- Hoarseness, neck pain, crepitus, loss of normal midline neck landmarks.
- Fiberoptic examination is a key to the diagnosis; computed tomography scans are extremely helpful.
- Consider concomitant injuries with penetrating trauma.
The larynx serves three important functions: airway protection, regulation of respiration, and phonation. Injury to the larynx resulting from trauma can therefore be devastating. Fortunately, laryngeal trauma is rare and occurs in only a small percentage of trauma victims. Standardized protocols have been developed to help guide the accurate evaluation and identification of injuries requiring operative intervention. Early diagnosis and treatment are critical to prevent dire consequences, including death.
External Laryngeal Trauma
The relatively low incidence of laryngotracheal injuries results from the natural defenses that the body has to protect the vital structures that allow us to breathe. The relatively high position of the sternum and low position of the mandible along with the thick musculature of the lateral neck allow only a relatively short segment of the airway to be exposed.
Furthermore, there is a naturally protective reflex that causes the head to be flexed downward when startled, allowing for further protection of this region. Injury typically occurs when the body cannot protect this area. This generally occurs in motor or recreational vehicle accidents, assaults (including domestic violence), sports injuries, or strangulation. In motor vehicle accidents, the laryngeal skeleton and/or cricoid cartilage may be shattered between the steering wheel and the cervical spine. Clothesline injuries, although rare, may result classically in cricotracheal separation and bilateral recurrent laryngeal nerve injuries.
The pediatric age group deserves special mention because children have anatomic differences that make the management of laryngeal injuries a distinct entity when compared with the management of similar injuries in adults. Although children are less prone to laryngeal fracture owing to the high position of the larynx in the neck and the increased pliability of the laryngeal cartilage, their diminutive anatomy makes them more vulnerable to life-threatening complications from the injury.
Penetrating trauma to the neck is challenging because up to 30% of patients have multiple structures injured. Penetrating neck trauma usually results from stabbings or gunshot wounds. The severity of a penetrating injury is determined by the mass and velocity of the missile. Therefore, generally, high-velocity, large-caliber bullets will create more damage. However, a variety of bullet types are available that can increase local tissue damage, either by breaking up or exploding on contact or by spiraling in the tissues.
Because of sophisticated intensive care units, critically ill patients are being sustained longer on ventilatory support with the potential long-term consequences of affected speech and airway patency. Such complications may include scarring of the laryngeal structures, subglottic or tracheal stenosis, formation of granulation tissue, and vocal fold paralysis/paresis. Although the true incidence is unknown, complication rates of 4–19% have been ...