Management of acute blunt and penetrating external laryngeal trauma

External laryngotracheal trauma: a case series and an algorithmic management strategy

OBJECTIVES

External laryngotracheal trauma (ELT), blunt or penetrating, is a rare but potentially life-threatening injury. Immediate care in the emergency department can be challenging because it requires managing a potentially unstable airway and may have associated vascular injuries with massive bleeding. Here, we look at the details of injury, treatment measures, and outcomes in patients following ELT.

METHODS

We retrospectively analyzed 22 patients treated at our center for ELT from January 2005 up to December 2021 with varying grades of injury. We looked at their status at presentation, management strategy and functional status.

RESULTS

In our report, we include 18 men and 4 women having varying Schaefer injury grades. Eight patients had tracheostomy at presentation and eight had vocal fold immobility. Two patients were treated endoscopically, 12 had open surgery and 8 received no treatment. Of the patients undergoing open surgery, thyroid cartilage fracture was seen in 9 patients, thyroid plus cricoid fracture and cricotracheal separation were seen in 3 patients each. All patients were safely decannulated and spontaneous recovery of vocal cord palsy was seen in some patients.

CONCLUSION

The success of managing ELT relies on fast decision-making, correct patient evaluation, securing the airway and maintaining the hemodynamic stability. Early surgical intervention must be aimed at optimally treating the larygotracheal injuries to prevent long-term disastrous consequences.

A Novel Concept for Surgical Management of a Traumatic Comminuted Cricoid Fracture

The cricoid plays 2 key roles: phonation and maintenance of the airway frame, both of which are lost in cases of comminuted cricoid fractures. The management of these 2 functions becomes a challenge in planning surgical treatment. We report the treatment course in a case of traumatic comminuted cricoid fracture that was resolved with good airway and phonatory functions. A 25-year-old man fell down the stairs and complained of respiratory discomfort and hoarseness of voice. A computed tomography scan showed comminuted cricoid fracture; therefore, surgery was performed to restore the patient's airway and phonation functions. We found that the airway was maintained by the anterior part and that the phonation depended on the posterior part of the cricoid. This novel concept helped clarify the treatment goal in this case of comminuted cricoid fractures. Furthermore, it is important that the anterior part of the cricoid is reconstructed with sufficient internal diameter, while the posterior part of the cricoid is reconstructed in the correct position.

Laryngeal Trauma

Laryngeal trauma is rare but potentially fatal. Initial evaluation includes efficient history and physical examination, imaging, bedside flexible laryngoscopy, and if necessary, operative endoscopic evaluation. Multiple classification systems exist for laryngeal trauma, and each has its merits. We recommend a patient-centered approach, rather than using the classification alone. Secure airways are the primary goal of acute management, with awake tracheostomy more often indicated over oral intubation compared with traumas not involving the larynx. More severe injuries typically require surgical intervention. Early intervention results in optimal voice and airway outcomes.

CT Findings in Laryngeal Trauma and the Clinical Implications

PURPOSE

Acute traumatic osseous and cartilaginous injuries to the larynx are rare injuries presenting to the emergency department. Despite the low reported incidence, laryngeal trauma carries a high morbidity and mortality. The purpose of this study is to identify fracture and soft tissue injury patterns in laryngeal trauma and explore associations with patient demographics, mechanisms of injury, urgent airway and surgical intervention.

METHODS

A retrospective review of patients with laryngeal injury who underwent multidetector computed tomography (MDCT) imaging was performed. The CT findings of laryngeal and hyoid fracture location, fracture displacement, and soft tissue injuries were recorded. Clinical data including patient demographics, mechanisms of injury, frequency of airway and surgical intervention were also recorded. Correlation of imaging characteristics with patient demographics, mechanism of injury and interventions were assessed for statistical significance using χ2 and Fisher's exact tests.

RESULTS

The median patient age was 40 years old with a strong male predominance. The most common mechanisms of injury included motor vehicle collisions and penetrating gunshot wounds. Thyroid cartilage fractures were the most common fracture type. Findings of fracture displacement and airway hematoma had a higher correlation with requiring urgent airway management.

CONCLUSION

Radiologists' early recognition and prompt communication of laryngeal trauma to the clinical service is important to reduce associated morbidity and mortality. Displaced fractures and laryngeal hematomas should be promptly conveyed to the clinical service as they are associated with more complex injuries and higher rates of urgent airway management and surgical intervention.

Acute Emergent Airway Issues in Sports

Emergent airway issues are rare in competitive sports. However, when airway compromise occurs, the sideline physician will be relied upon to manage the situation and the airway. . The sideline physician is tasked with not only the evaluation of the airway, but also management until the athlete can get to a higher level of care. Familiarity with the assessment of the airway and the various techniques for the management of airway compromise on the sideline are of the utmost importance in the unlikely event that an airway emergency should occur.

A Neglected Open Laryngeal Wound: A Rare Presentation of Neck Trauma

Laryngotracheal trauma can be potentially lethal. Improper healing can have long term sequelae such as permanent voice change, laryngotracheal stenosis and impaired swallowing severely affecting an individual's quality of life. Thus early identification and prompt treatment is paramount to achieve good outcomes in laryngotracheal trauma. A 45 year old male presented with an open laryngeal wound 12 days after sustaining the injury. Surgical closure of the wound was done. A suprahyoid drop was done to achieve tension free repair of the laryngeal rent. Chin to chest sutures were used to maintain neck flexion in the post-operative period. We were able to achieve a good surgical outcome with regards to the patients voice, airway and swallowing in spite of the delayed presentation.

Systematic Review of Laryngeal Fractures and Trends in Operative Management

Study Design

Systematic review of the literature.

Objective

The goal of this study is to review the current literature on the trends in management of laryngeal fractures following trauma.

Methods

Independent searches of the PubMed and MEDLINE databases were performed. Articles from the period of 1963 to 2020 were collected. All studies which described laryngeal fractures using the Boolean method and relevant search term combinations, including "Laryngeal", "Fracture", "Operative", and "Management" were collected.

Results

A total of 588 relevant unique articles were identified for analysis. Of these, 24 articles were deemed appropriate for inclusion in the literature review. Due to variability in study design and outcome measures, formal synthesis of data in the form of a meta-analysis was not possible.

Conclusions

Laryngeal fractures are rare traumatic injuries that require early identification and evaluation with complex management options. This comprehensive review aims to highlight the breadth of the topic with regard to presentation and clinical management. Though there remains no clear best practice for laryngeal fracture management, we review trends in clinical practice throughout the literature.

[Management of blunt and penetrating laryngeal trauma]

Patients presenting with laryngotracheal trauma can be in a life-threatening situation. Early recognition of the severity of the injury and, if necessary, surgical intervention within the first 24-48 h increases the chance of achieving a good functional late result. Preservation or restoration of voice and swallowing function is the long-term therapeutic goal. Precise assessment of the extent of the injury can be achieved using a combination of computed tomography and flexible laryngotracheoscopy. Symptoms often do not reflect the extent of the injury, which can vary from endolaryngeal hemorrhage to complete laryngotracheal separation. Conservative treatment consists of observation with symptomatic therapy. On the other hand, surgery may include endolaryngeal repair and/or transcervical reconstruction; securing the airways is of utmost importance.

Isolated Cricoid Fracture and Thyroid Hematoma in Blunt Injury of the Neck

Introduction Blunt trauma to the neck may result in life threatening injuries due to airway compromise. Thyroid Injury in a previously normal gland is rare, so is Isolated Cricoid Fracture. The expanding thyroid hematoma and an unstable larynx compound the effects of compression and lead to sudden deterioration of the patient. Case Report We report the case of young male, who sustained a blunt injury in front of the neck. He developed a swelling in the front of his neck and suddenly deteriorated, needing intubation and airway management. Computed Tomographic imaging of the neck showed thyroid hematoma and fracture of the cricoid ring requiring an emergency hemi thyroidectomy and fixation of the cricoid fracture. Discussion This case brings forth the occurrence of two rare entities, Thyroid hematoma and Isolated Cricoid fracture in the same patient needing expert airway management and exploration.

Comparing Outcomes in Transcatheter Embolization for the Management of Penetrating versus Blunt Trauma

Purpose This article assesses potential factors associated with successful embolization and/or mortality benefit among patients with penetrating (PT) compared to those with blunt abdominal trauma (BT) undergoing emergent angiography.

Methods A retrospective study of arterial embolization for BT and PT at a tertiary care academic center in an urban setting between 2018 and 2020 was conducted. Fischer's exact and Student's t-tests were used to assess differences between PT and BT, regarding technical success, in-hospital mortality, number of vessels embolized, and requirement of Operating Room (OR) for bleeding control after embolization.

Results Forty-three patients underwent embolization. Twenty-three presented with BT versus 20 with PT. There was no difference in the rate of success between the two groups (91.3% vs. 100%; p = 0.49). No difference was observed in mean days of survival among BT and PT patients treated by embolization (mean [standard deviation]: 13.7 [2.6] vs. 19.1 [2.79] days; p = 0.160). There was no difference in mortality between the two groups (13.0% vs. 10.5%; p = 1.00). Mean number of vessels embolized was higher in the BT group compared to PT (2.26 [1.32] vs. 1.44 [1.03], p = 0.044). The rate of BT patients who required subsequent OR intervention for hemorrhage control after embolization was similar to those with PT (8.7% vs. 10.5%; p = 0.84).

Conclusion The rate of mortality, technical success, and requirement of subsequent OR intervention for hemorrhage control was comparable between BT and PT. BT was associated with a higher mean number of vessels embolized compared to PT. Our case series may provide insight in the use of embolization for PT, but further investigation is needed with larger cohorts.

What we have learned from a patient with partial tracheal rupture caused by penetrating neck injuries: a case report

BACKGROUND

Airway management of patients with direct airway trauma caused by penetrating neck injuries is always challenging. When a failed airway occurs and surgery access is difficult, it is crucial to find the optimal approach to save the life. We propose the concept "Cannot intubate, Cannot oxygenate, Difficult surgery access" to describe this emergency scenario.

CASE PRESENTATION

We report a case of a 24-year-old woman who presented with partial tracheal rupture and pneumothorax caused by a knife stab injury to the neck. A "double setup" strategy, simultaneous preparation for orotracheal intubation and tracheotomy, was carried out before rapid sequence induction. A tracheotomy under local anesthesia or an awake intubation was not preferred in consideration that the patient had a high risk of being uncooperative owing to existing mental disease and potential smothering sensation during operation. During rapid sequence intubation, distal part of the tube penetrates the tear and creates a false lumen outside the trachea then a failed airway subsequently occurred. Rescue tracheotomy was successfully performed by an otolaryngology surgeon, with the help of limited ventilation using sequential bag-mask and laryngeal mask airway ventilation provided by an anesthesiologist, without severe sequelae.

CONCLUSIONS

The endotracheal tube have a risk of penetrating the tear outside the trachea in patient with partial tracheal rupture during orotracheal intubation, and once it occurs, proceeding directly to an emergency invasive airway access with optimizing oxygenation throughout procedure might increase the chance of success in rescuing the airway.

Cricohyoidoepiglottopexy in an emergency scenario: Evaluation and management of a severe laryngeal trauma

We describe the clinical evaluation and the management of a severe laryngeal trauma in a suicidal patient. We aim to demonstrate how the cricohyoidoepiglottopexy, which is a surgical technique mainly performed for oncological purposes, can be successfully used in this emergency setting.

Laryngeal Trauma, Its Types, and Management

Laryngotracheal wounds are rare; however, they have a significant mortality rate. These wounds can be blunt or penetrating. Usually, the larynx is protected from blunt trauma by the sternum and jaw. A "clothesline" injury happens when the exposed neck is struck by a hard object, such as a wall wire or tree branch, or when an attack is intended to damage the larynx. Additionally, injuries may occur when the neck is stressed due to damage, such as in a rear-end accident that causes a whiplash-like injury or when the larynx is intentionally targeted for harm. Penetrating neck trauma may result in injury to the larynx. Assume a patient has suffered a penetrating or severe neck injury. It is usually evident from their medical history or a quick trauma evaluation in that case. However, it is recommended to be cautious for anterior neck injuries in general and to have a low threshold for establishing a surgical airway. The priority is securing an airway when a patient with a laryngeal injury arrives in the emergency room. The operating surgeon may request any flexible laryngoscopy, computed tomography (CT), esophagram, and chest X-ray for additional examination, depending on the nature of the damage and the patient's health. After the examination, the initial step in treating laryngeal injuries should be to locate and secure the airway. According to the evaluation and management based on the Schaefer classification system for laryngeal injury, the patient is treated based on whether the patient has impending airway obstruction or a stable airway. Medical management or observation and surgical management depend on the site and severity of the injury, patient condition, and type of injury. There are several complications related to laryngotracheal trauma, which can be minor or even fatal. Following successful treatment, postoperative and rehabilitative care, vocal rest, speech therapy, and swallowing therapy may be necessary.

Total Laryngectomy Following Severe Laryngeal Trauma: A Case of Surgical Dilemma

External laryngeal trauma is a rather rare occurrence, and comprises a varying severity of injuries. Every laryngeal injury is unique and the management can be invariably complex. For the most severe forms of external laryngeal trauma, reparative procedures and laryngeal stenting (after control of the airway) are considered standard treatment. We present a case of a complex laryngeal trauma with extensive loss of tracheal cartilage and soft tissues which was treated with total laryngectomy.

Laryngeal trauma: a review of current diagnostic and management strategies

PURPOSE OF REVIEW

The purpose of this review is to provide the most up to date information on evaluation and management of laryngeal trauma.

RECENT FINDINGS

Timely diagnosis and proper treatment of laryngeal fractures are imperative for preserving a functional larynx. This review will focus on evaluation and management strategies.

SUMMARY

The larynx provides significant functions including respiration, phonation, and airway protection. Algorithms have been developed in order to standardize the evaluation and management of these injuries to preserve a functional larynx. Physicians must diagnose and treat these laryngeal traumas in a timely fashion in order to prevent morbidity and, rarely, mortality.

Characterization of Laryngotracheal Fractures and Repairs: A TQIP Study

OBJECTIVES

Laryngotracheal trauma is poorly studied and associated with serious morbidity and mortality. This study reports features associated with laryngotracheal fractures, and factors associated with laryngeal fracture repair.

STUDY DESIGN

Retrospective database study SETTING: American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP®) METHODS: ACS-TQIP® 2014-2015 participant user data files were queried for laryngotracheal fractures using the International Classification of Diseases (ICD) 9th edition encodings. Demographic, diagnostic and procedure characteristics were analyzed with univariate chi-squared analysis and multivariate logistic regression.

RESULTS

We extracted 635 cases of laryngotracheal injury, with a median Injury Severity Score of 16 (IQR: 10 - 25). Most were caused unintentionally (65.7%), followed by assault (28.8%). Blunt trauma (79.5%) was more common than penetrating trauma (20.0%). These trends were upheld in the subgroup of repaired fractures, which made up 12.6% (80/635) of cases. The median length of hospital stay was 6 days (IQR: 3 - 13) in all fractures and 10 days (IQR: 6 - 14) in the subgroup of repaired fractures, while the median length of ICU stay was 4 days (IQR: 2 - 9) in all fractures and 4.5 (IQR: 6 - 14.3) in the subgroup of repaired fractures. Cut/pierce injuries (OR: 4.7, P < 0.001) and ISS (OR: 0.97, pP = 0.026) significantly affected rate of laryngeal fracture repair.

CONCLUSION

Laryngotracheal fractures are uncommon but serious injuries. Our results show that penetrating causes of injuries have the shortest time to repair, and that a higher ISS score is negatively associated with repair.

Management of paediatric laryngotracheal trauma

Objective

To summarise and describe the clinical presentations, diagnostic approaches and airway management techniques in children with laryngotracheal trauma.

Methods

The clinical data related to laryngotracheal trauma diagnosed and treated at the Beijing Children's Hospital, between January 2013 and July 2018, were retrospectively reviewed. Disease diagnosis, treatment, management and outcomes were analysed.

Results

A total of 13 cases were enrolled, including 7 cases of penetrating laryngotracheal trauma. The six cases of blunt laryngotracheal trauma were caused by collisions with hard objects. In all cases, voice, airway and swallowing outcomes were graded as ‘good’, except for one patient who had residual paralysis of the vocal folds.

Conclusion

Flexible fibre-optic laryngoscopy and computed tomography can play an important role in diagnosing laryngotracheal trauma. The airway should be secured and, if necessary, opened by tracheal intubation or tracheostomy.

[Case report on traumatic complete laryngotracheal separation with a positive outcome]

HISTORY

A 21-year-old female was injured by accidental strangulation. Dyspnea and stridor occurred with delay, and led to emergency intubation.

FINDINGS

Physical examination showed strangulation marks and neck emphysema. Computed tomography confirmed laryngotracheal separation and revealed misplacement of the ventilation tube.

DIAGNOSIS

Further surgical exploration revealed complete laryngotracheal (cricotracheal) separation.

TREATMENT

After initial emergency tracheotomy, cricotracheal reanastomosis was achieved by a two-stage surgical approach.

CONCLUSION

Laryngotracheal separation is associated with high mortality. In the case presented herein, the patient survived and was discharged from hospital without a tracheostomy tube despite bilateral recurrent laryngeal nerve palsy.

Clinical, Radiologic, and Endolaryngeal Findings in Laryngeal Fractures: A 15-Year Case Series

Objective

Laryngeal fractures are rare injuries; recent data describing these injuries and associated examination findings are limited. This study aims to describe injury etiology and outcomes associated with laryngeal fractures.

Study Design

Retrospective case series.

Setting

Academic tertiary center.

Methods

Patients with laryngeal fractures from 2005 to 2020 were identified in a retrospective chart review. Patient demographics, injury mechanisms, management, and voice outcomes were examined. Fracture type, radiologic, and endolaryngeal examination findings were analyzed for associations between fracture etiology and examination characteristics.

Results

Laryngeal fractures most commonly occurred at the thyroid cartilage. Fractures were most commonly due to sport-related injuries. Mechanism of injury was not associated with specific radiologic or endolaryngeal findings. Mechanism of injury was additionally not significantly associated with the need for intubation, surgical intervention, or tracheotomy. Fracture location was significantly associated with intubation requirement (P = .015), with 40% of patients with concomitant thyroid and cricoid fractures requiring intubation. Mechanism of injury significantly correlated with dysphonia at follow-up (P = .033). Mechanism of injury, fracture location, and surgical management were not associated with increased vocal fold injury or dysphonia.

Conclusion

There are no significant correlations between injury mechanism and fracture location, characteristics, radiologic findings, or endolaryngeal findings. These features emphasize the importance of a thorough and comprehensive laryngeal examination.

External penetrating laryngeal trauma caused by a metal fragment: A Case Report

BACKGROUND

Although external penetrating laryngeal trauma is rare in the clinic, such cases often result in a high mortality rate. The early recognition of injury, protection of the airway, one-stage laryngeal reconstruction with miniplates and interdisciplinary cooperation are important in the treatment of such patients.

CASE SUMMARY

A 58-year-old male worker sustained a penetrating injury in the left neck. After computed tomography scanning at a local hospital, he was transferred to our hospital, where he underwent tracheotomy, neck exploration, extraction of the foreign object, debridement and repair of the thyroid cartilage using titanium miniplates. An endo laryngeal stent was inserted, which was removed 12 days later. The patient recovered well and his voice rapidly improved after surgery.

CONCLUSION

Penetrating laryngeal trauma is uncommon. We successfully treated a patient with early laryngeal reconstruction and management by interdisciplinary cooperation.

Airway management in maxillofacial trauma

Airway management of patients with maxillofacial trauma remains a challenging task for an anesthesiologist in the emergency and perioperative settings due to anatomical distortion. Detailed knowledge of maxillofacial and airway anatomy is desired for the correct diagnosis of extent and severity of the injury. Basic principles of advanced trauma life support protocols should be followed while managing such patients. Establishing unobstructed airway remains the top priority while maintaining C-spine immobilization and preventing aspiration. Although multiple options exist for securing the airway, a universal technique of airway management may not be applicable to all the patients. Hence, a high index of suspicion along with timely and skillful management is warranted. In this brief review, issues affecting the airway management in cases of maxillofacial trauma are addressed with the possible uses of a wide range of airway management devices available in emergency and elective scenarios.

Traumatic laryngeal fracture: A case report

Background

The blunt laryngotracheal trauma is a potentially life-threatening infrequent cause of injury that can present with subtle symptoms which often lead to delay in diagnosis if not suspected.

Case presentation

The authors report a case of a 16-year-old adolescent admitted to the emergency room after a bicycle accident with isolated blunt cervical trauma subsequent to headphones use. The patient presented with odynophagia, hemoptysis, edema, tenderness, linear ecchymosis in the anterior cervical area and no signs of respiratory distress. Cervical computed tomography scan revealed an aligned left side thyroid cartilage fracture. The patient progressed with a complete clinical recovery and at 3 month-follow-up reported no symptoms.

Conclusions

Laryngeal fracture is a rare entity in patients with blunt cervical trauma. A high level of suspicion along with a systematic approach is essential for rapid recognition and early treatment, regardless of the severity of the presenting symptoms, in order to preserve airway and voice functions and improve outcomes.

Management of Laryngeal Trauma

The larynx is a complex anatomic structure and a properly functioning larynx is essential for breathing, voice, and swallowing. Laryngeal trauma is often associated with other injuries, including intracranial injuries, penetrating neck injuries, cervical spine fractures, and facial fractures. Although uncommon, laryngotracheal injuries may lead to life-threatening airway emergencies. Because laryngeal injuries are rare, even surgeons with a great deal of experience in managing maxillofacial trauma have limited exposure to management of laryngeal and tracheal injury. This article reviews a protocol for the evaluation, management, and treatment of these injuries in the trauma patient.

Management of traumatic laryngotracheal separation: Case series and review

Laryngotracheal separation injuries are a rare but serious condition, as survival from such injuries relies on proper airway management. As a result, recommendations for management have been based on small case reports and expert opinion. We reviewed our last 10 years of experience with managing laryngotracheal separation injuries and identified 6 cases for chart review. Awake tracheostomy or videolaryngobronchoscopy was used in each case to initially obtain the airway. Surgical repair was then performed immediately using nonabsorbable monofilament suture or a miniplate, and a low fenestrated tracheostomy was placed. All of our patients who followed up were decannulated, eating regular diets, and had satisfactory voice quality at 3 months postoperatively. Review of the literature revealed that, while management strategies have changed over time, treatment still varies widely depending on surgeon preference and the details of each injury. Outcomes from our series suggest that our described techniques and management strategies can be used with good outcomes. We believe that this is due to securing a safe airway, early surgical intervention with no unnecessary tissue dissection, effective reconstruction of the airway, and the fenestrated tracheostomy technique.

Cricotracheal separation: do not get fooled by what you see

INTRODUCTION

Laryngeal involvement in neck trauma is quite considerable. The presence of a cricotracheal separation type of injury can be easily missed and overlooked, especially if the neck does not show any external signs. Blunt trauma to the neck affects many anatomical structures inside the intact-looking neck that threatens the victim's life. At exploration, the surgeon must be aware of the full impact of the injury on different neck structures.

AIM OF WORK

Raise the attention on the proper management of laryngeal trauma victims.

PATIENTS AND METHOD

This is a retrospective study carried out on 23 patients who suffered from cricotracheal separation as a result of laryngeal trauma.

RESULTS

Cricotracheal separation is a frequent finding in an innocent-looking neck. The mechanism of the trauma itself is an excellent clue to suspect its presence.

CONCLUSION

This type of laryngeal injury must be kept in mind and must be suspected. Some recommendations and guidelines are presented on the proper handling of such patients.

Unique presentation of cricoid cartilage fracture causing intermittent dyspnea without preceding trauma

Cricoid cartilage fracture is generally caused by significant neck trauma and causes continuous dyspnea, neck pain, or hoarseness developing immediately after the traumatic episode. A 69-year-old woman without any history of trauma was admitted to our hospital with intermittent dyspnea. Six months before admission she had started to complain of dyspnea occurring several times a month without warning, improving spontaneously within a few hours without treatment. Her primary care doctor diagnosed asthma and she was treated with inhaled short-acting beta agonists and glucocorticoids, without improvement. On initial evaluation at our hospital, the cause of dyspnea was unclear. Laryngoscopy was performed, which excluded vocal cord dysfunction. A further attack of dyspnea occurred on the fourth admission day. Stridor was evident during the attack, and bronchoscopy revealed subglottic narrowing of the trachea on both inspiration and expiration with no mass or foreign objects. Computed tomography (CT) of the neck revealed cricoid cartilage fracture causing airway narrowing and dyspnea. She was orally intubated, and tracheostomy was performed 2 weeks later to maintain her airway, which resolved her dyspnea. This patient's presentation was unique in two aspects. First, there was no history of trauma that may cause her cricoid cartilage fracture. Second, her symptoms of dyspnea were intermittent rather than continuous. These aspects led to suspicions of other diseases such as asthma or vocal cord dysfunction, thus delaying the diagnosis. Cricoid cartilage fracture should be considered in patients with dyspnea of unknown cause, irrespective of continuous or intermittent symptoms and preceding traumatic episodes.

Blunt laryngeal trauma presenting as bilateral massive pneumothoraces and subcutaneous emphysema: a multidisciplinary approach to management

A 3-year-old boy had an unwitnessed fall from a highchair. The child had no loss of consciousness, vomiting, stridor or respiratory distress but within a few minutes had significant swelling in the neck, scalp and around the eyes. He was brought immediately to the emergency room where he deteriorated rapidly and was intubated with a cuffed oral endotracheal tube. A clinical diagnosis of blunt laryngeal trauma was made. Imaging showed no laryngeal disruption, but did reveal massive bilateral pneumothoraces, that were managed with chest tube. A multidisciplinary meeting with family led to a watchful waiting approach. The patient was successfully extubated at 1 week and healed with a clear voice.

Challenging tracheal resection anastomosis: Case series

OBJECTIVES

This study was conducted to review our experience in Otorhinolaryngology Department, Mansoura University Hospitals, Egypt, in the last 2 years in the management of high-risk patients who underwent cricotracheal resection due to different pathologies.

METHODS

This case series included nine patients with severe, grade III or IV subglottic / cervical tracheal stenosis. These patients were considered high risk patients due to unusual pathology / etiology of stenosis or associated surgical field morbidity. Four patients had recurrent stenosis after previous unsuccessful cricotracheal resection, three patients had subglottic stenosis due to external neck trauma which compromised the surgical field. One patient had upper tracheal neoplasm, and in 1 patient there was upper tracheal stenosis associated with tracheo-esophageal fistula.

RESULTS

Successful decannulation was achieved in all patients (n = 9) without any reported major intraoperative or postoperative compilations.

CONCLUSION

Cases of subglottic / upper tracheal stenosis due to uncommon pathologies like neoplastic lesions, external neck trauma compromising the surgical field and revision cricotracheal resection, can be successfully managed by cricotracheal resection. However, a highly skilled team, well familiar with these surgeries, is mandatory to achieve an optimum outcome.

Airway Management and Clinical Outcomes in External Laryngeal Trauma: A Case Series

External laryngeal trauma is a rare but potentially fatal event that presents several management challenges. This retrospective observational case series conducted at a level-1 trauma center over a 12-year period consists of 62 cases of acute external laryngeal trauma. Patient demographics, mode and mechanisms of injury, presenting signs and symptoms, initial imaging results, airway management, time to surgical management, and 6-month outcomes including airway status, deglutition status, and voice quality were investigated. No difference was found in mortality or 6-month outcomes between patients requiring surgical repair and/or tracheostomy versus patients with less severe injuries managed conservatively.

Surgical Emphysema in a Pediatric Tertiary Referral Center

BACKGROUND

Laryngeal trauma in pediatrics is extremely rare; however, because of the smaller pediatric larynx, it can have catastrophic consequences. Following laryngeal trauma, surgical emphysema is a relatively common presentation. In pediatrics, it can be a life-threatening condition. Here we describe 2 cases of laryngeal trauma resulting in extensive surgical emphysema.

CASES

The first case described involves bilateral pneumothoraces, airway compromise, and respiratory arrest and was managed with bilateral chest drains, intubation, and tracheostomy. The second case resulted in widespread surgical emphysema in a stable patient and was managed conservatively. Both cases were monitored closely for a period of time to ensure there were no further sequelae.

DISCUSSION

Patients with laryngeal trauma resulting in surgical emphysema have the potential to deteriorate rapidly. Furthermore, surgical emphysema degrades the quality of ultrasound images, which may delay the diagnosis. If there are any concerns about the safety of the airway, then it should be secured definitively with either endotracheal intubation or emergency tracheostomy depending on clinical judgment. It is acceptable to monitor patients closely in a high-dependency unit setting if they are stable and do not show any evidence of laryngeal edema.

CONCLUSIONS

We present 2 cases of laryngeal trauma that were dealt with effectively so that both patients made a full recovery. It is important to act quickly to secure the airway if there are any concerns about its patency. Stable patients with no evidence of laryngeal edema can be managed conservatively. Close monitoring is essential to prevent any potential airway compromise.

Management of Post-Traumatic Subglottic Stenosis and Pharyngosubglottic Fistula

Injury to the aerodigestive tract following external laryngeal trauma is rare. Reports of acquired laryngopharyngeal fistula are very few. We report a very rare presentation of penetrating neck trauma presenting with fracture of the cricoid cartilage, subglottic stenosis and pharyngosubglottic fistula. The term 'pharyngosubglottic fistula' is used here for the first time to describe a communication tract between hypopharynx and subglottis. The successful surgical management of this case is discussed.

Blunt neck trauma at a level I trauma centre: six-year retrospective case note review

BACKGROUND

Blunt neck trauma can cause serious morbidity and mortality rates of up to 40 per cent, but there is a paucity of literature on the topic.

METHOD

A retrospective case note review was performed for all blunt neck trauma cases managed at the Queen Elizabeth Hospital Birmingham between 1st January 2011 and 31st December 2017.

RESULTS

Seventeen cases were managed, with no mortality and limited morbidity. Most patients were male (70.6 per cent) and road traffic accidents were the most common cause of injury (41.2 per cent). The median age of patients was 40.6 years (range, 21.5-70.3 years). Multidetector computed tomography angiography of the neck was performed in 9 patients (52.9 per cent) with 'hot' reports made by on-duty radiology staff matching consultant reports in all but 1 case. Six patients underwent operative exploration yielding a negative exploration rate of 33.3 per cent. Imaging reports matched operative findings in 3 cases (60 per cent).

CONCLUSION

Blunt neck trauma is uncommon but usually presents in polytrauma. Imaging has inaccuracies when compared with operative findings, regardless of radiological experience.

Operative Management of Vocal Fold Avulsion Following Pediatric Laryngotracheal Separation

Laryngotracheal disruption in children is rare but life-threatening, and endolaryngeal injuries may go overlooked. We present the case of a 10-year-old boy who sustained near-complete laryngotracheal separation, multiple laryngeal fractures, and arytenoid and vocal fold avulsion following blunt cervical trauma. These injuries were not identified radiographically and only became apparent intraoperatively. Following surgical repair, the patient was successfully decannulated, eating a normal diet, and had a serviceable speaking voice within 2 months. In children, the diagnosis of severe endolaryngeal injuries may be elusive and therefore require high degree of clinical suspicion. Surgical success requires accurate diagnosis and prompt intervention.

Imaging of Neck Visceral Trauma

The neck visceral space is a complex region housing several vital structures. Diagnostic imaging plays an important role in the evaluation of neck visceral injuries. Many injuries are initially missed by both clinicians and radiologists because of their infrequency and the high likelihood of other more obvious injuries. Understanding which diagnostic modality to apply at given point in the work-up; recognizing relevant clinical signs, symptoms, and injury mechanisms; and knowing pertinent direct and indirect imaging findings of injury allow radiologists to either directly render the correct diagnosis or choose the most appropriate tool for doing so.

Laryngeal fracture presentation and management in United States emergency rooms

OBJECTIVES/HYPOTHESIS

There are limited data on laryngeal fracture presentation and management in US emergency departments (EDs). We aimed to characterize patients who are diagnosed with laryngeal fractures in the ED and identify management patterns.

STUDY DESIGN

Retrospective review of the Nationwide Emergency Department Sample (NEDS) from 2009 to 2011.

METHODS

The NEDS was queried for patient visits with a primary diagnosis of open or closed laryngeal fracture (International Classification of Diseases, Ninth Revision codes 807.5 and 807.6). Patient demographics, comorbidities, ED management, and hospital characteristics were extracted.

RESULTS

There were 3,102 ED visits with a diagnosis of laryngeal fracture during the study period. Mean patient age was 40.9 years (range, 3-93 years). The majority of patients were male (85.5%) and sustained a closed (vs. open) fracture (91.4%), with an overall mortality rate of 3.8%. The majority of patients were treated for more than one injury during the same visit (76.2%). Most patients were evaluated at a trauma hospital (53.9%), and most patients were admitted to the hospital (71.9%). Emergent intubation or tracheostomy was rarely reported (2.6% and 0.1% of all cases), and a minority of patients underwent fiberoptic flexible laryngoscopy in the ED (1.9%). Laryngeal fractures occurred more frequently during summer months (28.2%). Mean charge for the entirety of the ED stay was $4,957.34.

CONCLUSIONS

Laryngeal fracture is rare and frequently associated with other injuries. The frequency of emergent airway procedure, imaging, and flexible fiberoptic laryngoscopy is lower than expected, raising concerns about appropriate workup and management or recognition of injury in the ED setting.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:2341-2346, 2019.

Awake tracheal intubation for blunt airway trauma

A 64-year-old man sustained blunt trauma to the anterior neck following a mechanical fall resulting in an isolated laryngeal fracture of the left cricoarytenoid complex. Although there was no acute airway compromise, he developed worsening airway oedema which necessitated tracheal intubation. He underwent oral awake tracheal intubation with a flexible bronchoscope to facilitate formation of a tracheostomy under general anaesthesia. The challenges encountered in the clinical management of this case relate to decision making for the patient with airway trauma in the absence of the need for emergency tracheal intubation. We describe the advantages and pitfalls of various airway management strategies in the context of blunt airway trauma.

Trauma Airway Management: Induction Agents, Rapid Versus Slower Sequence Intubations, and Special Considerations

Trauma patients who require intubation are at higher risk for aspiration, agitation/combativeness, distorted anatomy, hemodynamic instability, an unstable cervical spine, and complicated injuries. Although rapid-sequence intubation is the most common technique in trauma, slow-sequence intubation may reduce the risk for failed intubation and cardiovascular collapse. Providers often choose plans with which they are most comfortable. However, developing a flexible team-based approach, through recognition of complicating factors in trauma patients, improves airway management success.

Maxillofacial Fractures Associated With Laryngeal Injury: A Craniofacial Surgeon Should be Alert

OBJECTIVE

Maxillofacial fractures with concomitant laryngeal injuries put both the quality and maintenance of life in jeopardy. Because of its low incidence, it is often overlooked in the clinical setting. The purpose of this study is to review the incidence, clinical presentations, managements, and outcomes of these patients.

METHODS

A retrospective analysis of medical records from 2008 to 2015 was conducted at a single institute. A case series (n = 12, which contributed 22.2% of laryngeal injuries in our institute) of these patients was presented, and propensity score matching was applied for further statistical analysis.

RESULTS

When comparing patients who sustained maxillofacial fractures with concomitant laryngeal injuries with patients with only maxillofacial fractures and no laryngeal injuries, subcutaneous emphysema (83.3% vs 4.2%, P < 0.001), neck pain (75.0% vs 6.3%, P < 0.001), dyspnea (75.0% vs 0%, P < 0.001), hoarseness (41.7% vs 0%, P < 0.001), neck swelling (66.7% vs 4.2%, P = 0.012), stridor (16.7% vs 0%, P = 0.037), hemoptysis (16.7% vs 0%, P = 0.037), and thoracic trauma (58.3% vs 10.4%, P = 0.001) all showed significant differences. The length of intensive care unit stay (7.42 days vs 3.21 days, P = 0.008), ventilator use (66.7% vs 18.8%, P = 0.002), and tracheostomy (58.3% vs 0%, P < 0.001) were also significantly different.

CONCLUSIONS

A significant portion of laryngeal injuries is concurrent with maxillofacial fractures. As a craniofacial surgeon, we should be alert to the signs of laryngeal injury. Diagnosis of laryngeal injuries should be established before definitive surgery for maxillofacial fractures.

Traumatic Injuries of the Ear, Nose and Throat

This article reviews the presentation, diagnosis, and management of common traumatic injuries of the ear, nose, and throat, including laryngeal trauma, auricular and septal hematomas, and tympanic membrane rupture.

Traumatic Airway Injuries: Role of Imaging

Airway Injuries are rare but often immediately life threatening. Incidence ranges from 0.5-2 % in blunt and 1-6 % in penetrating trauma. Upper airway injuries (UAI) are often clinically apparent and get shunted during the primary survey in the emergency department. Few UAI and majority of lower airway injuries (LAI) are occult on primary survey and need a high suspicion index. Clinically, the diagnosis of tracheobronchial injury is delayed in many patients because the airway column is maintained by the peribronchial tissue. Imaging in the form of MDCT, in conjunction with endoscopy, plays a role in delineating the exact site and extent of injury and ruling out associated vascular and esophageal injuries for definitive management of UAI. Chest radiographs and ultrasonography help raise suspicion of LAI by detection of pneumomediastinum, persistent pneumothorax and/or subcutaneous emphysema and should be followed up with multidetector computed tomography (MDCT) which is the mainstay of diagnosis. However, it requires careful evaluation of the airway tract and a thorough knowledge about the mechanism of trauma for detection of subtle injuries. Reconstructions in multiple planes and use of various post-processing techniques including minimum intensity projection (MinIP) images enhance the detection rate. The specific signs of LAI on CT include discontinuity in the tracheobronchial tree, focal intimal flap projecting in the lumen, focal soft tissue attached to the tracheal/bronchial wall, complete cut off of the bronchus/trachea and the fallen lung sign. We, hereby, illustrate the imaging spectrum of traumatic airway injuries in detail and discuss their management implications.

Isolated vocal cord hematoma developing after blunt neck trauma

Introduction

Blunt laryngeal trauma is a rare causes of emergency applications. Early diagnosis and treatment are important.

Case presentations

A 62-year-old woman applied to emergency department with pain over the larynx, hoarseness and dysphagia that starting after blunt laryngeal trauma. The patient had no respiratory distress. There was no ecchymosis and edema in the laryngeal area. Computed tomography showed no thyroid and cricoid cartilage fractures. Isolated hematoma was seen in the left vocal cord at the endoscopic view.

Conclusion

Endoscopic examination is important when there is no obvious physical examination finding on the in blunt neck trauma.