Laryngeal Trauma

Injury to the airway is an important cause of death in patients with head and neck trauma. Laryngeal trauma must be recognized early to avoid catastrophic sequelae. Securing the airway is the most important initial step in the management of these injuries to preserve life. The most preventable factor in morbidity and mortality is likely a delay in diagnosis. Less severe laryngeal injuries may initially go undiagnosed, whereas major injuries can lead to early mortality.

Blunt trauma is a common cause of death in motor vehicle crashes. The mechanism of blunt laryngeal trauma is typically caused by a hyperextension of the neck (i.e., against the dashboard) with compression and fixation of the larynx against the cervical spine, which leads to fracture or comminution of cartilage with associated soft tissue injury. Laryn-gotracheal disruption can occur from "clothesline" injury, which can occur with motorcycle and snowmobile accidents.

Penetrating trauma is becoming more common with an increase in civilian violence. Knife and gunshot wounds are the most common cause of death in homicide cases. Other traumatized structures in the neck can include the great vessels, the esophagus, and the cervical spine.

Signs of laryngotracheal trauma include tenderness over the larynx, anterior neck contusion, subcutaneous emphysema, palpable fractures or crepitus, loss of thyroid prominence, tracheal deviation, and hemoptysis. Symptoms include hoarseness, shortness of breath, inability to tolerate the supine position, and dysphagia.

Examination should include flexible fiberoptic laryngos-copy in every patient, if possible, to evaluate the anatomy and function of the larynx. Diagnostic imaging includes cervical spine films, chest films, and CT scan. Unless physical examination and flexible fiberoptic laryngoscopy are normal, CT should be done in most cases. The decision to take a patient to the OR is based on history, physical examination, flexible fiberoptic laryngoscopy, and CT scanning.

As with any trauma patient, management of the airway is of primary importance. Some controversy still exists on the optimal management of the airway. Most authors recommend awake/local tracheotomy as the safest and least traumatic method of securing the airway in an adult patient with laryngeal trauma. Some reports recount the disastrous outcome of a lost airway after attempted oral or nasal intubation in patients with laryngeal trauma. However, many still advocate intubation as the initial method of securing the airway. Emergency cricothyroidotomy can be performed if time does not permit a formal tracheotomy.

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