High Yield Topics

Tracheal and Laryngeal Injuries

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Ovid: 5-Minute Sports Medicine Consult, The


Tracheal and Laryngeal Injuries
Jeffrey Feden
Razib Khaund
Basics
Description
  • Injuries to the larynx and trachea may result from either blunt or penetrating trauma involving the head, neck, or upper chest.
  • Although they are relatively uncommon and sometimes subtle, these potentially life-threatening injuries must not be overlooked.
Epidemiology
  • Laryngotracheal (LT) trauma occurs at an estimated frequency from 1/5,000 to 1/30,000 ED visits.
  • Laryngeal injuries comprise <1% of blunt and 7% of penetrating trauma cases; only 10% result from athletic trauma (1).
  • Mortality is as high as 20% and 40% for penetrating and blunt injuries, respectively (2).
Risk Factors
  • Contact and collision sports
  • Sports with high-velocity projectiles (ie, baseball, hockey, lacrosse)
  • Motor sports
Etiology
  • Laryngotracheal trauma may cause obstructive edema, submucosal hematomas, cartilage fractures, mucosal tears, or complete laryngotracheal separation.
  • Low-velocity trauma may cause soft tissue swelling, lacerations, contusions, abrasions.
  • High-velocity trauma may injure laryngeal muscles and nerves.
  • Forceful compression to the chest against a closed glottis may cause laryngeal fractures and mucosal disruption.
Commonly Associated Conditions
  • Penetrating trauma is associated with additional injury to the chest, esophagus, vasculature, or nerves in 86% of cases; esophageal injury occurs 50% of the time.
  • Blunt trauma is associated with intracranial injury (17%), cervical spine injury (13%), chest injury (13%), and esophageal injury (13%) (2).
  • Pneumothorax may accompany distal tracheal injuries.
Diagnosis
History
Signs or symptoms may be absent initially in up to 1/3 of those with LT trauma.
Physical Exam
  • Dysphonia (ie, hoarseness) and dyspnea are most common.
  • Cough, hemoptysis, odynophagia, respiratory distress, stridor
  • Loss of anatomic landmarks, anterior cervical tenderness, SC crepitus, cervical ecchymosis, or hematoma
Diagnostic Tests & Interpretation
Imaging
  • Chest radiograph to evaluate for associated trauma
  • Cervical spine radiographs to evaluate for cervical spine injury
  • Plain radiographs may show hyoid bone elevation or prevertebral air.
  • CT scan of the cervical region may be performed if the airway is stable and provides additional anatomic detail that may help to guide management decisions.
Diagnostic Procedures/Surgery
  • Flexible bronchoscopy is the preferred initial method for evaluating the stable airway.
  • Fiberoptic laryngoscopy may provide more detail about laryngeal anatomy and vocal cord function.
Treatment
Pre-Hospital
  • Initial treatment focuses on the primary survey and ABCs in accordance with Advanced Trauma Life Support guidelines.
  • Control the airway and immobilize the cervical spine.
  • Rapidly transport to the nearest ED while continuing to manage the airway.
  • Oral airways, combitubes, and laryngeal mask airways fail to provide a definitive airway by virtue of not passing below the larynx.
  • Orotracheal intubation and cricothyroidotomy may be contraindicated in cases of significant trauma or complete LT separation; either must be undertaken with extreme caution to avoid losing the airway or causing greater injury.
ED Treatment
  • Prompt assessment of the stable airway includes flexible bronchoscopy and/or fiberoptic laryngoscopy in consultation with ENT, followed by close observation, further imaging with CT scan, or surgical management in the operating room.
  • Preferred management of an unstable airway includes awake tracheotomy under local anesthesia in the operating room (2).
Additional Treatment
  • Observation in an ICU for at least 24 hr is indicated for significant LT that does not require emergent surgical intervention.
  • Some patients may develop signs or symptoms up to 48 hr after injury.
  • Monitor for signs of progressive airway compromise, and prepare for the possibility of urgent tracheotomy.

    • P.605


  • Humidified air and head of the bed elevation
  • Serial bronchoscopic examinations
  • Cryotherapy with wet ice for treatment of soft tissue injury
  • Vocal rest
  • Minimize laryngeal irritation from gastric acid with H2 blockers or proton pump inhibitors.
  • Antibiotics and systemic corticosteroids are controversial.
  • Use narcotic pain medications and sedatives with caution to avoid their effects of respiratory depression.
Additional Therapies
  • Following initial treatment, prompt phoniatric evaluation is mandatory for all patients.
  • Speech therapy may be required to restore vocal quality or to avoid permanent restrictions of phonation.
Surgery/Other Procedures
  • Indications for surgery include initial airway instability, progressive airway decline despite conservative treatment, and complex LT injuries.
  • Operative interventions range from tracheotomy to open reduction and internal fixation (ORIF) of the injured cartilaginous structures.
  • 25–80% of patients with LT trauma will require surgery.
Ongoing Care
  • Long-term treatment goals involve restoring the anatomy, airway patency, and vocal quality.
  • All athletes should be sent for phonic and speech therapy evaluations; speech therapy may be necessary to restore vocal quality.
Patient Education
  • Dysphonia is the most common and problematic complication after LT trauma.
  • Phoniatric evaluation is essential, and speech therapy may be important even after minor injuries.
Prognosis
  • Prognosis depends on injury severity, but complications may be avoided by early diagnosis and proper initial management.
  • Voice disorders typically are associated with the most severe injuries, but even minor injuries can cause permanent problems with phonation.
  • Most patients can expect excellent airway patency and good voice quality following LT trauma that has been recognized and treated appropriately.
  • Prognosis is worse for those with late presentations (who already may have laryngeal stenosis).
Complications
  • Dysphonia, hoarseness, voice fatigue, poor vocal control are most common.
  • Vocal cord paralysis owing to recurrent laryngeal nerve injury
  • Permanent phonic disorders owing to laryngeal scarring or infection
References
1. Paluska SA, Lansford CD. Laryngeal trauma in sport. Curr Sports Med Rep. 2008;7:16–21.
2. Atkins BZ, Abbate S, Fisher SR, et al. Current management of laryngotracheal trauma: case report and literature review. J Trauma. 2004;56:185–190.
Additional Reading
Bhojani RA, Rosenbaum DH, Dikmen E, et al. Contemporary assessment of laryngotracheal trauma. J Thorac Cardiovasc Surg. 2005;130:426–432.
Brosch S, Johannsen HS. Clinical course of acute laryngeal trauma and associated effects on phonation. J Laryngol Otol. 1999;113:58–61.
Mussi A, Ambrogi MC, Ribechini A, et al. Acute major airway injuries: clinical features and management. Eur J Cardiothorac Surg. 2001;20:46–51, discussion 51–52.
Codes
ICD9
  • 807.5 Closed fracture of larynx and trachea
  • 807.6 Open fracture of larynx and trachea
  • 925.2 Crushing injury of neck
Clinical Pearls
  • Laryngotracheal trauma may be immediately life-threatening.
  • Diagnosis often requires a high index of suspicion.
  • Prompt recognition and airway management are essential.
  • Complications and airway compromise may not develop until 24–48 hr following injury.
  • Consideration of associated traumatic injuries is also important.


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