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Table of Contents
STUDENTS CORNER
Year : 2012  |  Volume : 2  |  Issue : 2  |  Page : 98-100

External laryngeal trauma: A management dilemma


Department of ENT, Bharati Hospital and Research Centre, Pune Satara Road, Pune, Maharashtra, India

Date of Web Publication5-Feb-2013

Correspondence Address:
Haris M Qadri
C/O - ENT Department Bharati Hospital and Research Centre Pune Satara Road, Pune - 43, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2230-9748.106994

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   Abstract 

External laryngeal trauma though uncommon but it is a life threatening ENT emergency. Early diagnosis, prompt establishment of a secure airway is the key for good outcome. Here we present a series of three cases of external laryngeal injury with significant trauma managed conservatively with good recovery to discuss the present concepts in management of external laryngeal trauma. The first case was presented with neck swelling and inability to speak after suicidal attempt. CT scan showed fracture of thyroid cartilage and hyoid bone. Second patient following trauma had change in voice and pain in neck with extensive injury clinically and on CT scan showed gross emphysema in soft tissue planes extending from skull base to mediastinum with comminuted fracture of anterior thyroid cartilage. The third patient presented with change in voice and respiratory distress. CT scan showed cricoid fracture at subglottic level. All these three patients were managed conservatively with systemic steroids, antibiotics and nebulization without any surgical intervention. All three patients showed complete recovery. Conclusion: External Laryngeal trauma can be managed conservatively without active surgical intervention with good voice airway.

Keywords: Conservative management, emergency, emphysema, cricoid fracture


How to cite this article:
Qadri HM, Goyal P, Bansal A. External laryngeal trauma: A management dilemma. J Laryngol Voice 2012;2:98-100

How to cite this URL:
Qadri HM, Goyal P, Bansal A. External laryngeal trauma: A management dilemma. J Laryngol Voice [serial online] 2012 [cited 2021 Apr 22];2:98-100. Available from: https://www.laryngologyandvoice.org/text.asp?2012/2/2/98/106994


   Introduction Top


External laryngeal trauma is an rare but potentially lethal injury. It is a rare and life-threateningspectrum of injuries. Schaefer reported a cases of 139 pts an incidence of 1in 30,000 emergency visits over a 27-year period for blunt injuriesalone. [1]

External trauma to the larynx is unique because it threatens both the quality and maintenance of life. [2] Essential to the vocal and airway sphincteric functions of the larynx is restoration of the skeletal framework and epithelial lining of this organ. [3] Essential to such preservation is the early recognition, accurate evaluation, and proper treatment of such injuries.

For management of laryngeal trauma various schools of thought exist. Also the exact point of intervention in terms of tracheostomy and external surgery is not clear in literature.

Here is how we managed three cases of acute laryngeal trauma conservatively and brief insight of recent literature review.


   Case Reports Top


Case 1

Fifty-five-year-old male was brought after suicidal attempt with swelling in neck [Figure 1], inability to speak, and vomiting. There was h/o oral bleed and respiratory distress.
Figure 1: Strangulation mark on neck externally

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On examination

There was strangulation mark of 1 cm width resent around the neck. Subcutaneous emphysema was present from the level of hyoid to clavicle. Tenderness was present over thyroid cartilage. Neck girth was 44 cm.

Videolaryngoscopy [Figure 2] showed echymosis present on Rt. supraglottic region anteriorly to the base of epiglottis. Subcutaneous emphysema was present. Bilateral vocal cords were mobile.
Figure 2: Echymosis on the supraglottis

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X-ray cervical spine: showed extensive soft tissue emphysema in neck which was extending into mediastinum.

MSCT neck and larynx: Emphysema was involving the subcutaneous planes of neck, neck spaces extending from base of the skull upto superior mediastinum. Anterior laryngeal wall disruption at C4-C5 vertebral level. There was fracture of thyroid cartilage and hyoid bone [Table 1].
Table 1: Thyroid cartilage findings on CT (n = 3)

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Case 2

Fourty-four-year old male was brought with complaints of iron rod hitting his neck anteriorly while working in his workshop. Following which patient had change in voice and pain in neck. He also gave history of oral bleed and odynophagia.

On examination

Neck: Oedema was present over anterior aspect of neck. Bilateral surgical emphysema was also present. There was tenderness present over hyoid and thyroid cartilage. Girth was 35 cm.

Videolaryngoscopy showed edematousendolarynx. There was minimal phonatory gap present. Lt. vocal cord not mobile. Rt. vocal cord was mobile.

X-ray cervical spine: showed extensive surgical emphysema in neck.

MSCT neck/larynx

Gross emphysema was noted in soft tissue planes extending from skull base to mediastinum. Comminuted fracture of anterior thyroid cartilage was noted [Table 1]. There was linear air filled track tracking from vestibule of larynx to subcutaneous fat planes is noted, suggestive of traumatic rupture.

Case 3

Seventy-six-Year old female came with history of assault by a stranger who tried to snatch her necklace from her neck. She presented with H/o change in voice, respiratory distress, and vomiting.

On examination

Neck: There was swelling over anterior aspect of neck, strangulation mark was present.

Laryngeal framework widening was present. Laryngeal crepitus was present. Neck Girth was 40 cm.

Videolaryngoscopy showed left aryepiglottic fold echymosis. Left vocal cord was immobile and right vocal cord was mobile. Pooling of saliva was also present.

X-ray cervical spine: There was surgical emphysema seen in neck.

CT neck [Figure 3]

There was cricoid fracture present at the level of subglotic region [Table 2]. Surgical emphysema was present.
Figure 3: Fracture of cricoid

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Table 2: Cricoid cartilage findings on CT

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Learning points

Laryngeal trauma although uncommon can be life-threatening. [3] Literature review suggests that examination, video laryngoscopy, and radiological imaging is necessary in all suspected laryngeal traumas. [4]

Laryngotracheal injury has been classified by Schaefer as under: [5]

  • Group I injuries include minor endolaryngeal hematoma, edema, or laceration without detectable fracture.
  • Group II injuries have edema or hematoma, minor mucosal disruption without exposed cartilage, and non-displaced fractures noted on CT scan.
  • Group III Massive edema, mucosal disruption, displaced fractures, exposed cartilage, and/or cord immobility.
  • Group IV injury is the same as group III with the addition of two or more fracture lines, skeletal instability, or significant anterior commissure trauma.
We had three cases of external laryngeal trauma due to various causes' one being due to suicide, one due to blunt trauma, and third due to assault. The severity of laryngeal injury was more or less similar in these cases. First having anterior laryngeal wall disruption, second having communited fracture of thyroid, and third having cricoid cartilage fracture.

According to the Schaefer classification above cases were in groups 2 and 3 of laryngeal trauma. Tracheotomy and plan for open procedure are advised by Schaefer in such cases; however, we observed these cases very closely under steroid cover and monitored the progress of patient's condition. Remarkably, all three patients improved to completely normal without any intervention.

From this case series we as post graduates realize that all external laryngeal trauma do not need tracheotomy or surgical intervention, they can be managed by steroids cover and close observation.

 
   References Top

1.Schaefer SD. The acute management of external laryngeal trauma. A 27-year experience. Arch Otolaryngol Head Neck Surg 1992;118:598-604.  Back to cited text no. 1
[PUBMED]    
2.Biller HF, Moscoso J, Sanders I. Laryngeal trauma. In: Ballenger JJ, Snow JB, editors. Otorhinolaryngology: Head and neck surgery. Philadelphia, PA: Lippincott Williams and Wilkins; 1996. p. 518-25.  Back to cited text no. 2
    
3.Close DM. Traumatic avulsion of the larynx. J Laryngol Otol 1981;95:1157-8.   Back to cited text no. 3
[PUBMED]    
4.Schaefer SD. Laryngeal and esophageal trauma. In: Cummings CW, Fredrickson JM, Harker LA, Krause CJ, Schller DE, Richardson MA, editors. Otolaryngology, head and neck surgery. New Yourk: Mosby-Year Book, Inc.; 1998. p. 2001-12.   Back to cited text no. 4
[PUBMED]    
5.Schaefer SD, Close LG. Acute management of laryngeal trauma. Update. Ann Otol Rhinol Laryngol 1989;98:98-104.  Back to cited text no. 5
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]



 

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