|Year : 2016 | Volume
| Issue : 1 | Page : 21-24
Laryngeal injury and subcutaneous emphysema caused by an episode of sneezing: A rare case treated with observation alone
David Forner, Timothy Phillips, Timothy Brown
Department of Surgery, Division of Otolaryngology – Head and Neck Surgery, Dalhousie University, Halifax, Canada
|Date of Web Publication||5-Apr-2017|
Otolaryngology Clinic, 3rd Floor, Dickson Building, VG Site, QE II Health Sciences Centre, 5820 University Ave., Halifax, NS B3H 2Y9
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Traumatic laryngeal injuries can be life-threatening medical events which often require intervention by otolaryngologists. To our knowledge, this is the fourth case report of laryngeal injury resulting from a sneezing episode, and the first to be treated with observational treatment alone. The following is a case report of a 33-year-old man with subcutaneous emphysema caused by laryngeal injury as a result of a sneezing episode. The patient presented to his local emergency department with anterior neck pain, odynophagia, hoarseness, and trace hemoptysis. The Division of Otolaryngology – Head and Neck Surgery was consulted after an enhanced computerized tomography scan revealed extensive subcutaneous emphysema seemingly centered around the level of the hyoid bone. Nasopharyngoscopy and gastrografin swallow were performed. Nasopharyngoscopy revealed a right vocal cord hematoma extending into the immediate anterior subglottis. Gastrografin swallow revealed no signs of esophageal perforation. The patient was discharged without further medical intervention with follow-up scheduled. Repeat nasopharyngoscopy was performed during follow-up, 6 weeks later and demonstrated complete resolution of the vocal cord hematoma. The patient was noted to have developed significant muscle tension dysphonia on the follow-up visit, likely secondary to defensive laryngeal posturing stemming from the initial injury. He was subsequently referred for voice therapy. We demonstrate the first case of treating an endolaryngeal barotrauma injury as a result of a sneezing episode with observational treatment alone. To the best of our knowledge, only three other case reports of sneezing causing laryngeal injury have been published, all of which necessitated additional medical or surgical interventions, ranging from voice restriction to systemic corticosteroids.
Keywords: Endolaryngeal injury, fracture, sneezing, subcutaneous emphysema, vocal cord hematoma
|How to cite this article:|
Forner D, Phillips T, Brown T. Laryngeal injury and subcutaneous emphysema caused by an episode of sneezing: A rare case treated with observation alone. J Laryngol Voice 2016;6:21-4
|How to cite this URL:|
Forner D, Phillips T, Brown T. Laryngeal injury and subcutaneous emphysema caused by an episode of sneezing: A rare case treated with observation alone. J Laryngol Voice [serial online] 2016 [cited 2017 Oct 20];6:21-4. Available from: http://www.laryngologyandvoice.org/text.asp?2016/6/1/21/203889
| Introduction|| |
Traumatic laryngeal injuries are usually secondary to blunt, or penetrating forces applied to the anterior neck from a diverse set of causes. Vehicular collisions, blunt or penetrating weapon assaults, and falls account for a large percentage of traumatic injuries to the laryngeal cartilages. Despite the frequency of sneezing in the general population, and the high pressures generated during such events, laryngeal barotrauma as a result of sneezing is rare, with only three other reports in the literature.,,
Symptoms associated with blunt or closed laryngeal injury largely depend on the severity of the damage. As such, signs and symptoms may include neck pain, stridor, subcutaneous emphysema, hemoptysis, hematoma, ecchymosis, laryngeal tenderness, vocal cord immobility, loss of anatomical landmarks, and bony crepitus. The severity of injury, and the associated signs and symptoms, in laryngeal trauma, has come to be grouped into the Schaefer-Fuhrman classification. The classification ranges from one to five in terms of severity. The injury mechanism of this case-report is somewhat unique as it is a barotrauma from a sneeze. There is not a predefined classification system for these type of injuries, likely due to their rarity.
Traditional management of minor laryngeal injuries includes steroids, anti-reflux medications, antibiotics, voice rest, and humidification. On the opposite end of the spectrum, management of more severe laryngeal injuries may require tracheotomy and endoscopic or open surgical repair of the injuries with possible stenting.
We, therefore, report a case of an endolaryngeal injury, resulting in subcutaneous emphysema and vocal cord hematoma, caused by an episode of sneezing, treated with conservative observation only.
| Case Report|| |
A 33-year-old male presented to his local emergency room with trace hemoptysis and extreme pain in his anterior neck following a sneeze. The patient, with a history of smoking but otherwise healthy, was driving his car when he sneezed and felt a “popping” sensation in his throat. He was able to drive himself to the hospital.
A lateral plain X-ray of the neck suggested subcutaneous emphysema, which prompted an enhanced computerized tomography scan [Figure 1], confirming subcutaneous emphysema spreading inferiorly from the hyoid bone, down the thyroid cartilage, posterior to the sternocleidomastoid muscles bilaterally, and as far as the mediastinum inferiorly. There was no identifiable fracture of the laryngeal framework or cervical trachea. While the patient's airway remained stable, with either stridor or signs of respiratory distress he did experience odynophagia, decreased neck mobility secondary to pain, and new onset hoarseness.
|Figure 1: (a and b) Enhanced computerized tomography scans at the time of initial injury presentation showing subcutaneous emphysema. The air tracked from hyoid bone down to the mediastinum, however, no obvious fracture in the larynx was noted|
Click here to view
Otolaryngology-Head and Neck Surgery was consulted to see the patient, and the patient underwent flexible nasopharyngoscopy revealing a right vocal cord hematoma, which extended slightly into the immediate anterior subglottis and base of the petiole of the epiglottis [Figure 2]. There were no other endolaryngeal injuries identified, and vocal fold mobility was intact bilaterally. A gastrografin swallow was performed and revealed no signs of esophageal perforation. The injury was classified as a Schaefer Stage 1 injury although arguably injuries from barotrauma do not necessarily easily fit into this classification system.
|Figure 2: Nasopharyngoscopy at time of initial injury presentation, showing right vocal cord hematoma|
Click here to view
It was suggested to the patient that he should be admitted to hospital for observation. However, the patient preferred to return home, and as the patient's odynophagia and neck mobility improved in the 20-h period between the initial sneezing event and consult with otolaryngology, and there was a lack of concerning upper airway signs and symptoms of obstruction, the patient was sent home without intervention. Follow-up with the attending laryngologist was arranged for 2 weeks' time.
The patient missed his initial follow-up at 2 weeks, so was seen 4 weeks after the injury. At that time, his neck mobility and dysphagia had improved back to baseline. Flexible nasopharyngoscopy with stroboscopy demonstrated resolution of the vocal fold hematoma, however, it did demonstrate marked primary muscle tension that had developed after the injury [Figure 3]. This resulted in a markedly hoarse voice. The hoarseness had reportedly not been present before the injury and stroboscopy confirmed normal laryngeal mobility and vocal fold pliability. The patient was referred for voice therapy.
|Figure 3: Repeat nasopharyngoscopy at time of follow-up reveals no vocal cord hematoma|
Click here to view
| Discussion|| |
Subcutaneous emphysema as a result of laryngeal injury due to spontaneous sneezing is an extraordinarily rare occurrence. To the best of our knowledge, such a case has only been reported three times in the literature, the first in 1950, the second in 2007, and the latest in 2011. The first, described by Quinlan, involved a 44-year-old male with a violent sneezing attack, followed by a “clicking” in his throat and development of anterior neck pain, odynophagia, and hoarseness. The patient was treated with neck strapping, diet restriction, and voice restriction, and reportedly recovered fully. Similarly, Beato et al. reported a 41-year-old male with dysphonia, odynophagia, and neck pain following severe sneezing. The patient was treated with intravenous antibiotics and corticosteroids, reflux management, and voice restriction, and again made a full recovery. Finally, Faden et al. reported a 38-year-old male with hemoptysis, throat pain, and hoarseness following a closed-nose sneeze. Interventions, in that case, were similarly relatively conservative: Humidified oxygen through face-mask, systemic corticosteroids, reflux management, systemic antibiotics, voice restriction, head of bed elevation, and pain control. This patient, too, made a full recovery.
The sneezing reflex consists of two phases, the nasal phase, and the respiratory phase. The nasal phase begins upon irritation of the nasal mucosa and stimulation of various trigeminal nerve branches. When a particular threshold of irritation is reached, the respiratory phase begins, prompting closure of the eyes, deep inspiration, and forced expiration. During this phase, the glottis closes and subglottic airway pressure increases. A study by Gwaltney et al. demonstrated intranasal pressures up to 176 mmHg for closed-nose sneezing, with open nose sneezing reaching a mean intranasal pressure of 4.6 mmHg. The glottis then dilates, causing high-velocity air to escape the mouth and nose, with the speed of a sneeze potentially reaching above 100 km/h. Indeed, it is easy to see how such vast pressures and high velocities may induce injury.
Sneezing injuries themselves are not limited to the larynx. Injury due to sneezing has been reported in rib fractures, ocular emphysema, diaphragmatic tears, stapedial fracture, and has even been reported to cause sagittal band rupture in hand.
Management of laryngeal trauma is largely dependent on the Schaefer classification of the individual injury. Five classification groups were created by Schaefer, ranging in severity from minor endolaryngeal hematomas to complete laryngotracheal separation. Traditional management of minor laryngeal injuries typically includes systemic steroids, anti-reflux medications, antibiotics, voice rest, and humidification. As previously noted, on the opposite end of the spectrum, management of more severe laryngeal injuries may require tracheotomy and endoscopic or open surgical repair of the injuries with possible stenting.
While accidental barotraumatic injuries to the larynx are rare, of these, the more common etiology is secondary to complications of jet ventilation. The type of injury can range from minor subcutaneous emphysema of the neck to bilateral pneumothorax; with the rate of these complications at 8% and <1%, respectively.
We report here the fourth case of subcutaneous emphysema caused by laryngeal injury as a result of sneezing. This is the first case to be managed without any direct medical or surgical intervention, with results comparable to previously reported cases. It should be noted that the patient refused admission to the hospital for observation despite a recommendation by Otolaryngology – Head and Neck Surgery. The patient in this study has made a full anatomic recovery by the 4-week follow-up but developed secondary muscle tension dysphonia which required voice therapy.
| Conclusions|| |
To our knowledge, this is the fourth report of sneezing causing laryngeal cartilage barotrauma and associated subcutaneous emphysema with vocal cord hematoma. Furthermore, this is the first such report to treat with a wait and watch approach. Although a rare occurrence, both trainees and experienced physicians should be aware of the possible association of sneezing and laryngeal barotrauma, including proper investigation and treatment options.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Dunsby AM, Davison AM. Causes of laryngeal cartilage and hyoid bone fractures found at postmortem. Med Sci Law 2011;51:109-13.
Faden DL, Elackatuu A, Platt M. The “closed-airway sneeze”: An unusual cause of laryngeal fracture. Otolaryngol Head Neck Surg 2011;145:515-6.
Beato Martínez A, Moreno Juara A, López Moya JJ. Fracture of thyroid cartilage after a sneezing episode. Acta Otorrinolaringol Engl Ed 2007;58:73-4.
Quinlan PT. Fracture of thyroid cartilage during a sneezing attack. Br Med J 1950;1:1052.
Schaefer SD, Close LG. Acute management of laryngeal trauma. Update. Ann Otol Rhinol Laryngol 1989;98:98-104.
Sniezek JC, Thomas RW. Laryngeal trauma. Resident Manual of Trauma to the Face, Head, and Neck. 1st
ed.. Alexandria, VA: American Academy of Otolaryngology – Head and Neck Surgery Foundation; 2012. p. 179-82.
Songu M, Onerci TM. Phyiolosgy and pathophysiology of sneezing and itching: Mechanisms of the symptoms. In: Onerci TM, editor. Nasal Physiology and Pathophysiology of Nasal Disorders. Berlin: Springer Berlin Heidelberg; 2013. p. 139-52.
Nishino T. Physiological and pathophysiological implications of upper airway reflexes in humans. Jpn J Physiol 2000;50:3-14.
Gwaltney JM Jr., Hendley JO, Phillips CD, Bass CR, Mygind N, Winther B. Nose blowing propels nasal fluid into the paranasal sinuses. Clin Infect Dis 2000;30:387-91.
Alderson BR. Stress fractures of the first rib. Br J Radiol 1944;17:323-6.
Gauguet JM, Lindquist PA, Shaffer K. Orbital emphysema following ocular trauma and sneezing. Radiol Case Rep 2015;3:124.
Karangizi AH, Renaud SJ, Rao JN, Chetty G. Diaphragmatic and intercostal muscle tear after an episode of violent sneezing: Spontaneous diaphragmatic injury. Ann Thorac Surg 2013;96:301-2.
Azem K, Caldarelli DD. Sudden conductive hearing loss following sneezing. Arch Otolaryngol 1973;97:413-4.
Sarihan A, Can Ç, Bulut M. The unusual reason of the hand injury: Sneeze. Emerg Med J 2016;33:22, 29.
Jaquet Y, Monnier P, Van Melle G, Ravussin P, Spahn DR, Chollet-Rivier M. Complications of different ventilation strategies in endoscopic laryngeal surgery: A 10-year review. Anesthesiology 2006;104:52-9.
[Figure 1], [Figure 2], [Figure 3]