Injuries above the glottis
Introduction
Introduction Damage above the glottis is a clinical manifestation of open neck injury. Dislocation of the sacral cartilage and hemorrhage of the glottis or glottis also have hoarseness or loss of sound, and sometimes throat lary occurs when inhaling. Patients often complain of swallowing pain, difficulty swallowing, coughing, and unable to turn the head. After the prevention of infection and inhalation injury, due to airway and lung damage, cilia function destruction, airway secretions and foreign bodies can not be discharged in time, local and systemic resistance decreased, etc., often cause airway and lung infection. Once infected, if the treatment is not timely, it can be complicated by acute respiratory failure, and become an important lesion of systemic infection, which induces sepsis.
Cause
Cause
(1) Causes of the disease
The factors that cause open neck injuries are mostly cuts and penetrating injuries. Usually it is injured by a sharp device (self-injury and his injury), and most of the wartime injuries are caused by firearms (bomb wounds and shrapnel injuries, etc.).
(two) pathogenesis
Neck cuts occur in the area of the ring, and the neck is the most. The neck injury can be divided into three areas according to the anatomical part: the I area is the sternal fossa to the ring cartilage; the II area is between the ring cartilage and the mandibular angle; the III area is the mandibular angle to the skull base.
Different lesions, pathological changes are also different, common pathological changes are:
1. Laryngeal trachea, pharyngeal esophagus continuous interruption: continuity is destroyed, there may be a laryngeal cartilage fracture displacement, and the anterior and posterior diameter of the throat becomes shorter, the glottic closure is abnormal. Laryngeal trachea, pharyngeal esophageal soft tissue edema, or submucosal hematoma. The air escaped from the laryngotracheal or pharyngeal esophageal rupture is not smoothly discharged, or the irritating cough can cause gas to directly enter the neck connective tissue space and subcutaneous tissue, resulting in subcutaneous emphysema, mediastinal emphysema and even cardiac tamponade.
2. Pleural rupture: If the rupture is not quickly blocked by clots, connective tissue or ruptured muscle fragments, air will enter the pleural cavity and affect the respiratory movement of the lungs. There is not much gas entering, breathing is limited, and breathing difficulties are not obvious or very mild. If the apical rupture of the pleura is not occluded, the air will easily enter the pleural cavity during inhalation, and the air will not escape when exhaled. The pressure in the pleural cavity will gradually increase, forming a tension pneumothorax, compressing the lung tissue and causing the mediastinum to be healthy. Side shift. At this time, the gas exchange is seriously hindered. When a large amount of bleeding occurs, it also causes a blood chest.
3. Cervical dislocation and spinal nerve injury.
Examine
an examination
Related inspection
Oral endoscopy blood routine
1. Laryngeal tracheal injury: Open injury in the midline of the neck or near the midline has the possibility of damaging the laryngotracheal tube.
(1) Outgassing and loss of sound: There are bubbles in the wound during the injury, or there is a vocal or a loss of sound. If the laryngeal cartilage fracture is displaced, the normal outline of the laryngeal is unclear, and the anteroposterior diameter of the larynx becomes short, so that vocal or vocalization can occur immediately Because the fracture pieces overlap, the vocal cords move to the outside, the glottis is incompletely closed or completely unable to close, causing a large amount of air to leak, losing enough air pressure under the glottis, and only a breathable voice can be emitted at this time.
(2) difficulty in swallowing, limited head rotation: dislocation of the sacral cartilage and glottic or glottic upper and lower hematoma also have hoarseness or loss of sound, sometimes throat lary when inhaling. Patients often complain of swallowing pain, difficulty swallowing, coughing, and unable to turn the head.
(3) Difficulty breathing: due to inhalation of blood, saliva, vomit and broken tissue pieces, or due to foreign body obstruction, laryngeal, tracheal cartilage fracture displacement, laryngeal edema, laryngeal submucosal hematoma, etc., may have difficulty breathing, sometimes Progressive.
(4) Subcutaneous emphysema and mediastinal emphysema: the neck is swollen and can be pronounced. Severe cases of subcutaneous emphysema in the neck can be extended up and down. Up to the hairline, down to the chest wall, abdominal wall, or even the entire trunk, up to the upper and lower limbs. The gas in the interstitial space of the neck can be extended to the mediastinum to form mediastinal emphysema and pneumothorax. Severe mediastinal emphysema can hinder the reflux of the vena cava blood, affecting blood circulation, and then breathing difficulties.
The innocence of the neck was innocent, and the anterior sternum disappeared in the percussion. The X-ray of the lateral sternum showed air behind the sternum.
(5) cardiac tamponade: air in the mediastinum can also enter the pericardial cavity, causing cardiac tamponade. At this time, the patient's venous pressure is increased, the heart sound is weak, the blood pressure is lowered, the pulse is slow, and the heart is also enlarged. Mediastinal emphysema, pneumothorax or cardiac tamponade can cause rapid death of the patient. It should be detected early, and the upper mediastinum should be evacuated or drained in time, and the thoracic surgery should be consulted urgently to make appropriate treatment to save the patient's life.
(6) Physical examination:
1 In the early stage of the displacement of the laryngotracheal cartilage fracture, the laryngeal cartilage is flattened or collapsed on one side, and the normal sign of the larynx disappears; the incision and larynx on the thyroid cartilage disappear during percussion; sometimes the frictional sound of the broken cartilage can be found, or can be touched Clear fracture displacement.
2 When the subcutaneous emphysema is swollen, the neck can be swollen. Anyone with subcutaneous emphysema in the neck should be alert to the presence or absence of mediastinal emphysema.
3 to determine the throat tracheal injury. If the injury is a cut, the degree of cartilage injury, the degree of rupture of the laryngotracheal tube, and the withdrawal of the tracheal stump should be known from the open wound.
The trachea can sometimes be completely disconnected and retracted upwards and downwards. When the trachea contracts downward, it presents severe dyspnea and cyanosis. Those with laryngotracheal injury may have cough during swallowing, which may be caused by food falling into the respiratory tract or by tracheoesophageal fistula.
2. pharyngeal tube injury:
(1) hematemesis and difficulty swallowing: vomiting blood, hematemesis, swallowing pain and difficulty swallowing when the esophagus ruptures.
(2) Leakage, air leakage: Saliva, food or air can leak from the pharyngeal esophagus when swallowing. There may also be subcutaneous emphysema, pneumothorax and mediastinal emphysema in the neck.
(3) Infection: The pharyngeal esophageal injury is easily complicated by deep neck or mediastinal infection.
(4) Physical examination: clear the condition of the pharyngeal esophagus. When the visual examination cannot confirm whether the pharyngeal esophagus is ruptured, the soft saline wound of the neck can be filled with sterile physiological saline, and the patient can swallow the mouth. There is a bubble in the neck wound, which means that the pharyngeal esophagus is broken. You can also use the purple or methylene blue thin solution to swallow the patient. If the neck wound has a dye color, it means that the pharyngeal esophagus is broken. Fiberoptic esophagoscopy can directly observe the pharyngeal esophageal injury.
In the cutting injury, it is easy to find a broken mouth, sometimes the esophagus is completely cut, and the cervical vertebra can be seen deep in the incision. However, the cerebral esophageal rupture caused by the neck piercing injury is sometimes easily overlooked, and even a neck incision exploration is required to be discovered.
3. Vascular damage.
4. Thoracic catheter injury: The thoracic duct starts from the chyle pool in front of the second lumbar vertebral body. It is formed by the combination of the left and right lumbar trunks and the intestines. It is inserted up into the chest cavity and is placed in front of the spine between the azygous vein and the thoracic aorta. Upward, gradually tilting left to the left neck, and into the left venous angle. Therefore, when the thoracic duct is ruptured above the fifth thoracic vertebra, the left chylothorax occurs, and when the fifth thoracic vertebra is ruptured, the right chylothorax appears.
When the left neck is damaged, it is easy to have chest tube injury. At this time, the wound may have chyle outflow, or the chyle solution may be taken out when the pleural puncture is diagnosed, or the thoracic duct injury is found only when the neck is opened for exploration. The amount of chyle released by thoracic duct injury can reach as much as 1~3L within 24h, containing high fat and high protein, which often causes severe dehydration and malnutrition in patients. A large accumulation of chyle in the pleural cavity can cause severe breathing difficulties.
5. Thyroid damage: It is easy to detect in patients with cut wounds. The gland may be cut or cut a part; but it can only be found when the injury is often found in the neck. The thyroid is rich in blood vessels, and there is more blood loss after injury, and it is easy to form a hematoma and even cause suffocation.
6. Salivary gland damage: can damage the submandibular gland or parotid gland. There is saliva in the wound, but no foam.
7. Pleural apex injury: mainly manifested as patency of the respiratory tract, but there is difficulty breathing. Check to find a pneumothorax or blood pneumothorax. The lungs are partially restricted in breathing and the breathing difficulties are not obvious. It is only necessary to observe them closely and no special treatment is required. If there is a lot of air entering the pleural cavity, it is very difficult to breathe, and the air or blood in the pleural cavity should be taken out. When the tension pneumothorax is involved with mediastinal shift, the patient's breathing is extremely difficult, the hair is weak, and the condition is very critical. The blood must be drawn immediately, and then closed chest drainage is performed to save the patient's life.
8. Cervical vertebrae injury: mild can be asymptomatic, or complain of mild neck pain, head and neck remain in a fixed position, movement is impeded, cervical vertebra may have tenderness, cramps or deformities. Patients with severe cervical spine injury may have high paraplegia (four limb paralysis) or sensory disturbance in the spinal nerve distribution area below the injury.
For patients suspected of cervical spine injury, be careful to move. Should be fixed when carrying the head position, do not over-head, so as not to increase the damage of the spinal cord, resulting in sudden high paraplegia or death.
9. Cutbone or clavicle fracture: local swelling, congestion or deformity, etc., there is tenderness, bone friction or fracture overlap. Severe pain during swallowing, increased pain when the tongue is stretched, is a feature of the hyoid bone fracture.
Diagnosis
Differential diagnosis
Differential diagnosis of damage above the glottis:
Injury above tracheal carina: Moderate inhalation injury refers to more than tracheal carina, including damage to the throat and trachea.
