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Laryngeal Injury


Laryngeal Injury

Article Author:
Kerollos Shaker
Article Author:
Ryan Winters
Article Editor:
Elizabeth Jones
Updated:
3/14/2020 10:56:47 AM
For CME on this topic:
Laryngeal Injury CME
PubMed Link:
Laryngeal Injury

Introduction

Laryngotracheal injuries have a high mortality rate although they are infrequently seen. These injuries may be penetrating or blunt and can occur in the supraglottic, glottic or infraglottic regions. The goal with any patient presenting to the emergency department with a laryngeal injury should to be to secure an airway and obtain rapid surgical intervention.

Etiology

Laryngeal injuries occur more commonly in unrestrained drivers during motor vehicle accidents where the extended neck strikes that dashboard or the steering wheel with compression of the larynx between the object and the cervical spine. Fortunately, the motor vehicle accident injuries to the neck have decreased due to the increased use of seatbelts, improved dashboard designs, and the presence of airbags. Other causes include penetrating trauma, assault, attempted strangulation, near hanging, and clothesline injuries.Iatrogenic laryngeal injury can occur during bronchoscopy, emergent intubation or percutaneous tracheostomy.[1]

Epidemiology

Injuries to the larynx account for less than 1% of all traumatic injuries.It is a common cause of death in patients with head and neck trauma, second to intracranial injury. Children have a higher risk of respiratory compromise from this injury due to their lack of laryngeal cartilage calcification which starts in the teenage years. The Schaefer Classification System is used to grade the severity of laryngeal injuries. This classification ranges from:

  1. Minor endolarygeal hematoma or laceration without fracture
  2. Severe edema, hematoma, non-displaced fracture or minor mucosal disruption without exposed cartilage
  3. Massive edema, large mucosal lacerations, displaced fractures or vocal cord immobilization, with exposed cartilage
  4. Severe disruption of anterior larynx, unstable fractures, 2 or more fracture lines, and extensive mucosal injuries
  5. Complete laryngotracheal separation.[2]

In clinical practice, most providers sort the patients into stable or unstable categories.

History and Physical

The patient with a laryngotracheal may present in extreme distress or may only complain of mild hoarseness. Most patients have some vocal change or pain to the neck. Evaluation of the neck may reveal bubbling or air leakage from a neck wound, subcutaneous air and crepitus over the larynx, dysphonia, dyspnea, aphonia, stridor, laryngeal crepitus, neck wound, or neck hematoma. Patients with laryngeal injuries may not tolerate lying flat. There may be no visible neck wound initially. 

Evaluation

Patients presenting with an injury to the neck can appear initially stable but decompensate quickly. All patients should be placed on cardiac and pulse oximetry monitoring and two large IVs should be established. All patients require evaluation of the airway, breathing, and circulation. Those with signs of significant injury or respiratory distress will need a definitive airway. After stabilizing the patient, the completion of the primary and second survey should be completed to evaluate for other signs of trauma or injury.

On physical examination, the provider should assess air movement, vocal quality, abnormal airway sounds, neck wounds, neck swelling and crepitus in neck soft tissues.

Xrays and CT scans may be useful in the diagnosis of laryngotracheal injury, but are only appropriate for patients with no respiratory distress or signs of impending airway failure. Plain radiographs can be used to evaluate for foreign bodies, fracture, or airway edema. CT scan of the neck and chest has a sensitivity of 100% and provides excellent details about laryngeal integrity. Because vascular injury occurs with blunt or penetrating neck injury CT angiogram of the neck should be ordered in trauma patients. Injuries not seen on CT are unlikely to require surgical intervention. Flexible nasopharyngoscopy or laryngoscopy allows evaluation of laryngeal integrity directly and should be considered at the time of intubation.

The associated esophageal injury occurs in 4-6.3% of patients with laryngeal injury. Because esophageal injury can be life-threatening the esophagus must be imaged. Barium swallow, CT esophagoscopy with contrast and flexible and rigid esophagoscopy may be used to diagnose the esophageal injury. Rigid esophagoscopy is the most sensitive, but requires anesthesia. All patients already having surgery should have rigid esophagoscopy, while others may by evaluated using barium swallow, CT or esophagoscopy according to local availability. [3]

Treatment / Management

The initial management of laryngeal injuries is to evaluate and establish an airway. The first decision point is "Is the airway stable?" If the patient is talking normally, the airway is patent.[4] The following signs and symptoms increase the necessity of intubation, cricothyroidotomy, or tracheotomy: respiratory distress, neck hematoma, significant bleeding, subcutaneous neck emphysema, stridor, hoarseness, hemoptysis, thrill or bruit, and distorted neck anatomy. For those with a significant laryngeal fracture or impending airway obstruction, tracheostomy should be performed.

In the vast majority of the patients, flexible fiberoptic intubation via the nasal or oral route is the preferred method for patients with laryngeal trauma. Fiberoptic intubation allows for direct visualization of the larynx, trachea and upper airway structures. Rapid sequence intubation using direct laryngoscopy (DL) may be appropriate when anatomic structures are maintained, but is not optimal.  This is because the airway below the vocal cords is not visualized with DL. A tracheal tear or partial laryngotracheal separation could be worsened by a blindly placed endotracheal tube. For patients with neck trauma that distorts the anatomic landmarks or those with significant hematemesis or hemoptysis, a surgical airway is preferred. Prior to airway attempts, it is prudent to prepare for fiberoptic laryngoscopy, rapid sequence intubation using DL, and surgical airway. If bag-mask ventilation is needed, it should be gentle as overaggressive bagging may harm the patient.

Airway management in laryngotracheal injury may require rapid coordination of available resources. ED physicians, anesthesiologists, trauma surgeons and/or otolaryngologists as well as respiratory therapy may assist in airway management depending on local expertise and availability. A team approach is often best with the ED physician or anesthesiologist attempting fiberoptic intubation with a surgeon at bedside ready to perform an emergency tracheostomy as needed.

Unstable patients who display other injuries in the neck such as active hemorrhage or penetrating neck wound need immediate management in the operating room. Stable patients can be monitored, taken to the CT scanner for imaging, and admitted for further testing and observation. All patients who are watched require frequent examinations of the neck/chest for possible delayed symptoms.[5]

In 2014 Schaefer reviewed 90 years of publications about an acute laryngeal injury.[3] He proposed the following management scheme based on his literature review and clinical experience:

Impending Airway Obstruction: Expert airway management resulting in tracheostomy, intubation or cricothyrotomy as described above. All patient are then evaluated with direct laryngoscopy and esophagoscopy. Treatment of findings after laryngoscopy and esophagoscopy should be as follows:

  • Normal endolarynx or mucosal injury without fracture--Observation
  • Thyroid or cricoid fracture with intact endolarynx--Neck exploration, open reduction and internal fixation (ORIF) of laryngeal skeletal fractures with plating without thyrotomy.
  • Unstable fractures or anterior commissure disrupted or major mucosal lacerations--ORIF of fractures, repair of mucosal lacerations and endolaryngeal stent or lumen keeper. 
  • Stable laryngeal fracture, anterior commissure intact, minor mucosal alterations--Neck exploration, ORIF of laryngeal skeletal fractures with plating thyrotomy, primary closure of lacerations.

Stable Airway: Flexible fiberoptic laryngoscopy and computed tomography of the neck. Videostroboscopy of the larynx and electromyography of the larynx may also be used according to availability and local expertise. Treatment is dictated by findings of these studies.

  • Normal endolarynx with or without reversible mucosal injury without fracture--observation.
  • Endolarynx or cartilage disruption--tracheostomy or intubation, direct laryngoscopy and esophagoscopy, neck exploration and repair of findings as under "impending airway obstruction."
  • Schaefer further concludes from this review that treatment of airway injuries within 24 hours yields the best results.

Differential Diagnosis

Vascular injury – produces hemorrhage, hypotension, and stroke symptoms

Pharyngoesophageal injury – produces blood in saliva, hematemesis, and hemoptysis

Pneumothorax – respiratory distress

Pertinent Studies and Ongoing Trials

There are no randomized trials of laryngotracheal injury.

Prognosis

Laryngotracheal injuries have a high mortality rate and require early airway management. Missing a significant laryngeal injury can lead to airway obstruction and death. Patients with abrasions and/or small lacerations of the larynx or trachea are usually managed conservatively.  Patients with laryngeal fractures who receive early airway management have an improved recovery rate. Patients who receive early diagnosis and treatment have better vocal and airway outcomes.

Complications

Laryngotracheal injuries can lead to many complications such as dyspnea, voice change, chronic pain, laryngeal stenosis, dysphagia, recurrent pneumonia, airway obstruction, and death.

Postoperative and Rehabilitation Care

In almost all injuries, hospitalization is required for observation. Some laryngotracheal injuries such as small mucosal injuries, nondisplaced fractures, and hematomas may be managed conservatively with elevation of the head, humidified air, analgesia, antibiotics, steroids, vocal rest, and clear diet.The long-term goal of treatment for these patients is to restore their swallowing mechanism and voice. [6]

Consultations

During the management of the patient with an unstable airway, the physicians with the most experience with unstable airway management should be consulted immediately. It may be appropriate to involve ED physicians, anesthesiologists, trauma surgeons and head and neck surgeons. Head and neck surgeons should be consulted in all suspected laryngeal injures to assist in evaluation and management of the injury.

Deterrence and Patient Education

Patients with trauma to the neck whether sustained in a motor vehicle accident, gun shot, attempted hanging, knife to the neck, or assaults should present to the Emergency Department for evaluation as injuries to the larynx or trachea are serious and can result in death. Even if the person is currently asymptomatic, serious delayed complications may occur. In those patients having trouble breathing, the doctor will need to place a tube in the throat either through the mouth or by cutting a hole in the neck. Stable patients without significant trauma may need imaging, observation in the ED, or admission.

Pearls and Other Issues

  • Laryngotracheal injuries are serious, have high mortality, and require airway management
  • Airway compromise may be delayed
  • Fiberoptic intubation is the preferred method for intubation
  • Prepare for surgical airway in the event that oral intubation fails
  • Stable injuries need additional imaging such as CT scan, esophageal imaging and observation
  • Unstable injuries need operative management
  • Do not delay surgical consultation [7]

Enhancing Healthcare Team Outcomes

The management of a laryngeal injury requires multiple personnel to successfully resuscitate the patient. If an injury is suspected, nursing staff, respiratory therapist, emergency medicine physician and trauma surgeon will need to be involved. Communication about the trauma assessment should take place with emphasis of establishing an airway. In order to improve this, all equipment should be present immediately on patient's encounter to the ED including flexible fiberoptic scope in addition to airway kit and mechanical ventilation. [8]



(Click Image to Enlarge)
Classification used in determining laryngeal injury severity
Classification used in determining laryngeal injury severity
Moonsamy P, Sachdeva UM, Morse CR. Management of Laryngotracheal Trauma. Ann Cardiothoracic Surg. 2018;7(2):210-216.

References

[1] Kragha KO, Acute traumatic injury of the larynx. Case reports in otolaryngology. 2015;     [PubMed PMID: 25821621]
[2] Moonsamy P,Sachdeva UM,Morse CR, Management of laryngotracheal trauma. Annals of cardiothoracic surgery. 2018 Mar;     [PubMed PMID: 29707498]
[3] Schaefer SD, Management of acute blunt and penetrating external laryngeal trauma. The Laryngoscope. 2014 Jan;     [PubMed PMID: 23804493]
[4] Brennan J,Gibbons MD,Lopez M,Hayes D,Faulkner J,Eller RL,Barton C, Traumatic airway management in Operation Iraqi Freedom. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. 2011 Mar;     [PubMed PMID: 21493199]
[5] Fuhrman GM,Stieg FH 3rd,Buerk CA, Blunt laryngeal trauma: classification and management protocol. The Journal of trauma. 1990 Jan;     [PubMed PMID: 2296072]
[6] Levine RJ,Sanders AB,LaMear WR, Bilateral vocal cord paralysis following blunt trauma to the neck. Annals of emergency medicine. 1995 Feb;     [PubMed PMID: 7832358]
[7] Schaefer SD, The acute management of external laryngeal trauma. A 27-year experience. Archives of otolaryngology--head     [PubMed PMID: 1637537]
[8] Butler AP,Wood BP,O'Rourke AK,Porubsky ES, Acute external laryngeal trauma: experience with 112 patients. The Annals of otology, rhinology, and laryngology. 2005 May;     [PubMed PMID: 15966522]