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Laryngeal Fractures

Epidemiology
Rare
M>F
Associated injuries:
Intracranial injuries (13%)
Open neck injuries (9%)
Cervical spine fractures (8%)
Esophageal injuries (3%)

Etiology
Penetrating vs. blunt
High vs. low velocity
Most commonly:
Road traffic accident
Clothesline injury

Also:
Direct blows (e.g. assaults, sports injuries, hanging,
manual strangulation, iatrogenic causes)

Pathophysiology - 1
Laryngeal fracture: Skeletal disruption cricothyroid
& cricoarytenoid dislocation
RTA: extended neck of unrestrained passenger hits
steering wheel or dashboard
Clothesline injury: Moving person hits stationary
object
Manual strangulation: low-velocity, high-amplitude
injury multiple fractures with no cartilage
displacement, no hematoma, and no mucosal tears
Direct transfer of severe forces to the larynx
devastating injuries

Pathophysiology - 2
Injuries:

Mucosal tears
Dislocations
Fractures
Also:

Edema
Hematoma
Cartilage necrosis
Voice alteration
Cord paralysis
Aspiration
Airway loss

Pathophysiology - 3
Supraglottis:
Horizontal fractures of thyroid alae
Disruption of hyoepiglottic ligament
superior & posterior displacement of
epiglottis false lumen anterior to epiglottis
? cervical emphysema

Glottis:
Cruciate fractures of thyroid cartilage near
attachment of true vocal cords

Pathophysiology - 4
Subglottis:
Crushing force on cricoid cartilage
Injury to cricothyroid joint + bilateral
recurrent laryngeal nerve injury
bilateral vocal cord paralysis

Hyoid bone:
Weakest part is center, where most
fractures occur

Pathophysiology - 5
Cricoarytenoid joint:
Thyroid ala displaced medially or larynx compressed
against cervical vertebrae cricoarytenoid
dislocation, often unilateral

Cricothyroid joint:
Anterior trauma to neck inferior cornu of thyroid
cartilage displaced posterior to cricoid cartilage
limits cricothyroid muscle function pitch control is
lost.
Injury to recurrent laryngeal nerve vocal cord
paralysis

Clinical Presentation - 1
History / Signs of cervical trauma
Symptoms of laryngeal trauma:
Hoarseness
Neck pain
Dyspnea
Dysphonia
Aphonia
Dysphasia
Odynophonia
Odynophagia

Clinical Presentation - 2
Thorough physical examination
First clear cervical spine of injury
Signs of laryngeal trauma:

Stridor
Subcutaneous emphysema
Hemoptysis
Hematoma
Ecchymosis
Laryngeal tenderness
Vocal cord immobility
Loss of anatomical landmarks
Bony crepitus

Clinical Presentation - 3
Tenderness upon palpation of larynx
acute fracture (probably)
Inspiratory stridor supraglottic
airway obstruction
Expiratory stridor subglottic airway
obstruction
Inspiratory + expiratory stridor
glottic ?

Workup

ABC
Cervical spine x-ray chest x-ray
( Barium swallow, cervical arteriography)
Endoscopy: transnasal fiberoptic laryngoscopy
IDL: avoid
CT scan (esp. 3D): extent & location of injury
MRI: not helpful
Fiberoptic nasopharyngoscopy, Direct
larnygoscopy, Bronchoscopy, Esophagoscopy

Treatment Medical - 1
Minor injuries:
Edema
Hematoma
Small, insignificant mucosal tears

Goal is to return to pre-injury laryngeal


function:
Ventilation
Phonation
Protection of lower airway

Treatment Medical - 2
Close clinical observation: in first 2448 hours after injury
Bed rest: with head of bed elevated
30-45
Voice rest: to minimize edema,
hematoma formation, and
subcutaneous emphysema
Humidified air: reduces crust
formation and transient ciliary
dysfunction

Treatment Medical - 3
NPO: followed by clear, liquid diet
TPN: Consider
NG tube: Avoid
Systemic corticosteroids: controversial (they retard
inflammation, swelling, and fibrosis, and help prevent
granulation tissue formation)
Systemic antibiotics: not required if minor trauma;
required if mucosal tears or compound fractures (no
antibiotics local infection + perichondritis
delayed healing + airway stenosis)
Antireflux medication: H2-blockers / PPI; help reduce
granulation tissue formation and tracheal stenosis

Treatment - Surgical