Central Annals of Otolaryngology and Rhinology
Case Report
Laryngeal Injury in Neonate
and Temporary Extracorporeal
Membrane Oxygenation
1 2
Nanna Browaldh *, Yinghua Li , Lars Falk , Andreas Ekborn , 3
Björn Westrup2, and Georgios Papatziamos1
1
Department of Otorhinolaryngology, Karolinska University Hospital, Sweden
2
Department of Neonatology, Astrid Lindgren´s Children´s Hospital, Karolinska
University Hospital, Sweden
3
ECMO Unit, Karolinska University Hospital, Sweden
Abstract
Laryngeal or tracheal injury in neonates is a severe and life-threatening condition.
Early diagnosis of airway damage is crucial. In the present case, a laryngeal rupture
occurred during a difficult vaginal delivery. In this case report, we describe the
advantages of ECMO treatment in connection with acute airway surgery and also the
need for multidisciplinary management of the troublesome pediatric airway.
ABBREVIATIONS
ECMO: Extracorporeal Membrane Oxygenation; CPR:
Cardiopulmonary Resuscitation
INTRODUCTION
Idiopathic laryngeal injury in neonates is rare, but potentially
fatal. Difficult delivery by instrumentation increases the risk
due to cervical traction; moreover, tracheal lacerations have
also been reported after endotracheal intubation. The condition
usually presents with respiratory distress associated with
subcutaneous emphysema and pneumomediastinum [1]. The
injury can be treated conservatively, but some patients require
surgical management [2]. This paper describes a case with a
life-threatening laryngeal injury in a neonate, managed with
surgical repair and treatment with extracorporeal membrane
oxygenation (ECMO).
CASE REPORT
A 33-year-old healthy primipara with a normal pregnancy
was admitted at 41 wks+0 for delivery. The delivery progressed
slowly and a vacuum extraction was performed. Subsequently,
there was an imminent shoulder dystocia, which was resolved
within one minute. The Apgar score was 3, 7, and 9 at 1, 5, and
10 minutes, respectively. Umbilical blood gases were normal,
birth weight 5000 g, birth length 55 cm, and head circumference
38 cm. Due to an absence of spontaneous breathing, the infant
was briefly bag-ventilated but recovered promptly with normal
respiration at 2 min. In order to further stabilization, a ventilation
mask with continued positive airway pressure was used up to 13
Cite this article: Browaldh N, Li Y, Falk L, Ekborn A, Westrup B, et al. (2016) Laryngeal Injury in Neonate and Temporary Extracorporeal Membrane Oxygen-
ation. Ann Otolaryngol Rhinol 3(12): 1145.
*Corresponding author
Nanna Browaldh, Department of Otorhinolaryngology,
Head and Neck Surgery, Karolinska University Hospital,
Huddinge, SE-141 86 Stockholm, Sweden, Tel: 46 (0) 8
585 800 00; Email:
Submitted: 01 November 2016
Accepted: 21 November 2016
Published: 22 November 2016
ISSN: 2379-948X
1 Copyright
© 2016 Browaldh et al.
OPEN ACCESS
Keywords
• Laryngeal injury
• Subglottic rupture
• Delivery injury
• Instrumental delivery
• Neonate
• Extracorporeal membrane oxygenation
• Subcutaneous emphysema
minutes of age. At delivery the large head and the swollen face
and neck region were already noticed, but were considered to be
due to the infant’s apparent large-for-length constitution.
At 30 minutes of age the baby suddenly developed
respiratory distress, cyanosis, and bradycardia, and was difficult
to ventilate manually. The child received cardiopulmonary
resuscitation (CPR) and was intubated at approximately 40
minutes and recovered. Considering the prompt recovery by
adequate ventilation in both incidents, the cause was believed
to be difficulties in providing clear airways due to the swollen
face, and the infant was extubated. However, immediately after
extubation the child could not maintain a patent airway. At
reintubation, using indirect laryngoscope HEINE, Herrshing,
Germany, there seemed to be a resistance just below the vocal
cords. The infant stabilized promptly. Since the swelling of
the neck had progressed, the infant was transported to the
neonatal intensive care level III. On arrival, 3.5 hours after
birth, the baby suddenly became bradycardic and cyanotic and
did not respond to positive pressure ventilation. Under the
suspicion of extubation, reintubation was performed without any
difficulties, but with little response in chest movement. An X-ray
of the thorax confirmed cervical subcutaneous air and bilateral
pneumothoraces, (Figure 1). Even though the large bilateral
pneumothoraces were drained, and conventional ventilation was
tried, the child did not improve. The blood gas showed a pH of 6.5,
pCO2 of 18, and a BE of -28. The saturation was between 50–70%
for approximately 40 min during this third event.
Due to the massive air leakage from the airways, ECMO
treatment was recommended. FiO2 was maintained at 100% until
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At 10 weeks of age, the follow-up at the otorhinolaryngology

(ORL) department showed that the patient´s voice was a bit weak
and leaking. A flexible nasofiber endoscopy showed scar tissue
in the anterior commissure, but with retained abduction and
adduction ability of the vocal cords. Subglottic thickening was
also seen. The patient was breastfed without difficulties.
At the 10-month follow-up at the ORL department, the
infant’s voice had improved. There was no stridor at rest, though
still a subglottic airway narrowing that remained at the two-year
follow-up.
Currently, the patient is two years old and has been diagnosed
with mild cerebral palsy with increased muscle tonus and delayed
motor skills. The social abilities are developing quite well.
Figure 1 X-ray of the thorax.

full ECMO flow was reached. The patient was cannulated with
a veno-arterial approach by direct exposure of the carotic and
jugular vessels with a 10 F cannula and a 14 F cannula respectively.
ECMO-flow was maintained at 500 ml/min. Anticoagulation was
initiated at the time of cannulation with a bolus dose of 50 IU/kg
of heparin after which a heparin infusion was started to achieve
an Activated Partial Thromboplastin Time of 70 – 80 seconds. At
the same time as ECMO was initiated, the otolaryngologist was
consulted and a laryngeal injury was confirmed by removing
the endotracheal tube and performing a laryngoscopy with an
intubation laryngoscope together with a rigid nasal endoscope
and a battery light source. A venoarterial approach was chosen
due to extreme bradycardia, and the child had also had CPR
Figure 2 Tracheal rupture as seen at first endoscopy. Traumatic
performed in the minute prior to the start of ECMO. The child was opening of the cricothyroid membrane with marginal involvement of
then transferred to the operating room. the anterior commissure.
During ECMO treatment, the otolaryngologists performed a
conventional direct laryngoscopy and rigid bronchoscopy that
revealed a laceration in the cricothyroid membrane and also that
the right vocal cord was detached from the anterior commissure.
Through a transverse collar incision and a laryngofissure, surgical
repair was made see Figures (2-4). Under visual monitoring and
with a suction catheter as a guide wire, an endotracheal tube
was inserted from the nose. Thereafter, the laryngeal cartilage
was sutured along the laryngofissure line. The cricothyroid
membrane laceration was closed and the collar muscles adapted.
To minimize the risk of air leakage [3], the patient was not
ventilated during the next four hours. Hypothermia treatment
was induced for 48 hours due to the asphyxia. After five days of
ECMO treatment, the patient was decannulated and transferred to
the neonatal intensive care unit. The child developed convulsions,
but with good response to anticonvulsive treatment, and a
renewed electroencephalography indicated recovery. Magnetic
resonance imaging at 6 days of age revealed extracerebral
bleeding and extracranial and subdural hematomas, as well as Figure 3 External view of the traumatic opening of the cricothyroid
minor intracerebral bleeding, which was considered to be caused membrane immediately before suturing. A transverse collar incision
by asphyxia, though complications due to ECMO treatment could was made at the level of the cricoid. Once the anterior tracheal wall
not be excluded. was reached, the laryngeal laceration was seen, through which the
vocal cords could be observed from underneath. A laryngofissure was
At day 11, the patient underwent a new laryngoscopy and performed by dividing the thyroid cartilage in the midline, with the
rigid bronchoscopy, which showed mobile vocal cords and left vocal cord still attached to the anterior commissure. The right
normal healing of the anastomosis. Extubation was performed, vocal cord was attached together with the mucosa to reshape the
and the baby was referred to a neonatal care unit. anterior commissure, which was also on the right side.

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DISCUSSION
The laryngeal injury in the present case was a very severe
condition. The otolaryngologist was consulted late in the process
when ECMO was already initiated. ECMO is not the first treatment
of choice, but was initiated as the child had a life-threatening
uncontrolled condition. It then served as a way to achieve a safe
and unrushed repair of the neonate airway.
Tracheal injury in neonates is extremely rare and has an
associated mortality of 75% [4]. Kacmarynski et al. reported four
cases with spontaneous tracheal and subglottic tears in neonates
[5]. There are also case reports that describe the rupture
as a complication of endotracheal intubation [4]. Excessive
hyperextension of the neck places the most strain on the anterior
portion, and may cause overstretching which surpasses the
elasticity of the tissues and results in a rupture [6]. The carina is
fixed, and a common area of tracheal injury is within 2.5 cm of the
carina, which is the least mobile region.
It has been theorized that there must be a weak area
predisposed to rupture in the trachea or larynx of these patients,
compared with the many deliveries using traction that do not
result in airway injury [6,7]. Further, laryngotracheal damage
from birth trauma may be aggravated by blind endotracheal
intubation [5].
The diagnosis can be confirmed by flexible nasofiberendoscopy
or direct laryngoscopy. Conservative treatment is mainly used
in small laryngotracheal tears, and a surgical approach is used
when the damage is considered to be more extensive [8].
The reason for the tracheal injury in this child is unkown.
The first symptoms of respiratory distress usually appear within
30 minutes. Early recognition and treatment is important. As
in this case, important signs of laryngotracheal damage are: [1]
risk factors for a macrosomic baby, particularly in mothers with
small pelvic dimensions, [2] instrumental delivery and shoulder
dystocia [3], extended time of traction on the neck and posterior
traction on the head that adds bending stress to the axial stress
on the anterior portion of the airway [4], complicated intubation
with several attempts, and [5] signs of subcutaneous emphysema,
pneumothorax, and pneumomediastinum.
Figure 4 Vocal cords 11 days postoperatively at extubation. Slight
edema of vocal cords, but good definition of anterior commissure
similar to what is normally found after an intubation of this duration.
Ann Otolaryngol Rhinol 3(12): 1145 (2016)
Browaldh et al. (2016)
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In cases with pediatric airway anomalies, the advantage of
cooperation between many different specialities is clear [9]. The
present case underscores the importance of early consultation
with an otorhinolaryngologist for endoscopic investigation.
Moreover, the possibility of controlled intubation may limit the
damage.
Further, the current case is an example of when ECMO can
be used outside the conventional indications. Compared to
cardiopulmonary bypass, ECMO requires less anticoagulation
therapy and it also avoids sternotomy. The crucial role of ECMO
in patients where ventilation is impossible due to the location
and severity of the laryngeal-tracheobronchial injury has been
described earlier [10,11] Kunisaki et al., describe the advantages
of ECMO in neonates, all with tracheal anomalies and where
ECMO served as a bridge to lifesaving tracheal reconstruction
immediately after birth [12]. Another advantage of ECMO is the
possibility of reducing airway pressure and decreasing ventilator
pressure [13,14].
There are several causes that explain the need for ECMO
in the present case. Firstly, there is the need to save the
patient´s life in a critical situation. Secondly, the rupture of the
airway can lead to life threatening tension pneumothorax and
pneumomediastinum, especially when the patient receives
positive pressure ventilation, which can be prevented by
ECMO. Thirdly, the need for emergency tracheostomy may be
avoided. A tracheostomy might worsen the chances of surgical
repair, depending on its placement relative to the location of
the injury. Fourthly, after surgical repair it is desirable to have
low airway pressures, which may impair the tidal volumes and
cause hypoxia. ECMO therapy enables not only reduction of the
mean airway pressure, but suspension of ventilation. This will
facilitate the tissue-healing process. The disadvantages of ECMO
are mainly due to the anticoagulation treatment, which increases
the risk of bleeding [15].
The absence of chest movements during ventilation indicates
that the tip of the tube was probably dislodged into the ruptured
cricothyroid membrane. The repeated intubations might have
worsened this situation due to the natural tendency the tip has
to move anteriorly.
Retrospectively, other treatment options might have been
available. However, in this case it was extremely difficult to
visualize the entrance to the larynx, and the diagnosis of ruptured
airway was made late with an endoscope. If the child had been
intubated past the injured area with a cuffed tube, the damaged
area would have been relieved and the air leakage would have
ceased, likely making the ECMO treatment unnecessary.
CONCLUSION
Pediatric airway injuries require a multidisciplinary approach.
In hindsight, an early consultation of an otolaryngologist may
have avoided ECMO treatment in this case. Nevertheless,
the possibility of ECMO in cases where a secure airway is not
achieved can be crucial until a surgical and definitive treatment
has been completed.
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Cite this article

Browaldh N, Li Y, Falk L, Ekborn A, Westrup B, et al. (2016) Laryngeal Injury in Neonate and Temporary Extracorporeal Membrane Oxygenation. Ann Otolaryngol
Rhinol 3(12): 1145.

Ann Otolaryngol Rhinol 3(12): 1145 (2016)

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