | <60 mg/kg | up to 5 days |
Ibuprofen** (per os) (ATC: M01AE01) | >6 years – 200-400 mg; 4-6 years – 150 mg; 1–3 years – 100 mg; 6-12 months – 50 mg 3–6 months – 50 mg | 8 h 6–8 h 8 h | 12-17 years – 1 g; 6-12 years – 800 mg; 4-6 years – 450 mg; 1-3 years – 300 mg; 6-12 months – 200 mg; 3-6 months – 150 mg | 4 days |
Ibuprofen** (rectal suppositories) (ATC: M01AE01) | 3-9 months – 60 mg 9-24 months – 60 mg | 8 h 6 h | 3-9 months – 180 mg 9-24 months – 240 mg | no more than 3 days |
Ketoprofen** (ATC: M01AE03) | from 15 years – 100 mg IV, IM | 12 h | 200 mg | no more than 2 days |
Ketoprofen** (per os) (ATC: M01AE03) | granules for oral solution >6 years – 40 mg | 8 h | 120 mg | no more than 2 days |
Metamizole sodium (ATC: N02BB02) | from 15 years – 500-1000 mg IV, IM; 3 months - 1 year – 50-100 mg/10 kg IM | 8–12 h | from 15 years – 2 g; | 3 days |
It is recommended to administer systemic antibacterial therapy to all patients with an open wound or in the presence of complications and associated injuries for the prevention and treatment of infectious complications [7, 9, 28, 33, 37].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
Comment: The proximity of the larynx to the oropharynx increases the risk of infection in injured laryngeal tissues. Systemic antibacterial drugs must be prescribed [7]. Cephalosporin drugs (third-generation cephalosporins) are prescribed: cefotaxime** (ATC Code: J01DD01) or ceftriaxone** (ATC Code: J01DD04), infusion antimicrobial therapy with metronidazole** (ATC code: J01XD01); if emphysema spreads to the mediastinum and there is a risk of mediastinitis, carbapenem group drugs are used: meropenem** (ATC Code: J01DH02). The dose, frequency, and duration of the course of treatment are variable and chosen depending on the clinical situation.
Table 4. Recommended systemic antibacterial drugs (ATC: J01 (ABAs)) for neck injuries
Drug | Single dose | Frequency of administration | Duration of use |
|---|---|---|---|
Cefotaxime** (ATC: J01DD01) | IV or IM. Adults and children >12 years (body weight >50 kg): 1 g; children <12 years (body weight <50 kg): 50–75 mg/kg; newborns: 25 mg/kg | 2 times a day | 7–10 days |
Ceftriaxone** (ATX: J01DD04) | Adults: 1–2 g IV, IM; children 2 months–12 years: 20–100 mg/kg IV, IM; newborns (from 15 days), infants, and young children 20–80 mg/kg IV, IM | 1 time a day | 7–10 days |
Metronidazole** (ATC: J01XD01) | IV drip. Administration rate 5 ml/min. >12 years: 500 mg; <12 years: 7.5 mg/kg | 3 times a day | 7–10 days |
It is recommended to administer tetanus toxoid vaccine to all patients with laryngeal trauma involving damage to the integrity of the skin and mucous membranes when contaminated particles enter the wound [33, 37].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: Emergency tetanus immunoprophylaxis should be carried out as early as possible and up to 20 days from the moment of injury, considering the duration of the incubation period in tetanus. Emergency tetanus prophylaxis consists of specific immunoprophylaxis with tetanus toxoid** (ATC: J07AM01), human tetanus immunoglobulin** (ATC: J06BB02), or purified concentrated liquid equine tetanus antitoxin (ATC: J06AA02 tetanus antitoxin**) according to the instructions for use.
It is recommended to prescribe hemostatic agents to all patients with laryngeal trauma in the presence of signs of external bleeding or bleeding from the throat for the purpose of stopping it [21, 25, 28].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
Comment: minor external bleeding in wounds of the larynx and trachea is stopped by applying an aseptic pressure bandage and prescribing hemostatic agents.
For this purpose, drugs from the groups of other systemic hemostatic agents (ethamsylate** (ATC: B02BX01)) and antifibrinolytic agents (tranexamic acid** (ATC: B02AA02), aminocaproic acid** (ATC: B02AA01)) are used.
Ethamsylate** (ATC: B02BX01) is administered intravenously or intramuscularly to adults at 250-500 mg to stop bleeding, followed by 250 mg every 4-6 hours; to children at 10-15 mg/kg/day in 3-4 divided doses for 5-10 days.
Tranexamic acid** (ATC: B02AA02) is administered as an IV drip or slow IV push at an administration rate of 1 ml/min (50 mg/min). It is prescribed at a dose of 10-15 mg/kg every 6-8 hours in adults and 20 mg/kg/day in children over 1 year of age until bleeding stops.
Aminocaproic acid** (ATC: B02AA01) is used as an IV drip. Adults are administered 4-5 g of the drug during the first hour; in case of ongoing bleeding – 1 g/hour for no more than 8 hours until bleeding stops; if necessary, infusions are repeated every 4 hours; maximum daily dose is 30 g. Children – 100 mg/kg body weight in the first hour, then – 33 mg/kg/h; maximum daily dose – 18.0 g/m2 of body surface area (up to 1 year – 3 g; 2-6 years – 3-6 g; 7-10 years – 6-9 g; from 10 years – same as for adults). For acute blood loss: children under 1 year – 6 g; 2-4 years – 6-9 g; 5-8 years – 9-12 g; 9-10 years – 18 g. Duration of therapy is 3-14 days.
It is recommended to place a nasogastric tube (feeding tube) and prescribe therapeutic parenteral nutrition in case of hypopharyngeal or esophageal injury, pronounced edema in the hypopharyngeal region, and the inability to eat naturally to prevent food from entering the respiratory tract [28].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
3.2. Surgical treatment
Surgical treatment for laryngeal trauma and bleeding from the throat has a number of specific features.
It is recommended to perform surgical treatment in patients presenting with the following manifestations of trauma: laryngeal stenosis in the stage of decompensation, hemorrhage, presence of an open wound, wound contamination, presence of foreign bodies, non-viable tissues, soft tissue loss, skin deficit, presence of pronounced or progressive emphysema, fracture of the cartilaginous framework of the larynx with displacement of cartilaginous fragments narrowing the laryngeal lumen, in order to timely prevent the progression of a life-threatening pathology [21, 22, 28]:
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
It is recommended to perform surgical treatment in patients with pharyngeal bleeding in order to stop it [68, 69].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
Comments: the following manipulations and surgical interventions are used to stop bleeding: wound packing, coagulation of the bleeding vessel, wound closure. In case of massive uncontrollable bleeding, endovascular occlusion procedures or vessel ligation (external carotid artery) are performed. In case of extensive laryngeal damage when the source of bleeding cannot be identified, or in intra-laryngeal bleeding, ligation of the feeding vessels—the superior thyroid or external carotid artery—is performed, having previously secured the airway against blood aspiration by performing tracheotomy below the site of injury [33].
It is recommended to approach the treatment of victims with severe neck injuries and trauma using the "Damage control surgery" principle to prevent adverse outcomes of injuries and trauma [25, 33].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
Comments: "Damage control surgery" is a staged programmed surgical strategy aimed at preventing adverse outcomes of injuries and trauma by reducing the scope of the initial surgery and deferring the definitive repair of damaged organs and structures until the patient's vital functions are stabilized.
Surgical intervention on the neck as the first stage of the "damage control" strategy includes:
1) elimination of respiratory disorders (asphyxia) by endotracheal intubation, typical or atypical tracheotomy;
2) temporary or definitive cessation of bleeding by vascular suture, ligation, or tight packing of the injured blood vessel area, as well as temporary shunting of the common and internal carotid arteries;
3) prevention of further soft tissue infection of the neck by hollow organ contents (mucus, saliva) by placing sutures or applying ointment-soaked tampons to the injury site;
4) immobilization of the neck with a Schanz collar (cervical collar) in case of cervical spine injury.
Tracheal intubation is a standard emergency medicine procedure to establish and maintain airway patency. Cervical spine immobilization is maintained during emergency airway procedures. Use an endotracheal tube one size smaller than anticipated to account for laryngeal edema and prevent further damage to its structures [7].
It is recommended to perform awake tracheotomy in patients with significant laryngeal edema, especially if it is progressing, to prevent the loss of airway patency due to increasing stenosis [15, 21, 22, 28, 45].
GPP CLOE 4Grade of Recommendation C (Level of Evidence – 4).
Comment: at the trauma site, it is permissible to insert a tracheostomy tube (any hollow tube) through the wound canal into the laryngeal or tracheal lumen, perform konicotomy or cricothyroidotomy followed by replacing the atypical tracheostomy with a typical one, with mandatory suturing of the trachea to the skin. The formation of a permanent stoma allows changing an obstructed or dislodged tracheostomy tube at any time without fear of tissue displacement and stoma closure, which is especially important during medical evacuation stages and in combat conditions. Intubation should be avoided whenever possible, as the endotracheal tube can further injure the larynx, destabilize laryngeal fractures, or lead to acute airway trauma. Tracheotomy in children is recommended only under combined inhalation anesthesia [46].
It is recommended to take measures to stop bleeding (if present) in all patients on an emergency basis to prevent hemorrhagic shock [21, 25, 28].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
Comment: minor external bleeding in laryngeal and tracheal injuries is stopped by applying an aseptic pressure bandage and prescribing hemostatic agents; if ineffective (continuing bleeding), ligatures are applied to the bleeding vessel in the wound.
It is recommended to perform surgical debridement of the wound, which is carried out according to the wound type in patients with injuries of the larynx and pharynx in order to prevent complications [21, 25, 28, 33]
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
Comments: proposed scope of intervention according to the wound type.
superficial wound – cleansing, sanitation, primary skin suturing;
deep wound with damage to soft tissue structures – surgical debridement (incision, excision, repair of damaged structures, drainage and skin suturing, anti-inflammatory and antibacterial therapy);
extensive degloving and crushed wounds – primary surgical debridement of the wound and wound defect, sanitation, primary or delayed skin defect plasty, repair of damaged structures, drainage, skin sutures, anti-inflammatory and antibacterial therapy, transfusion therapy (as indicated).
Surgical debridement of laryngeal wounds should be conservative and performed as early as possible. Easily accessible foreign bodies and only clearly non-viable, crushed soft tissues are removed, while the laryngeal mucosa is preserved as much as possible. Small wounds (up to 0.5 cm) of the larynx and trachea may be left unsutured and treated by draining the injury area.
It is not recommended to perform surgical wound debridement in patients with superficial wounds, scratches, abrasions, small wounds with wound edge separation of less than 1 cm, multiple small wounds without damage to muscles and fascial sheaths, as well as puncture wounds without damage to internal organs, vessels, and nerves [15, 25].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
Comments: for the types of wounds described above, wound toilet is performed without surgical debridement, including (at the discretion of the attending or on-duty physician) approximating the wound edges with medical adhesive tape or medical fixing adhesive tape without suturing it.
It is recommended to perform surgical wound drainage using available methods and means (placement of a wound drain, rubber glove drain, etc.) until discharge ceases in all patients with wounds to accelerate wound cleansing [25, 28, 33].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
It is not recommended to suture the wound in the presence of signs of wound infection and/or purulent-inflammatory complications until these processes are resolved in all patients in order to prevent further development of wound (including anaerobic) infection [25, 33].
GRL CLEL 5Grading of Recommendations Assessment, Development and Evaluation (GRADE) Level C (Level of Evidence – 5).
It is recommended to fix any displaced laryngeal cartilage fractures in all patients with laryngeal cartilage fractures to prevent the dislocation of cartilage fragments [22, 47, 48].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: fixation minimizes fragment dislocation in the postoperative period. There are two perspectives regarding the timing of surgical intervention in laryngeal and tracheal trauma: some authors recommend the earliest possible intervention (within the first 24–48 hours) [9, 10, 49, 50], while others recommend delaying it for a week or more to reduce tissue edema [51, 52]. Neck injuries are highly diverse, and the timing of intervention must be considered individually in each specific case, depending on the severity of the trauma and concomitant pathology.
It is recommended to perform thyrotomy in case of rupture of the mucous membrane of two or more anatomical regions, the free margin of the vocal folds, or fractures of the cartilaginous framework [11, 22, 49, 51].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comments: this intervention allows for the restoration of the damaged mucous membrane and primary closure of lacerations of the vocal folds using 5/0 or 6/0 absorbable suture material. All exposed cartilage must be covered either primarily or using local mucosal flaps. If the fracture is located more than 3 mm from the anterior commissure, a median thyrotomy should still be performed.
It is recommended to reduce displaced or dislocated arytenoid cartilages depending on the degree of their damage [11, 22].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
Comments: isolated lacerations involving these cartilages can be treated by repeat mucosal coverage. Complete displacement of the arytenoid cartilages from the articular surface of the cricoid cartilage requires traumatic rupture of the cricoarytenoid joint ligaments.
It is recommended to perform laryngotracheoplasty using local tissues after a standard tracheostomy in penetrating laryngeal injuries with cartilage damage and without significant displacement, following wound revision to close the post-traumatic defect [9, 11].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
Comments: if necessary, the surgery is performed via a combined approach—external and endoscopic (transoral microlaryngoscopy)—to assess the state of the laryngeal lumen, the preservation of the mucous membrane, and the possibility of closing the laryngeal defect without forming a laryngostomy. A finger-cot obturator is placed into the laryngeal lumen for several days, with its fixation threads brought out externally through the tracheostomy opening; the need and advisability of installing an endoprosthesis are subsequently determined.
It is recommended to form a laryngotracheostomy in all patients with penetrating laryngeal injuries involving significant destruction and displacement of cartilages, tissue tears in the anterior commissure area, and pronounced cicatricial deformation of the laryngeal lumen following wound revision, in order to prevent the formation of scar strictures [25, 28, 33].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
Comments: in the first days after surgery, the laryngeal lumen is packed with a Mikulicz gauze tampon impregnated with combined chloramphenicol-based ointments (ATX code: D06C antibiotics in combination with antimicrobials), followed by its replacement with a silicone prosthesis to restore laryngeal function [51–59,]; multiple comminuted fractures of the laryngeal skeleton often require both internal stenting and external fixation due to laryngeal movement during swallowing; if laryngeal fractures can be stabilized without using an internal lumen splint and mucosal damage is minimal, stenting should be avoided [50].
It is recommended to perform laryngoplasty (suturing the larynx by the lower horns of the hyoid bone – laryngohyodeopexy) in fractures of the hyoid bone accompanied by detachment of the larynx, and to perform tracheoplasty (suturing the trachea to the thyroid cartilage – tracheolaryngopexy) in detachment of the larynx from the trachea — in order to prevent complications [25, 28, 33].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
Comments: following tracheal avulsion from the larynx, the latter is usually pulled upward, while the trachea retracts into a retrosternal position, which necessitates a low tracheostomy incision. Pneumothorax typically accompanies laryngeal avulsion and requires timely detection and treatment.
3.3. Pain management
It is recommended to use local anesthetics (ATX code: N01B) during surgical wound debridement and manipulations in the laryngeal cavity (taking into account the characteristics of the wound, pain intensity, and the patient's allergy history) for analgesia [42, 60].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
3.4. Diet therapy
It is recommended a general restorative diet for all patients, with adequate amounts of proteins, fats, carbohydrates, mineral salts, and vitamins, except for patients with underlying medical conditions that require appropriate dietary modifications (diabetes mellitus, etc.) [28].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
Comment: depending on the presence or absence of a nasogastric tube or gastrostomy, enteral or parenteral medical nutrition is prescribed.
4. Medical Rehabilitation and Sanatorium-Resort Treatment
It is recommended for patients who have suffered blunt neck trauma with damage to the larynx and laryngopharynx, as well as patients who underwent laryngotracheoplasty without laryngostomy (laryngotracheostomy) formation or who have already undergone plastic closure of a laryngostomy (laryngotracheostomy), to have a repeat follow-up appointment (examination, consultation) with an otorhinolaryngologist at their local outpatient clinic; in case of impaired vocal function, a consultation with a phoniatrician (phonopedist) is indicated to prevent and correct dysphonia [22, 61, 62].
GRL CLEL 5Grading of Recommendations Assessment, Development and Evaluation (GRADE) Level C (Level of Evidence – 5).
It is recommended that patients who had an open neck wound with laryngeal damage and underwent laryngotracheoplasty with laryngostomy (laryngotracheostomy) formation remain under the observation of the inpatient otorhinolaryngologist [22, 61, 62].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
5. Prevention and Dispensary Observation
It is recommended to prevent iatrogenic internal trauma to the larynx and laryngopharynx during mechanical ventilation, esophagogastroduodenoscopy (EGD), and bronchoscopy [28, 61, 63, 64].
Level of Evidence CGrade of Recommendation 5Strength of Recommendation C (Level of Evidence – 5).
Comments: tracheal intubation and fiberoptic examinations should be performed as carefully as possible, without damaging laryngeal structures. In cases of difficult intubation, the use of a videolaryngoscope is recommended.
Specific prevention of other types of laryngeal and pharyngeal trauma has not been developed.
It is recommended to have a repeat otorhinolaryngologist appointment (examination, consultation) after 1 month, and then once every 3 months for a year, in order to timely identify indications for reconstructive surgery [9, 28].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
Comments: during the examinations, video laryngoscopy of the larynx is performed, laryngoscopy using a stroboscope (laryngostroboscopic examination) is carried out, and external respiratory function is assessed (as indicated). The timing of repeat surgical interventions aimed at decannulation (removal of the tracheostomy tube) and the restoration of anatomical integrity, as well as the laryngeal and tracheal lumen, is determined individually depending on the patient's general condition and the clinical and functional state of the hollow organs of the neck [9, 28].
6. Organization of Medical Care
All specialists providing first aid at both the pre-hospital and hospital stages must recognize the signs of airway obstruction and possess airway management skills while ensuring protection of the cervical spine. The likelihood of successful airway restoration increases with the availability of special equipment and the skills for its proper and safe use. Guaranteed capabilities for the safe performance of airway management procedures (e.g., endotracheal intubation, cricothyroidotomy, tracheotomy) must be provided at all levels (pre-hospital and hospital) [44].
It is recommended to hospitalize patients with laryngeal and pharyngeal trauma to monitor upper airway patency [22].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
Comments: Inpatient observation should be performed for 24–48 hours for mild injuries that may progress or lead to airway compromise (edema, hematoma), particularly in pediatric patients [1, 2]. Laryngeal trauma in children is also a life-threatening condition due to the risk of cardiogenic shock resulting from bradycardia, arrhythmia, blood pressure drop, or cardiac arrest related to innervation features [37]. More severe injuries require a longer period of hospitalization and rehabilitation. Small, non-progressive hematomas with an intact mucosa will likely resolve spontaneously without major consequences. Large or expanding hematomas can lead to airway obstruction and require tracheotomy.
7. Additional Information
Risk factors for an unfavorable outcome of surgical treatment:
Systemic factors: advanced age, immunodeficiency states, cachexia, infection, oncological process, carbohydrate metabolism disorders, collagenoses, and other systemic diseases.
Local factors: injury to the esophagus, the neurovascular bundle of the neck, the spine, purulent-inflammatory changes (cervical phlegmon, mediastinitis), repeated trauma, infection, presence of foreign bodies.
Prognosis: with primary plasty and restoration of the laryngeal lumen, organ deformation with severe functional impairment generally does not occur. However, much depends on the type of injury, the extent of damaged laryngeal structures, individual characteristics, and comorbid conditions. Laryngeal and tracheal injuries are classified as severe, disfiguring injuries that often lead to disability, and due to the frequent development of secondary scar changes, may require repeated reconstructive surgeries, the prognosis of which is often uncertain.
Criteria for Evaluating the Quality of Medical Care
Quality assessment criteria for primary health care in adults and children with laryngeal trauma (ICD-10 codes S10.0, S10.1, S11.0, R04.1)
№ | Quality criteria | Evaluation of compliance |
|---|---|---|
1. | An initial examination (evaluation, consultation) by an otorhinolaryngologist was performed | Yes/No |
2. | Laryngoscopy performed | Yes/No |
3. | Bleeding from the external wound was controlled (stopped) (if present) | Yes/No |
4. | A referral for hospitalization was issued for patients with complicated laryngeal trauma | Yes/No |
Quality assessment criteria for specialized medical care in adults and children with laryngeal trauma (ICD-10 codes S10.0, S10.1, S11.0, R04.1)
№ | Quality criteria | Evaluation of compliance |
|---|---|---|
1. | An initial examination (evaluation, consultation) by an otorhinolaryngologist was performed | Yes/No |
2. | Laryngoscopy performed | Yes/No |
3. | Bleeding from the pharynx or larynx was controlled (stopped) if present | Yes/No |
4. | Yes/No | |
5. | Surgical wound debridement was performed (if necessary) | Yes\No |
6. | Yes/No |
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Appendix A1. Working Group Composition
Golovanov A.E., MD, Assoc. Prof. – is a member of the National Medical Association of Otorhinolaryngologists, no conflict of interest.
Kuts B.V., PhD, Assoc. Prof. – Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest.
Egorov V.I., MD, Prof. – Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest.
Alekseenko S.I., MD, Assoc. Prof. – Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest.
Tkachuk I.V., PhD – Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest.
Appendix A2. Methodology for Developing Clinical Guidelines
Target audience for these clinical guidelines:
otorhinolaryngologists;
surgeons;
thoracic surgeons;
emergency medicine physicians;
medical students, residents, and postgraduate students.
Table 1. Levels of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)
LoE | Definition |
|---|---|
1 | Systematic reviews of studies with reference standard control or systematic reviews of randomized controlled trials with meta-analysis |
2 | Individual studies with reference standard control or individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3 | Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report |
5 | Only justification of mechanism of action or expert opinion is available |
Table 2. Levels of Evidence (LoE) grading scale for prevention, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, therapeutic, and rehabilitative interventions)
LoE | Definition |
|---|---|
1 | Systematic review of RCTs with meta-analysis |
2 | Individual RCTs and systematic reviews of studies of any design except RCTs, with meta-analysis |
3 | Non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case reports or case series, case-control studies |
5 | Only justification of the mechanism of action of the intervention (preclinical studies) or expert opinion is available |
Table 3. Scale for assessing the grades of recommendation (GR) for prevention, diagnostic, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, diagnostic, therapeutic, and rehabilitative interventions)
GoR | Definition |
|---|---|
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
B | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of evidence of proper quality; all considered efficacy criteria [outcomes] are unimportant, all studies have low methodological quality, and their conclusions regarding outcomes of interest are inconsistent) |
Procedure for updating clinical guidelines.
The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.
Appendix A3. Reference Materials
These clinical guidelines were developed taking into account the following regulatory legal documents:
Constitution of the Russian Federation.
Federal Law No. 323-FZ dated November 21, 2011, "On the Fundamentals of Healthcare Protection in the Russian Federation."
Order of the Ministry of Health of the Russian Federation No. 203n dated May 10, 2017, "On Approval of Criteria for Assessing the Quality of Medical Care."
Order of the Ministry of Health of the Russian Federation No. 905n dated November 12, 2012, "On Approval of the Procedure for Providing Medical Care to the Adult Population in the Profile 'Otorhinolaryngology'."
Order of the Ministry of Health of the Russian Federation No. 927n dated November 15, 2012, "On Approval ofതം the Procedure for Providing Medical Care to Victims with Associated, Multiple, and Isolated Traumas Accompanied by Shock."
Order of the Ministry of Health of the Russian Federation No. 388n dated June 20, 2013, "On approval of the procedure for the provision of emergency, including specialized emergency, medical care."
Resolution of the Government of the Russian Federation No. 554 dated July 24, 2000, "On Approval of the Regulations on the State Sanitary and Epidemiological Service of the Russian Federation and the Regulations on State Sanitary and Epidemiological Regulation" (Collected Legislation of the Russian Federation, 2000, No. 31, Art. 3295; 2004, No. 8, Art. 663; No. 47, Art. 4666; 2005, No. 39, Art. 3953)
Resolution of the Chief State Sanitary Doctor of the Russian Federation No. 4 dated January 28, 2021, "On Approval of Sanitary Rules and Norms SanPiN 3.3686-21 'Sanitary and Epidemiological Requirements for the Prevention of Infectious Diseases'" (along with "SanPiN 3.3686-21. Sanitary Rules and Norms...") (Registered with the Ministry of Justice of Russia on February 15, 2021, No. 62500). Prevention of infectious diseases. Prevention of tetanus.
Order of the Ministry of Health of the Russian Federation No. 788n of July 31, 2020, "On Approval of the Procedure for Organizing Medical Rehabilitation for Adults" (registered by the Ministry of Justice of the Russian Federation on September 25, 2020, registration No. 60039).
Appendix A3.1 Explanation of Notes
** – a medicinal product included in the List of Vital and Essential Drugs for medical use for 2020 (Decree of the Government of the Russian Federation No. 2406-r dated October 12, 2019)
# – off-label use outside the indications registered in the medicine's instructions is carried out by decision of the medical commission, with the permission of the Local Ethics Committee of the medical organization (if any), subject to the signed informed consent of the parents (legal representative) and the patient over 15 years of age.
Appendix B. Physician Action Algorithms
Appendix C. Patient Information
Following discharge from the hospital, all patients are advised to continue treatment and follow-up with an otorhinolaryngologist in an outpatient setting.
In case of laryngeal trauma, the physician must inform the patient about the need to undergo procedures over an extended period, as recovery and rehabilitation take a long time. The consequences of laryngeal trauma can have a long-term impact on the quality of life, affecting speech, swallowing, and breathing functions. The patient must strictly follow all instructions of the attending physician.
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
Not applicable