Menu Close

Laryngotracheal Trauma

  • Home
  • Laryngotracheal Trauma
    •

Laryngotracheal Trauma.

The laryngotracheal complex plays a critical role in airway protection, swallowing, and phonation.  It consists of a cartilaginous framework, supported by various soft tissue structures like muscles and ligaments. The anatomical design allows the complex to absorb significant trauma, thus minimizing the likelihood of laryngeal injuries. But when these structures are injured, the consequences can be severe, leading to significant morbidity and even mortality. The subglottic region is the most vulnerable due to its complete cartilaginous ring structure.

Mechanisms of Laryngotracheal Injury. Injury to the laryngotracheal complex can affect various structures, including bone, cartilage, soft tissue, and neurovascular elements. The damage caused depends on the type of injury. Regardless of the mechanism, a compromised airway is a primary concern in all laryngotracheal injuries.

Types of Laryngotracheal Injuries.

  1. Blunt Injuries. Blunt trauma includes crush injuries, typically seen in motor vehicle accidents where a victim’s neck is hyperextended, and clothesline injuries, where high-velocity impact with a stationary object causes significant damage. Strangulation-type injuries, like those from hanging, can initially cause minor damage but may lead to airway compromise due to swelling.
  2. Penetrating Injuries. Penetrating injuries can vary depending on the weapon used and the location of the injury. Gunshot wounds often cause widespread damage, while stab wounds tend to cause more localized damage along the entry and exit paths.
  3. Inhalational Injuries. Inhalational injuries occur from toxic gases, fire exposure, or ingestion of caustic substances, leading to airway oedema. This type of injury can cause serious damage, requiring immediate airway management.
  4. Iatrogenic Injuries. Iatrogenic injuries are caused during medical procedures like intubation, laryngoscopy, or elective surgeries, including tracheostomy. These injuries can severely affect the laryngotracheal complex, especially in urgent airway procedures.

Pathology.

Laryngeal injury can involve various tissues, including mucosa, nerves (e.g., superior and recurrent laryngeal nerves), soft tissue (muscles, ligaments), cartilage (arytenoid, thyroid, cricoid), and the trachea. Healing often occurs by secondary intention, resulting in scarring, joint subluxation, and cartilage ankylosis. The disruption of the mucosal wave, non-vibrating segments, and possible glottic webbing can impair vocal function. Severe injuries may lead to cartilage fractures, muscle palsy, or non-union of the fractured laryngeal framework. The degree of damage ranges from minor external bruises to severe internal tears or fractures, with fractures becoming more common after 40 years due to cartilage calcification.

Pathological Changes.

Laryngeal trauma can lead to various structural abnormalities, depending on the force and location of the injury. One of the most frequent findings is haematoma and oedema, which often develop in the supraglottic or subglottic regions, obstructing the airway. Additionally, mucosal tears may occur, allowing air to escape into subcutaneous tissues, resulting in subcutaneous emphysema, a condition where crackling is felt under the skin.

Furthermore, dislocation or avulsion of the cricoarytenoid joints can impair vocal cord movement, while fractures may affect the hyoid bone, thyroid cartilage, or cricoid cartilage. In severe cases, the trachea may separate from the cricoid cartilage, often accompanied by recurrent laryngeal nerve injury, leading to vocal cord paralysis.

Classification of Laryngeal Trauma.

Laryngeal trauma can be categorized into different severity groups for more structured management:

  • Group 1: Minor endolaryngeal haematoma without detectable fracture.
  • Group 2: Oedema, haematoma, minor mucosal disruption, or undisplaced fractures.
  • Group 3: Massive oedema, mucosal tears, exposed cartilage, or vocal fold immobility.
  • Group 4: Similar to Group 3, but with more extensive laryngeal mucosal trauma or multiple fractures.
  • Group 5: Complete laryngotracheal separation.

Clinical Features of Laryngotracheal Injury.

The symptoms of laryngotracheal trauma vary depending on the structures involved and the injury’s severity. Key clinical signs include:

  1. Hoarseness, aphonia, and respiratory distress are often characterized by stridor, tachypnea, tachycardia, sweating, and the use of accessory muscles.
  2. Dysphagia, odynophagia, and aspiration may also occur, alongside local pain over the larynx that intensifies with speaking or swallowing.
  3. Haemoptysis is a possible symptom, typically due to laryngeal or tracheal mucosal tears.

Signs of Laryngotracheal Injury.

The clinical presentation of laryngotracheal trauma varies based on the extent of damage. Bruising or abrasions over the neck are common external indicators, while pain upon palpation suggests underlying injury. Subcutaneous emphysema may worsen with coughing, and the thyroid prominence might appear flattened due to cartilage fractures.

Moreover, crepitus—a grating sensation—may be felt if the hyoid bone or thyroid cartilage is fractured. In severe cases, a gap between fractured fragments can be detected. Additionally, separation of the cricoid cartilage from the trachea may lead to life-threatening airway compromise, necessitating immediate intervention.

Diagnostic Evaluation

  1. Indirect Laryngoscopy. Indirect laryngoscopy remains the most valuable tool for evaluating laryngeal injuries when the patient’s condition allows. It can reveal location and degree of oedema, haematoma, mucosal lacerations, posterior displacement of epiglottis, exposed fragments of cartilage, asymmetry of glottis or laryngeal inlet.
  2. Direct Laryngoscopy and Fibreoptic Laryngoscopy. Although direct laryngoscopy is less favourable in acute cases due to the risk of worsening airway obstruction, fibreoptic laryngoscopy offers a safer alternative. This method provides enhanced visualization without causing additional trauma, making it the preferred choice for evaluating laryngeal injuries.
  3. Imaging. Soft tissue neck X-rays help detect subcutaneous emphysema, mucosal swelling, and fractures of the hyoid bone or laryngeal cartilages. However, CT scans, especially 3D reconstructions, offer superior detail, aiding in the assessment of moderate to severe injuries. Additional imaging, such as chest X-rays, may be necessary to rule out pneumothorax or oesophageal tears.

Management Protocol for Laryngotracheal Trauma Dr Rahul Bagla ENT Textbook

Treatment of Laryngotracheal Trauma.

Early and effective management is crucial to preserve airway integrity, voice quality, proper upper aerodigestive function and swallowing function. Treatment approaches range from conservative measures to surgical interventions, depending on injury severity.

  1. Conservative Management. Patients with mild injuries require close monitoring for at least 24 hours to detect any respiratory compromise. Elevating the head, administering humidified oxygen, and enforcing voice rest help reduce swelling. Additionally, steroids are administered to minimize oedema and scarring, while antibiotics prevent the development of granulation tissue, perichondritis and cartilage necrosis.
  2. Surgical Intervention. Surgical intervention is necessary when conservative measures fail to improve airway function. Surgery aims to preserve the airway, prevent complications, and repair damage. Techniques include:
    • Tracheostomy: Preferred over intubation if airway obstruction is difficult.
    • Endoscopic Surgery: In cases where intubation fails, an anterior commissure scope can assist in placing a microlaryngoscopy tube, followed by endoscopic examination of the larynx. This allows for procedures like aspiration of hematomas, suturing of damaged vocal folds, and stent placement for voice preservation. Chronic laryngeal trauma can be treated with cold steel or laser techniques, including division of supraglottic webs and glottic adhesions. Mitomycin-C and other agents may be used to prevent fibrosis, while endoscopic dilation and injection of hyaluronic acid can treat injuries from intubation. Advanced techniques like CO2 laser ablation and balloon dilation are also employed for stenosis management.
    • Open Reduction: For severe injuries, surgical repair is performed within 3–5 days to optimize healing and if possible should not be delayed beyond 10 days. Fractures of the hyoid bone or laryngeal cartilages are stabilized using wires or titanium mini plates. Mucosal tears are sutured, and avulsed cartilage fragments are either repositioned or removed. In cases of laryngotracheal separation, end-to-end anastomosis reconnects the airway. Internal splinting with a laryngeal stent or silicone tube may be required for 2–6 weeks to maintain structural integrity. Additionally, a silastic keel can prevent anterior commissure webbing, ensuring optimal vocal function post-recovery.
  1.  

Complications of Laryngotracheal Trauma.

Common complications include:

  • Laryngeal stenosis at various levels (supraglottic, glottic, or subglottic).
  • Perichondritis or laryngeal abscess
  • Vocal cord paralysis due to nerve damage.

———— End of the chapter ————

Download the full PDF Link:

Reference Textbooks.

  • Scott-Brown, Textbook of Otorhinolaryngology-Head and Neck Surgery.
  • Cummings, Otolaryngology-Head and Neck Surgery.
  • Stell and Maran’s, Textbook of Head and Neck Surgery and Oncology.
  • Ballenger’s, Otorhinolaryngology Head And Neck Surgery
  • Susan Standring, Gray’s Anatomy.
  • Frank H. Netter, Atlas of Human Anatomy.
  • B.D. Chaurasiya, Human Anatomy.
  • P L Dhingra, Textbook of Diseases of Ear, Nose and Throat.
  • Hazarika P, Textbook of Ear Nose Throat And Head Neck Surgery Clinical Practical.
  • Mohan Bansal, Textbook of Diseases of Ear, Nose and Throat Head and Neck Surgery.
  • Hans Behrbohm, Textbook of Ear, Nose, and Throat Diseases With Head and Neck Surgery.
  • Logan Turner, Textbook of Diseases of The Nose, Throat and Ear Head And Neck Surgery.
  • Arnold, U. Ganzer, Textbook of  Otorhinolaryngology, Head and Neck Surgery.
  • Ganong’s Review of Medical Physiology.
  • Guyton & Hall Textbook of Medical Physiology.

Author:

Dr. Rahul Bagla ENT Textbook

Dr. Rahul Bagla
MBBS (MAMC, Delhi) MS ENT (UCMS, Delhi)
Fellow Rhinoplasty & Facial Plastic Surgery.
Renowned Teaching Faculty
Mail: msrahulbagla@gmail.com
India

———– Follow us on social media ————

Keywords: Voice box injury (laryngeal trauma), Windpipe damage (tracheal injury), Neck trauma (affecting breathing or voice), Laryngotracheal Trauma, Throat swelling (edema or hematoma), Airway blockage (from injury or swelling), Bruised throat (soft tissue damage)Crackling under skin (subcutaneous emphysema), Broken voice box bones (thyroid/cricoid fractures), Hoarse or lost voice (vocal cord damage), Breathing trouble after neck injury (airway compromise), Pain when touching the neckSwelling or bruising on the throat, Voice changes (raspy or weak voice), Difficulty swallowing, Noisy breathing (stridor or wheezing), Neck looks misshapen (flattened Adam’s apple), Coughing up bloodTests & Diagnosis (Simple Words), Throat camera exam (laryngoscopy), Neck X-ray or CT scan (to check for breaks), Breathing tests (to check airway function)Treatment (Plain Language)Resting the voice (no talking), Humidified air or oxygen (helps breathing), Medicines to reduce swelling (steroids), Surgery to fix broken parts (if severe), Tube in throat for breathing (tracheostomy if needed)

Leave a Reply

Your email address will not be published. Required fields are marked *