Tracheal tear from blunt neck trauma in children: Diagnosis and management

Paediatric Longitudinal Tracheal Laceration From Blunt Force Trauma: A Case Report

Tracheal lacerations in the paediatric population are not common; however, they can be life-threatening. Prompt diagnosis and management are essential for a good prognosis.

Here, we present the case of a nine-year-old boy who presented to the hospital following a bicycle handlebar injury with neck pain and subcutaneous emphysema of the anterior thorax and neck. Chest X-ray revealed pneumomediastinum and a small pneumothorax. A computed tomography scan revealed a posterior longitudinal laceration of the trachea, measuring 1.5 cm, located superior to the carina at T1/2. As the patient was clinically stable, did not require any supplemental oxygen, and the tear was smaller than 2 cm, conservative management with steroids and broad-spectrum antibiotics was implemented. The patient was transferred to a tertiary ENT centre in Glasgow for observation in the paediatric intensive care unit where he recovered uneventfully. A repeat cross-sectional imaging six days after the injury revealed successful healing of the laceration.

Non-surgical management of a tracheobronchial injury can be an effective approach. This can be considered in the case of tears measuring <2 cm and in clinically stable patients. Imaging-based diagnosis in the case of patients with minor injuries who are improving with conservative treatment may be sufficient, and confirmation with bronchoscopy would be of questionable clinical value in such patients.

Pediatric tracheal injuries: Report on 5 cases with special view on the role of bronchoscopy and management

INTRODUCTION

The purpose of these case reports is to draw the attention to the difficulties of diagnosing trachea injuries in children, who are often part of a polytrauma scenario.

MATERIALS

A retrospective multicenter analysis of 5 cases were analysed. The age of the children was between 1 and 16 years old. Injury mechanism was blunt thoracic trauma, misintubation and shot injury.

RESULTS

Case No.1. a three-year-old child suffered a train accident. Resuscitation and decompression of the tension pneumothorax were performed. CT found a pneumomediastinum and bubbles along the trachea. Thoracolaparotomy was performed. Bronchoscopy could not rule out a tracheal injury. The child died of a cerebral edema. Case No. 2: a 13 month drowned and was resuscitated. A chest drain was inserted to treat the pneumothorax. CT revealed a pneumomediastinum, which was drained and a small tear of the trachea. Bronchoscopy was not preformed. Case No. 3: 9 year-old polytrauma patient was airlifted with bilateral mini thoracostomies and chest drains for pneumothorax. CT revealed bilateral pneumothorax and pneumomediastinum. The chest drains were repositioned oxygenation improved, but some ventilation difficulties remained. CT revealed pneumomediastinum and a tracheal injury. This was bridged by a tube, and the mediastinum drained. The ventilation difficulties were resolved. Case No. 4: an eight-year-old boy was shot on the neck. The region was explored surgically and the laceration of the trachea was sutured. Case No. 5: 12-year-old girl suffered blunt thoracic trauma. CT revealed bilateral pneumothorax and pneumomediastinum. Bilateral thoracic drainage was performed, some ventilation problems persisted. CT and fiberoscopy revealed a rupture of the trachea. Thoracotomy was performed and the laceration was closed.

CONCLUSION

Pneumomediastinum and persistent ventilation difficulties should raise suspicion of a tracheal injury in a typical clinical scenario. Bronchoscopy is recommended for early diagnosis, despite the possibility of misdiagnosis. In certain cases CT scan only and close observation may be considered.