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Laryngology seminar Hyoid bone fracture R3 康焜泰 2007/7/11 Embryology of hyoid bone Second pharyngeal arch (hyoid arch) : Æ Reichert’s cartilage Æ lesser horn of the hyoid bone + upper portion of body Third pharyngeal arch: Æ greater horn + lower portion of body Anatomy of hyoid bone Derived from Greek word hyoeides meaning “shaped like the letter upsilon” (Os hyoideum; ligual bone) U-shaped or horseshoe shaped bone in the anterior neck C3 : angle between thyroid cartilage and mandible The only bone not articulated to any other bone Suspend from tip of the styloid process of temporal bone by stylohoid ligament Consist of 5 segments 1. body 2. greater cornua 3. lesser cornua • Body : (corpus oss. hyoidei) • Anterior surface : geniohyoideus(most) hyoglossus notch(lateral) mylohyoideus sternohyoideus omohyoideus • superior surface : genioglossus • Lateral border : connect greater cornu by synchondroses or bony union • The Greater Cornua(cornua majora) • Protect backward from lateral border of body • Upper surface : hyoglossus and constrictor pharyngis medius • Near junction : digastricus and stylohyoideus • Medial border : • hyothyroid membrane The Lesser Cornua(cornua minora) Two small, conical eminences, attach their base to junction body: fibrous tissue Greater cornua: diarthodial joint Apex : attach to stylohyoid ligament Ossified : 6 centers Body (2) : end of fetal life Greater cornua (1) : end of fetal life Lesser cornua (1) : 1st or 2nd year after birth Function : production of human speech Wider range of tongue and laryngeal movement Hyoid biodynamic system Æ regulate mastication, deglutition and phonation Suprahyoid muscle stylohyoid Styloid processÆ Body of hyoid Geniohyoid Inf. mental spine of mandible Æbody Mylohyoid Mylohyoid lineÆ body of hyoid Digastric Ant belly Digastric fossa of mandible Æ body and greater horn Post belly Mastoid notch of temporal bone Æ body and greater horn Elevate and retract hyoid boneÆ elongation mouth floor VII Pull the hyoid b. C1 via XII Anteriorly and superiorly Æ shorten mouth floor Elevate floor of mouth, tongue and hyoid during speech and swallowing V Raise and stable the hyoid V VII Infrahyoid muscle (Strap muscle) Manubrium and med Sternohyoid aspect of clavicleÆ Body of hyoid Omohyoid sternothyroid Scapula near the suprascapular notchÆinferior aspect of hyoid Post aspect of manubriumÆ thyroid cartilage thyrohyoid Oblique line of thyroid cartilage Æ inferior aspect of body and greater horn Depress hyoid bone following elevation during swallowing C1-C3 Depress and retract hyoid bone C1-C3 Depress the larynx and thyroid C1-C3 Ansa cervicalis Ansa cervicalis Ansa cervicalis Depress the hyoid C1(XIIl) and elevate the larynx Classification of hyoid bone fracture-1 1. inward compression fracture with outside periosteal tears 2. anterior-posterior compression fracture with inside periosteal tears 3. avulsion fracture Weintraub CM. Fracture of hyoid bone. Med Leg J 1961 1. inward compression fracture with outside periosteal tears manual strangulation, squeezing force pushing two cornua together 2. anterior-posterior compression fracture with inside periosteal tears Hanging or other antpost force Hyoid bone against C2 The causes of hyoid bone changed In the past : strangulations and hanging Æ Æ Æ road traffic accident recently Hyoid bone fracture in strangulation 1. Fractured in 1/3 all homicides by strangulation (14% thyroid and cricoid cartilage fracture) 2. Detect hyoid bone fracture Æ strangulation ? 3. Lack hyoid bone fracture Æ not exclude strangulation Fractured and unfractured hyoids from victims of strangulation 1.age , magnitude of force, nature, instrument (hand or ligature) 2. Fractured hyoid : older victims (39+/14 years) vs unfractured hyoid (30+/-10 years) Æ degree of ossification and fusion of synchondroses 3. Fractured hyoid: longer in ant-post plane, more steeply sloping Incidence : 0.002 % of all fractures Age : 15-55, most under 35 y/o Male (28 cases) > female (3 cases) Rare, because 1. hyoid bone well protect by mandible 2. mobility in all directions Rarer in pediatric Æ Hyoid bone not completely ossified Æ flexibility and decreased rigidity Causes and mechanisms: 1. Road traffic accidents (14 cases) 2. Gun shot and knife (3 cases) 3. basketball, ice hockey (3 cases) 4. falling assault (3 cases) 5. iatragenic, after C spine surgery or resuscitation (2 cases) Associated fractures Isolated hyoid bone fracture : 16 cases With mandibular fractures : 5 cases With facial bone fractures : 4 cases C spine injury : 3 cases Thyroid fracture, facial laceration, external carotid artery pseudoaneurysm, cricoid cartilage fractures Clinical manifestations Ecchymosis of the neck, edema, crepitus or stridor Ant. Neck pain Pain with nose blowing, swallowing Dysphonia Cough (persistent, painful) Gagging Decrease range of motion Dysphagia Dyspnea Respiratory distress hemoptysis Diagnosis Difficult Made with strong suspicious (history+physical examination) Radiographic diagnosis: Radiograph (Cervical lateral view) Computed tomography Laryngoscopy Surgical inspection (penetrating trauma) Neck lateral view, soft tissue density demonstrating hyoid bone fracture • Radiolucent line, interruption of cortical continuity, displacement of the fragment Neck lateral view, soft tissue density demonstrating hyoid bone fracture CT demonstrating hyoid bone fracture Complications Early complications Subcutaneous emphysema, dyspnea, pharyngeal tears, thyroid cartilage injury Late complications Dysphagia, stridor, pseudoaneurysm, of external carotid artery Treatment Close observation for minimally 48-72 hours : dysphagia, dysphonia and dyspnea may develop quickly Depend on severity, case by case Laryngoscopic examination unless contraindicated Associated injuries Æ taken into consideration Asymptomatic : close observation Symptomatic - mild to severe pain: analgesics limitation of head movement keep soft diet - pharyngeal laceration suture deep wound remove fragment of hyoid bone fracture fixation of fractured fragments by wiring dysphagiaÆ NG feeding - external laceration of the neck primary wound care excision of fragment of hyoid bone - respiratory distress endotracheal intubation tracheostomy surgical exposure and drainage of retropharyngeal space Prognosis Good except rare complications (dysphagia, crepitus by neck flexion, pseudoaneurysm of the external carotid artery) Conclusion 1. fracture of hyoid bone resulting from trauma other than strangulation is rare 2.most : traffic accident 3.Diagnosis: history, clinical manifestation, laryngoscopy Radiography 4. 48-72 hours observation 5. prognosis: good Reference 1. Levine E, Taub PJ. Hyoid bone fractures. Mt Sinai J Med. 2006 Nov;73(7):1015-8. 2. Boots RJ, Joyce C, Mullany DV, Anstey C, Blackwell N, Garrett PM, Gillis S, Alexander N.Near-hanging as presenting to hospitals in Queensland: recommendations for practiceAnaesth Intensive Care. 2006 Dec;34(6):736-45. 3. Sethi A, Sareen D, Chopra S, Mrig S, Agarwal AK.Pharyngeal perforation with deep neck abscess secondary to isolated hyoid bone fracture.J Laryngol Otol. 2005 Dec;119(12):1007-9. 4. Dalati T.Isolated hyoid bone fracture. Review of an unusual entity.Int J Oral Maxillofac Surg. 2005 Jun;34(4):449-52. Review 5. Bux R, Padosch SA, Ramsthaler F, Schmidt PH.Laryngohyoid fractures after agonal falls: not always a certain sign of strangulation.Forensic Sci Int. 2006 Jan 27;156(2-3):219-22. Epub 2005 Jul 15. Am J Forensic Med Pathol. 2003 Jun;24(2):179-82. Reference 6.Chowdhury R, Crocco AG, El-Hakim H.An isolated hyoid fracture secondary to sport injury. A case report and review of literature.Int J Pediatr Otorhinolaryngol. 2005 Mar;69(3):411-4. Epub 2004 Dec 8. Review 7. Ladenheim JC.Hyoid bone fracture from a gunshot wound.J Trauma. 2004 Jul;57(1):199 8. Gross M, Eliashar R.Hyoid bone fracture Ann Otol Rhinol Laryngol. 2004 Apr;113(4):338-9. 9. Campbell AS, Butler AP, Grandas OH. A case of external carotid artery pseudoaneurysm from hyoid bone fracture.Am Surg. 2003 Jun;69(6):534-5. 10.Nikolic S, Micic J, Atanasijevic T, Djokic V, Djonic D.Analysis of neck injuries in hanging. Reference 11.Doring A, Kahle M.[Isolated hyoid bone fracture]Unfallchirurg. 2000 Nov;103(11):996-8. German 12.Anthony R, Martin-Hirsch D, England J.Dysphagia secondary to iatrogenic hyoid bone fracture.Br J Neurosurg. 2000 Aug;14(4):3378. 13.Miller KW, Walker PL, O'Halloran RL.Age and sex-related variation in hyoid bone morphology. J Forensic Sci. 1998 Nov;43(6):1138-43. 14.Pollanen MS, Chiasson DA. Fracture of the hyoid bone in strangulation: comparison of fractured and unfractured hyoids from victims of strangulation.J Forensic Sci. 1996 Jan;41(1):110-3. The end