What is the management for closed traumatic subluxation of laryngeal cartilage?

Management of Closed Traumatic Subluxation of Laryngeal Cartilage

Immediate management of closed traumatic subluxation of laryngeal cartilage requires securing the airway, administering intravenous dexamethasone, and arranging for ENT consultation for potential closed reduction. 1

Initial Assessment and Airway Management

• Position the patient upright to reduce airway swelling and administer high-flow humidified oxygen 1
• Assess for signs of airway compromise including stridor, difficulty breathing, arterial oxygen desaturation, and tachypnea 1
• Perform laryngoscopy to evaluate the extent of injury and confirm the diagnosis of arytenoid subluxation 2
• Have equipment for emergency intubation readily available, as laryngeal trauma may progress to complete airway obstruction 3
• Use waveform capnography for continuous monitoring if intubation is required 3

Medical Management

• Administer intravenous dexamethasone (0.15-1.0 mg/kg, maximum 8-25 mg) to reduce laryngeal edema 1
• Continue dexamethasone with repeated doses every 6 hours to decrease stridor and reintubation risk 1
• Consider epinephrine nebulization for acute stridor as an adjunctive therapy 1
• Keep the patient nil by mouth as laryngeal competence may be impaired 3
• Monitor closely for signs of mediastinitis (severe sore throat, deep cervical pain, chest pain, dysphagia) which can occur after laryngeal trauma 3

Definitive Management

• Arrange urgent ENT consultation for evaluation and potential closed reduction 1
• For arytenoid subluxation, closed reduction with injection of corticosteroid suspension into the joint is recommended 4
• Early intervention yields better outcomes; delayed diagnosis and treatment may result in limited success 2
• In some cases, particularly those with minimal displacement, conservative management may be appropriate with spontaneous relocation as edema and hemarthrosis resolve 5
• Speech therapy may be beneficial as an adjunctive treatment option 2

Diagnostic Confirmation

• Flexible laryngoscopy alone is inadequate for definitive diagnosis 2
• Additional diagnostic modalities recommended include:
  • Helical computed tomography to evaluate cartilage position 2
  • Videostroboscopy to assess vocal cord function 2
  • Laryngeal electromyography to differentiate from vocal fold paralysis 2

Management Based on Severity

• For mild cases with stable airway: conservative management with steroids and close monitoring 5
• For moderate cases: closed reduction under direct visualization 4
• For severe cases with airway compromise: secure the airway first (intubation or surgical airway if needed), then address the subluxation 3

Prognosis

• Prognosis is generally good for isolated arytenoid subluxation without additional cartilaginous damage 6
• Outcomes are worse if the arytenoid cartilage is also dislocated rather than just subluxed 6
• The main long-term symptom is hoarseness, which may persist if not properly treated 4
• Early intervention typically results in better voice outcomes 2

Follow-up Care

• Continue monitoring for at least 24-48 hours after initial management to ensure airway stability 3
• Arrange follow-up laryngoscopy to assess healing and position of the arytenoid 2
• Consider speech therapy for persistent dysphonia 2
• Patient education about symptoms of worsening airway obstruction or mediastinitis that would require immediate medical attention 3