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All exposed cartilage should be covered either primarily or with local

mucosal advancement flaps. Displaced or subluxed arytenoid cartilages

should also be carefully repositioned.

C. Endolaryngeal Edema

Patients with significant laryngeal edema, particularly if it appears to be

progressing, should undergo awake tracheotomy to prevent airway loss.

After tracheotomy, the patient with significant laryngeal edema should

be evaluated with direct laryngoscopy and esophagoscopy to uncover

subtle injuries that may be masked by the edema and missed in initial

flexible fiberoptic laryngoscopy. Adjunctive measures, such as head-of-

bed elevation, corticosteroids, anti-reflux medications, and humidifica-

tion should be strongly considered.

D. Endolaryngeal Hematomas

Patients with endolaryngeal hematomas should be admitted to the

hospital for close airway observation, as even small hematomas may

progress. Small, nonprogressing hematomas with intact mucosal

coverage are likely to resolve spontaneously without significant

sequelae. Adjunctive therapies, such as steroids, anti-reflux medication,

humidification, and head-of-bed elevation are helpful. Large or expand-

ing hematomas may lead to airway obstruction and necessitate

placement of a tracheotomy.

E. Recurrent Laryngeal Nerve Injury

Recurrent laryngeal nerve injury may occur after blunt or penetrating

laryngeal injury. Recurrent laryngeal nerve injury after blunt laryngeal

trauma may be due to either stretching of the nerve or nerve compres-

sion near the cricoarytenoid joint.

If a vocal cord is persistently immobile after blunt trauma, the vocal

fold should be observed for as long as one year to await the possible

spontaneous regeneration of recurrent laryngeal nerve function.

If a recurrent laryngeal nerve is severed, primary repair should be

attempted. While vocal fold mobility will not be regained after even a

successful repair due to the mixture of abductor and adductor fibers

in the nerve, neural regeneration may prevent muscle atrophy,

resulting in improved vocal cord tone and vocal strength in the long

term.

If primary re-anastamosis of the severed nerve is not possible, the

ansa hypoglossi may be redirected and sutured to the distal stump of

the recurrent laryngeal nerve to improve vocal cord muscle tone.