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Zewnętrzny uraz krtani to bezpośrednie zagrożenie życia. Jak przebiega ocena urazu i leczenie?

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Do zewnętrznego urazu krtani najczęściej dochodzi w wyniku uderzenia z dużą siłą, np. na skutek wypadku komunikacyjnego czy pobicia, a także działania ostrego narzędzia lub broni palnej. Uszkodzenie krtani może grozić życiu pacjenta, dlatego konieczna jest natychmiastowa interwencja medyczna.

Krtań ze względu na położenie między mostkiem a żuchwą jest stosunkowo dobrze chroniona przed urazem zewnętrznym. Z drugiej strony jest jednak umiejscowiona centralnie na szyi i posiada delikatną budowę, co może zwiększać podatność na uszkodzenia.

Urazy zewnętrzne krtani dzieli się na urazy tępe, które najczęściej są konsekwencją wypadków komunikacyjnych, zawodów sportowych, duszenia czy prób samobójczych. Urazy występujące na skutek postrzału lub pchnięcia nożem określa się mianem urazów penetrujących krtani.

Uraz zewnętrzny krtani – objawy

Rodzaj objawu urazu krtani uzależniony jest od czynnika wywołującego uraz. Najczęściej obserwowane objawy to:

  • duszność,
  • ból,
  • zaburzenia głosu,
  • uporczywy kaszel,
  • chrypka,
  • krwioplucie,
  • odma podskórna szyi,
  • ból podczas przełykania pokarmów (odynofagia) lub zaburzenia połykania (dysfagia),
  • ślinotok,
  • obrzęk tkanek szyi,
  • przemieszczenie krtani,
  • wylewy krwawe na przedniej powierzchni szyi,
  • stridor wdechowy (świst, szmer krtaniowy).

Urazom krtani często towarzyszą uszkodzenia gardła, przełyku, naczyń szyi, nerwów czy szyjnego odcinka kręgosłupa. Niebezpiecznymi następstwami urazu krtani są odruchowy skurcz krtani, wstrząs kardiogenny, bradykardia, spadek ciśnienia tętniczego, zatrzymanie krążenia. Z kolei podrażnienie nerwów błędnych i ich gałęzi może prowadzić do spadku ciśnienia tętniczego, zwolnienia rytmu serca, zwężenia naczyń wieńcowych, arytmii, nagłego zatrzymania oddechu, skurczu krtani.

Ocena rozległości urazu krtani

W postępowaniu klinicznym, w przypadku wystąpienia zewnętrznego uraz krtani, podstawowe znaczenie ma wywiad dotyczący okoliczności wystąpienia urazu. Specjalista wykonuje również badanie palpacyjne szyi, laryngoskopię pośrednią i bezpośrednią, fiberoskopię, badania radiologiczne, np. RTG klatki piersiowej, tomografię komputerową, rezonans magnetyczny. Konieczna jest również ocena narządów sąsiadujących z krtanią, które mogły ulec uszkodzeniu.

Rodzaj urazu zewnętrznego krtani oceniany jest za pomocą 5-punktowej skali Schaefera:

I. niewielki krwiak wewnątrz krtani, bez widocznego złamania; postępowanie: ścisła obserwacja, kontrola fiberoskopowa krtani, nawilżanie powietrza, w wybranych przypadkach tomografia komputerowa;

II. obrzęk, krwiak, niewielki uraz błony śluzowej krtani, bez złamania; postępowanie: tracheotomia, laryngoskopia, bronchoskopia, ezofagoskopia, w wybranych przypadkach tomografia komputerowa;

III. masywny obrzęk, rozdarcie błony śluzowej, złamanie chrząstek, unieruchomienie fałdów głosowych; postępowanie: tracheostomia, endoskopia, operacja metodą otwartą;

IV. grupa III + ponad dwie szczeliny złamania lub masywny uraz krtani; postępowanie: jw.;

V. całkowite oderwanie krtani i tchawicy; postępowanie: bronchoskopia, tracheotomia, operacja metodą otwartą.

Postępowanie w przypadku uszkodzenia krtani

W przypadkach urazów krtani zawsze wymagana jest hospitalizacja pacjenta, ze względu na bezpośrednie zagrożenie życia. Najpilniejszym postępowaniem jest udrożnienie dróg oddechowych, a także opanowanie ewentualnego krwawienia, ustabilizowanie odcinka szyjnego kręgosłupa (gdy istnieje podejrzenie jego uszkodzenia), zapobieganie powstania obrzęku krtani. W przypadku rozległych urazów i narastania duszności nie zawsze możliwa jest intubacja dotchawicza, gdyż mogłaby ona powiększyć uraz. Dlatego w takich okolicznościach wykonuje się tracheotomię ze znieczuleniem miejscowym, zabieg polegający na otwarciu przedniej ściany tchawicy i wprowadzeniu rurki do dróg oddechowych.

Leczenie urazu krtani uzależnione jest od rozległości uszkodzenia. Urazy z grupy I i II klasyfikacji Schaefera mogą być leczone farmakologicznie. W praktyce klinicznej pacjentom podaje się glikokortykosteroidy i antybiotyki. W niektórych sytuacjach w urazach z grupy II, przy narastaniu duszności, wykonuje się tracheostomię. Leczenie chirurgiczne urazów grupy III i IV polega na wykonaniu tracheostomii z jednoczesną eksploracją szyi i krtani, a także z nastawieniem złamanych i przemieszczonych chrząstek, pokryciem ubytków błony śluzowej przemieszczonymi płatami z sąsiedztwa. W niektórych przypadkach stosuje się stenty wewnątrzkrtaniowe w celu stabilizacji rusztowania chrzęstnego i uniknięcia zrostów. Jak najszybsze wykonanie rekonstrukcji krtani zapobiega trwałym zniekształceniom. W przypadku całkowitego oderwania krtani od tachawicy, zalecana jest operacja, która polega na zespoleniu „koniec do końca”.

Źródła: mp.pl, G. Janczewski, „Otolaryngologia praktyczna. Podręcznik dla studentów i lekarzy”, tom 2, 2005, str. 127-129

 

Przeczytaj także: Najczęstsze powikłania po tracheostomii

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