Basics
Description
- Direct transfer of severe forces to the larynx
- Simple mucosal tears to fractured and comminuted cartilage:
- Epiglottis, thyroid, arytenoid, cricoid, corniculate, and cuneiform cartilages
Etiology
- Rare: 1/5,000 " 1/42,000 ED visits
- <1% of all blunt trauma
- Directly related mortality is 2 " 15%
- Blunt or penetrating trauma to the anterior neck associated with motor vehicle or motorcycle crash, assault, or recreational activities.
- Typical mechanism is hyperextension of neck with a direct blow to the exposed anterior neck.
- "Clothesline " injury is a classic mechanism (victim struck in neck by cord, wire, or branch hung across path of travel).
- Iatrogenic injuries from intubation are becoming more common with an aging population.
Bicycle handlebars:
- Extended neck hits the bar, compressing structures between the bar and vertebral column.
Diagnosis
Signs and Symptoms
- May be delayed for hours
- Blunt trauma recognition is most challenging
- Blood, cervical collar, or polytrauma may distract from subtle findings
- Neck tenderness
- Bruising or abrasions over the anterior neck
- Hoarseness or voice changes
- Hemoptysis
- Dysphonia
- Stridor
- SC or mediastinal emphysema
- Dyspnea
- Pneumothorax
- Loss of normal cartilaginous landmarks of neck
- Difficulty with mechanical ventilation
Essential Workup
- Endoscopic evaluation should take precedence over radiography, as mucosal edema may contribute to airway compromise more than skeletal injury.
- Cervical spine imaging:
- Plain radiographs are not very helpful and should not supplant cervical CT scan
- CXR:
- Identify pneumothorax, SC emphysema, and pneumomediastinum
- CT scan (with IV contrast) of cervical spine with fine cuts of larynx:
- Contrast may identify vascular injuries
- Recommended unless the patient is going directly to surgery
- Useful even in cases of apparently less severe symptoms and minor abnormalities on indirect laryngoscopy
- Pulse oximetry
MRI has not gained acceptance:
- Length of time
- Physical demands on injured patient
- Less helpful for skeletal structures
Diagnosis Tests & Interpretation
Lab
Arterial blood gas potentially useful if the patient is having respiratory difficulty:
- Identifies hypoxia, hypercarbia
Diagnostic Procedures/Surgery
- Fiberoptic laryngoscopy:
- Visualization of injuries involving the airway, vocal cords, ideally with a nasopharyngoscope
- Angiography:
- Penetrating injuries
- Only when concern exists for possible vascular injuries
- CT angiogram offers advantages to conventional angiography:
- Readily accessible and less invasive
- Can be rapidly performed
- Few complications
- Provides useful information on cervical soft tissues, aerodigestive tract, spinal canal, and spinal cord
- Fiberoptic bronchoscopy and esophagoscopy
- Surgery:
- As indicated by severity of injury
- Emergent surgical repair if necessary
Differential Diagnosis
Associated injuries:
- Intracranial injuries (13%)
- Open neck injuries (9%)
- Cervical spine injuries (8%)
- Esophageal injuries (3%)
- Carotid artery injury
- Phrenic nerve injury
- Hypoxic cerebral injury
- Airway edema
- Aspiration pneumonitis
- Air embolism
- The pediatric larynx is located higher in the neck and is more cartilaginous and mobile than in adults; thus, pediatric patients are more resistant to laryngeal fractures.
- Loosely attached submucosal tissue allows for greater soft-tissue trauma, massive edema, and hematoma formation:
- With smaller airway diameter, airway compromise can occur rapidly.
- Symptoms can vary from neck tenderness or hoarseness to respiratory distress and stridor.
- CT imaging may not add much to the physical and fiberoptic exam of the child as fractures of the poorly mineralized larynx may not be visualized.
Treatment
Pre-Hospital
- Cautions:
- Aggressive airway management may be necessary: Oxygen, suctioning
- Cervical spine immobilization
- Injury may be overlooked if patient is intubated pre-hospital for other injuries owing to loss of subjective complaints.
- Controversies:
- Elective intubation is not advocated.
Initial Stabilization/Therapy
Airway management is of primary concern:
- Severe injuries may require operative management.
- Early intubation to preclude progressive respiratory compromise.
- Formal tracheostomy under local anesthesia may be required rather than endotracheal intubation when more severe neck injury is present.
- Avoid repeated orotracheal intubation attempts:
- Proceed to surgical airway.
- Cricothyrotomy for severe maxillofacial injuries and injuries cephalad to cricothyroid cartilage.
- Avoid cricothyrotomy if hematoma present over the cricothyroid membrane or there is evidence of cricotracheal disruption.
- Emergent tracheostomy may be the only option to secure an airway.
- Elective intubation is not recommended.
- Mandatory flexible fiberoptic laryngoscopy
- CT scan if management course is in doubt
Ed Treatment/Procedures
- Supplemental humidified oxygen
- Elevate head of bed to decrease cerebral and neck soft tissue edema
- Maintain NPO status
- Voice rest as much as possible
- Obtain IV access
- Consult otolaryngologist for surgical evaluation
- Positive end-expiratory pressure and volume-controlled ventilation for severe pulmonary injury associated with acute respiratory distress syndrome or aspiration pneumonitis
Medication
- For laryngeal injury with SC emphysema:
- Assume that the mucosa of the upper airway has communicated with the deep tissue of the neck:
- Ampicillin/sulbactam: 1.5 " 3 g IV (peds: 50 mg/kg IV) q6h
- Clindamycin: 600 " 900 mg IV q8h (peds: 25 " 40 mg/kg/24h IV)
- Histamine-2 blockers to prevent irritation to mucosal injuries (e.g., ranitidine 150 " 300 mg IV; peds: 2 " 4 mg/kg/d div. q6h IV) or proton-pump inhibitors (e.g., pantoprazole 40 mg IV, no pediatric dosing)
- For laryngeal edema, steroids may be indicated:
- Not routinely used, but may be used for massive edema.
- Methylprednisolone 250 mg IV q4h (faster acting)
- Dexamethasone 8 " 10 mg IV q8h (peds: 0.15 " 0.6 mg/kg/dose IV)
If stridor present, consider nebulized racemic epinephrine: 2.25% 0.25 " 0.5 mL in 2.5 mL NS.
Follow-Up
Disposition
Admission Criteria
- Patients with true laryngeal injuries must be admitted to a monitored setting for observation and airway management; prepare for emergent surgical repair of laryngeal defect.
- Patients with suspected laryngeal injury or highly suspicious mechanism must be admitted to a monitored setting for observation and serial flexible fiberoptic laryngoscopic exams.
Mandatory admission is recommended in all patients for oximetry, oxygen, and serial fiberoptic laryngoscopic exams.
Discharge Criteria
Patients without evidence of serious laryngeal injury or airway edema or compromise after an appropriate period of observation in the ED (usually 6 hr):
- Patients can appear deceptively normal for several hours after injury; if there is any doubt, admit to a monitored setting.
Additional Reading
- Bell RB, Verschueren DS, Dierks EJ. Management of laryngeal trauma. Oral Maxillofac Surg Clin North Am. 2008;20(3):415 " 430.
- Comer BT, Gal TJ. Recognition and management of the spectrum of acute laryngeal trauma. J Emerg Med. 2012;43(5):e289 " e293.
- G ³mez-Caro A, Aus n P, Moradiellos FJ, et al. Role of conservative medical management of tracheobronchial injuries. J Trauma. 2006;61(6):1426 " 1434.
- Pancholi SS, Robbin WK, Desai A, et al. Laryngeal fracture: Treatment. Emed Otololaryngol Facial Plastic Surg. Available at: http://emedicine.medscape.com/article/865277-treatment. Updated October 22, 2012.
- Shires CB, Preston T, Thompson J. Pediatric laryngeal trauma: A case series at a tertiary childrens hospital. Int J Pediatr Otorhinolaryngol. 2011;75(3):401 " 408.
Codes
ICD9
- 807.5 Closed fracture of larynx and trachea
- 807.6 Open fracture of larynx and trachea
ICD10
- S12.8XXA Fracture of other parts of neck, initial encounter
- S12.8XXD Fracture of other parts of neck, subsequent encounter
- S12.8XXS Fracture of other parts of neck, sequela
SNOMED
- 32497008 Fracture of larynx (disorder)
- 14457000 Open fracture of larynx (disorder)
- 295723007 Fractured laryngeal cartilage (disorder)
- 88835002 Closed fracture of thyroid cartilage (disorder)