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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 supraglottic regions. The goal with any patient presenting to the emergency department with a laryngeal injury should be to secure an airway and obtain rapid surgical intervention.
Causes of Laryngotracheal Injuries
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.[rx]
Symptoms of Laryngotracheal Injuries
The common symptoms include
- Breathing noises that may change with position and improve during sleep
- Breathing problems that get worse with coughing, crying, feeding, or upper respiratory infections (such as cold)
- High-pitched breathing
- Rattling or noisy breaths
- High-pitched breathing
- Rattling or noisy breathing (stridor)
- Frequent infections in the airway, such as bronchitis or pneumonia (because your child can’t cough effectively or otherwise clear their lungs)
- Frequent noisy cough
- Exercise intolerance
- Prolonged respiratory infections
- Choking during feeding
- A halt in breathing, particularly when crying or during strenuous activity
- Blue spells (child appears blue because they aren’t getting enough oxygen)
Diagnosis of Laryngotracheal Injuries
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.
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. [rx]
Treatment of Laryngotracheal Injuries
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.[rx] 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.[rx]
In 2014 Schaefer reviewed 90 years of publications about an acute laryngeal injury.[rx] 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.