Laryngeal fractures: clinical findings and considerations on suboptimal outcome

Machine Learning for Treatment Management Prediction in Laryngeal Fractures

OBJECTIVES

Laryngeal fractures are rare but potentially life-threatening traumas. Complications, such as airway obstruction and disrupted laryngeal anatomy, associate with significant morbidity. Early identification of at-risk patients and optimal management remain crucial for improved outcomes. Recently, machine learning (ML) has attained great attention as a unique and novel technique for evaluating complex nonlinear relationships between multiple observations to create a predictive model with greater accuracy. This study aimed to demonstrate the potential of ML in predicting airway and surgical management of laryngeal fracture patients and identify key contributing parameters for the predictive performance of the ML models.

METHODS

The ML models were developed using a patient series managed at the Helsinki University Hospital during 2005-2019. The developed models were further evaluated independently using a different cohort collected from the same institution between 1995 and 2004.

RESULTS

The ML showed a weighted area under curve (AUC) of 0.93 and accuracy of 0.86 following training for airway management. Likewise, for treatment approach, weighted AUC was 0.85 and accuracy 0.78. Injury type, Schaefer-Fuhrman grade (SF gr), age at incident, cause of injury, and fracture of the cricoid, in decreasing order of significance, were the most prominent features for the model's predictive performance for airway management. Similarly, our model identified SF gr, fracture of the cricoid, injury type, age at incident, and cause of injury as the most significant predictors for surgical treatment approach.

CONCLUSIONS

The proposed prediction of management approach by an ML technique can provide accurate predictions and thus aid clinicians in administering early and personalized interventions. The model may serve as a supporting tool in recognizing at-risk patients and in timely decision-making. Further independent external validation is warranted for model generalizability.

Changes in occurrence and management of laryngeal fractures at the Helsinki University Hospital during 25 years

PURPOSE

Laryngeal fracture is a rare but potentially life-threatening trauma. Fractures vary from mild to dislocated and extensive with risk of severe complications. This study investigated the occurrence, clinical characteristics and management of laryngeal fractures in the last 15 years.

MATERIAL AND METHODS

A retrospective population-based cohort study reviewing all laryngeal fractures at the Helsinki University Hospital in 2005-2019. Patient records and imaging studies were systematically reviewed for mode of injury, fracture type, secondary complications, treatment modality, possible airway management, length of stay, and mortality. Results were compared with corresponding data from 1995 to 2004.

RESULTS

Overall 80 fracture patients were recorded (5.3/year); 79% were men and mean age was 42 years (range 18-78). Altogether 91% were closed and 9% open. While unintentional traumas were most common (54%), an increasing proportion were from intentional injury (10%) or Schaefer Gr IV in severity (35%). Altogether 46% had compromised airway and 21% needed airway intervention; airway narrowing was more common with cricoid (p = 0.042) and multiple fractures (p = 0.07) and correlated positively with amount of dislocation (p = 0.001) and number of fracture lines (p = 0.006). Surgery was performed for 33%, of which 46% were Schaefer Gr IV and 62% from intentional trauma. Mortality was 1.4%.

CONCLUSIONS

Deliberate and violence-related laryngeal fractures have increased. These often result in more extensive injuries predisposing to compromised airway and requiring surgical intervention and longer treatment. Most fractures are still treated conservatively with good long-term outcomes. An observation period of 24 h is recommended to detect any delayed complications. Mortality remains low.

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.

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.

Volume-outcome relationships in laryngeal trauma processes of care: a retrospective cohort study

PURPOSE

The extent to which patients with laryngeal trauma undergo investigation and intervention is largely unknown. The objective of this study was to therefore determine the association between hospital volume and processes of care in patients sustaining laryngeal trauma.

METHODS

This retrospective cohort study used the American College of Surgeons Trauma Quality Improvement Program database. Adult patients (≥ 18) who sustained traumatic laryngeal injuries between 2012 and 2016 were eligible. The exposure of interest was average annual laryngeal trauma volume categorized into quartiles. The primary and secondary outcomes of interest were the performances of diagnostic and therapeutic laryngeal procedures respectively. Multivariable logistic regression under a generalized estimating equations approach was utilized.

RESULTS

In total, 1164 patients were included. The average number of laryngeal trauma cases per hospital ranged from 0.2 to 7.2 per year. Diagnostic procedures were performed in 31% of patients and therapeutic in 19%. In patients with severe laryngeal injuries, diagnostic procedures were performed on a higher proportion of patients at high volume centers than low volume centers (46% vs 25%). In adjusted analysis, volume was not associated with the performance of diagnostic procedures. Patients treated at centers in the second (OR 1.94 [95% CI 1.29-2.90]) and third (OR 1.67 [95% CI 1.08-2.57]) volume quartiles had higher odds of undergoing a therapeutic procedure compared to the lowest volume quartile.

CONCLUSION

Hospital volume may be associated with processes of care in laryngeal trauma. Additional research is required to investigate how these findings relate to patient and health system outcomes.

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.

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.

Common Findings in Blunt Thyroid Fracture

Although blunt neck trauma is known to be rare, occurring in approximately 5% of all neck traumas, undiagnosed cases may have a devastating outcome. Physicians need to fully understand the mechanism of the injury and the external laryngeal trauma signs. A physician's precise diagnosis and proper management are necessary to avoid long-term complications or death. Although blunt laryngeal injuries are uncommon, prompt recognition of the subtle signs is crucial to avoid the catastrophic complications associated with such injuries. This case report aims to demonstrate the symptoms and signs of laryngeal injury in a young healthy male following a road traffic accident.

Comminuted Laryngeal Fracture Following Blunt Trauma: A Need for Strict Legislation on Roads!

Laryngeal fracture is a rare condition with potential life-long implications related to airway patency, voice quality, and swallowing. Rarity of the condition leads to lack of consensus on the most suitable way to manage this injury. The mode of injury can be prevented by strict legislation on the roads. We report a case of a 28-year-old Indian male who sustained a comminuted displaced fracture of the thyroid cartilage with disruption of anterior commissure due to blunt trauma caused by the metallic side rod of a ladder projecting from the rear of a vehicle in front of the bike on which he was riding. He presented with breathing difficulty, change in voice, surgical emphysema, and pneumomediastinum, but without any skin changes over the neck. His airway could be restored due to early tracheostomy and open reduction with internal fixation with sutures along with laryngeal stenting. He has no significant swallowing or breathing problem and reasonably good voice 6 months after surgery. This case highlights the need for strict legislation on roads in India and the importance of high level of suspicion for laryngeal fracture in acute trauma patient. Early identification and timely internal fixation not only restore the airway but also improve long-term voice and airway outcomes.

Blunt laryngeal trauma secondary to sporting injuries

BACKGROUND

Laryngeal injury after blunt trauma is uncommon, but can cause catastrophic airway obstruction and significant morbidity in voice and airway function. This paper aims to discuss a case series of sports-related blunt laryngeal trauma patients and describe the results of a thorough literature review.

METHOD

Retrospective case-based analysis of laryngeal trauma referrals over six years to a tertiary laryngology centre.

RESULTS

Twenty-eight patients were identified; 13 (46 per cent) sustained sports-related trauma. Most were young males, presenting with dysphonia, some with airway compromise (62 per cent). Nine patients were diagnosed with a laryngeal fracture. Four patients were managed conservatively and nine underwent surgery. Post-treatment, the majority of patients achieved good voice outcomes (83 per cent) and all had normal airway function.

CONCLUSION

Sports-related neck trauma can cause significant injury to the laryngeal framework and endolaryngeal soft tissues, and most cases require surgical intervention. Clinical presentation may be subtle; a systematic approach along with a high index of suspicion is essential, as early diagnosis and treatment have been reported to improve airway and voice outcome.

Laryngeal Injury and Pneumomediastinum Due to Minor Blunt Neck Trauma: Case Report

BACKGROUND

Serious isolated laryngeal injuries are uncommon in children.

CASE REPORT

We describe the case of an 8-year-old boy with laryngeal injury and pneumomediastinum due to minor blunt neck trauma. He presented to the emergency department complaining of odynophagia and hoarseness, but without respiratory distress. Emphysema was seen between the trachea and vertebral body on initial cervical spine x-ray study, and flexible laryngoscopy revealed erythema and mild edema of both the right vocal cord and the arytenoid region. He recovered with conservative management only. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We conclude that it is important to recognize subtle evidence of laryngeal injury secondary to blunt neck trauma to ensure early diagnosis. Initial cervical spine x-ray assessment should exclude both cervical spine fracture and local emphysema after blunt neck trauma. If patients with blunt neck trauma have evidence of a pneumomediastinum, the clinician should consider the possibility of aerodigestive injury.

Case Report: Neonate With Stridor and Subcutaneous Emphysema as the Only Signs of Physical Abuse

A stridulous, dysphonic cry with no external signs of trauma is a unique and unusual presenting sign for physical abuse. We report a previously healthy neonate with unremarkable birth history and medical history who presented with stridor and hypopharyngeal perforation due to physical abuse. This case highlights the need for further evaluation for traumatic injuries in the setting of unexplained new-onset stridor and consideration of physical abuse in the differential diagnosis.

Unusual airway injury following a motor vehicle collision

A 16-year-old male presented to the emergency department following a single-truck motor vehicle collision. The patient was the driver of an older model pickup truck that he lost control of while driving and went off of the road. He was restrained with a lap belt only, given the age of the vehicle. His only complaint at the presenting hospital was left-sided neck pain and hoarseness.

Traumatic laryngeal fracture in a collegiate basketball player

Laryngotracheal trauma is a rare condition that accounts for less than 1% of blunt trauma. Laryngotracheal fractures are uncommon in sports, even in settings where athletes are more vulnerable, including football, basketball, and hockey. If a laryngeal injury is suspected, immediate evaluation is required to avoid a delay in the diagnosis of a potentially life-threatening injury. A collegiate basketball player sustained an unusual fracture involving the cricoid and thyroid cartilage during practice. This case illustrates the importance of rapid identification and early management of patients with blunt laryngotracheal trauma in sports.

MDCT in the assessment of laryngeal trauma: value of 2D multiplanar and 3D reconstructions

OBJECTIVE

The purpose of this study was to analyze fracture patterns and related effects of laryngeal trauma and to assess the value of 2D multiplanar reformation (MPR) and 3D reconstruction.

MATERIALS AND METHODS

Among 4222 consecutively registered trauma patients who underwent emergency MDCT, 38 patients had presented with laryngeal trauma. Axial, 2D MPR, 3D volume-rendered, and virtual endoscopic images were analyzed retrospectively by two blinded observers according to predefined criteria. Laryngeal fractures, soft-tissue injuries, and airway compromise were evaluated and correlated with clinical, endoscopic, surgical, and follow-up findings.

RESULTS

Fifty-nine fractures (37 thyroid, 13 cricoid, nine arytenoid) were present in 38 patients. They were isolated in 21 (55%) patients. The other 17 (45%) patients had additional injuries to the neck, face, brain, chest, or abdomen. Laryngeal fractures were bilateral in 31 (82%) patients and were associated with hyoid bone fractures in nine (24%) patients. Arytenoid luxation was present in eight cartilages. Axial imaging missed 7 of 59 (12%) laryngeal fractures, six of eight (75%) arytenoid luxations, and four of nine (44%) hyoid bone fractures. Additional 2D MPR imaging missed 5 of 59 (8%) laryngeal fractures, five of eight (62.5%) arytenoid luxations, and two of nine (22%) hyoid bone fractures, whereas 3D volume-rendered images depicted them all. Virtual endoscopy and 3D volume rendering added diagnostic accuracy with respect to the length, width, shape, and spatial orientation of fractures in 22 of 38 (58%) patients; arytenoid luxation in six of eight (75%) luxations; and the evaluation of airway narrowing in 19 of 38 (50%) patients. Three-dimensional volume rendering was not of additional value in evaluation of the cricoid cartilage.

CONCLUSION

The use of 2D MPR and 3D volume rendering with or without virtual endoscopy improved assessment of thyroid and hyoid bone fractures, arytenoid luxations, and laryngotracheal narrowing, providing helpful data for optimal management.

Imaging of laryngeal trauma

External laryngeal trauma is a rare but potentially life-threatening situation in the acutely injured patient. Trauma mechanism and magnitude, maximum focus of the applied force, and patient related factors, such as age and ossification of the laryngeal cartilages influence the spectrum of observed injuries. Their correct diagnosis and prompt management are paramount in order to avoid patient death or long-term impairment of breathing, swallowing and speaking. The current review provides a comprehensive approach to the radiologic interpretation of imaging studies performed in patients with suspected laryngeal injury. It describes the key anatomic structures that are relevant in laryngeal trauma and discusses the clinical role of multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) in the acute emergency situation. The added value of two-dimensional multiplanar reconstructions (2D MPR), three-dimensional volume rendering (3D VR) and virtual endoscopy (VE) for the non-invasive evaluation of laryngeal injuries and for treatment planning is discussed. The clinical presentation, biomechanics of injury, diagnostic pitfalls and pearls, common and uncommon findings are reviewed with emphasis of fracture patterns, involvement of laryngeal joints, intra- and extralaryngeal soft tissue injuries, and complications seen in the acute emergency situation. The radiologic appearance of common and less common long-term sequelae, as well as treatment options are equally addressed.

[Penetrating injuries in the face and neck region. Diagnosis and treatment]

Penetrating head and neck injuries often present with vascular lesions and airway compromise and may be life-threatening. Thus controlling bleeding and airway stabilisation take priority in emergency treatment. High-velocity projectiles, fragmentations from improvised explosive devices (IEDs) and shrapnel can cause severe tissue injury, representing a challenge for the head and neck surgeon. Since several organ structures, such as the eyes, midface, pharynx, larynx, trachea, esophagus, nerves, vessels and vertebral spine can be injured at the same time, patients should be referred to a specialized trauma center for interdisciplinary treatment following emergency treatment. High-speed ballistic injuries were once confined to the battle field and have been uncommon in Europe since World War II. For this reason, experience among civilian head and neck surgeons is at present limited. With the increased incidence of terrorism and the use of IEDs as the preferred weapon in terrorism it has become important for civilian head and neck surgeons to understand the role of ballistic injuries in mass casualty events. The present paper discusses current viewpoints in the diagnosis and treatment of penetrating head and neck injuries.

Blunt cerebrovascular trauma causing vertebral arteryd issection in combination with a laryngeal fracture: a case report

Introduction

The diagnosis and therapy of blunt cerebrovascular injuries has become a focus since improved imaging technology allows adequate description of the injury. Although it represents a rare injury the long-term complications can be fatal but mostly prevented by adequate treatment.

Case presentation

A 33-year-old Caucasian man fell down a 7-meter scarp after losing control of his quad bike in a remote area. Since endotracheal intubation was unsuccessfully attempted due to the severe cervical swelling as well as oral bleeding an emergency tracheotomy was performed on scene. He was hemodynamically unstable despite fluid resuscitation and intravenous therapy with vasopressors and was transported by a helicopter to our trauma center. He had a stable fracture of the arch of the seventh cervical vertebra and fractures of the transverse processes of C5-C7 with involvement of the lateral wall of the transverse foramen. An abort of the left vertebral artery signal at the first thoracic vertebrae with massive hemorrhage as well as a laryngeal fracture was also detected. Further imaging showed retrograde filling of the left vertebral artery at C5 distal of the described abort. After stabilization and reconfirmation of intracranial perfusion during the clinical course weaning was started. At the time of discharge, he was aware and was able to move all extremities.

Conclusion

We report a rare case of a patient with vertebral artery dissection in combination with a laryngeal fracture after blunt trauma. Thorough diagnostic and frequent reassessments are recommended. Most patients can be managed with conservative treatment.

[Penetrating gunshot wound in the neck. Case report and review of the literature]

Penetrating gunshot neck injuries present a serious challenge for the primary attending surgeon. By means of a case treated in the German Field Hospital in Mazar-e-Sharif (northern Afghanistan) and a review of the literature, the principles of diagnosis and treatment of penetrating zone II neck injuries due to gunshots or shrapnel are presented.

Multidetector row computed tomography of the injured larynx after trauma

Laryngeal trauma is rare and can occur as an isolated injury or as part of multitrauma. On the basis of airway patency, it is decided whether the patient needs rapid surgical intervention or whether the patient would profit from preoperative imaging done with multidetector row multislice thin section computed tomography with multiplanar reconstruction in the soft-tissue and bone window setting. Grading the fracture pattern from minor isolated to multiple dislocated fracture lines helps to plan individual treatment options and to prevent long-term voice complications.