Case Report

Laryngotracheal disruption after blunt Neck trauma

Laryngotracheal injuries after motor vehicle accidents are rare. They are mostly confined to the cervical trachea, resulting from direct blunt injury to the anterior neck. In addition, complete laryngotracheal separation carries a high mortality rate immediately, and its early diagnosis is very difficult because of nonspecific signs in the settings of acute trauma. We present a case of a 27-year-old man who experienced a high-energy blunt trauma to the neck, and we discuss the clinical signs and symptoms in laryngotracheal injuries, the importance of imaging features and manage- ment in this kind of injury.

A 27-year-old male motorcyclist was transferred to the emergency department after a car hit him. Glasgow score was 3, and he received cardiopulmonary resuscitation immediately with orotracheal intubation. Physical examina- tion revealed subcutaneous emphysema from the supra- clavicular regions to the angle of the mandible, with slight tenderness when palpating the thyroid cartilage, without any

Fig. 1 Axial computed tomographic scan with contrast, at the level of the vocal cords, showing multiple fractures of thyroid (big arrow) and cricoid cartilages. Extensive hemorrhage and edema totally obliterate the airway (double asterisk) around the orotra- cheal tube. The internal jugular vein and the carotid (asterisk) are also shown. Bilateral marked emphysema resulting from the laryngotracheal disruption is also evident. The left thyroid ala is displaced medially against the arytenoid cartilage (small arrow).

penetrating wounds or ecchymosis of the skin. When he became stable, a high-resolution computed tomographic scan revealed complex fractures of the thyroid and cricoid cartilages, extensive hemorrhage and edema totally obliter- ating the airway (Fig. 1) with complete laryngotracheal disruption (Figs. 2 and 3), diffuse subcutaneous emphyse- ma, right pneumothorax, pneumomediastinum, pneumo- peritoneum, and right Hip fracture. He underwent immediate laryngotracheal reconstruction and insertion of bilateral Chest tubes. On regular follow-up, he was dysphonic, with a slight paresis of both vocal cords.

Airway trauma may be life-threatening, immediately or in the hours after acute injury. In civilian practice, blunt trauma to the airway from motor vehicle accidents used to be the most common cause of such injuries [1].

Laryngotracheal injuries represent less than 1% of all trauma injuries and account for more than 75% of immediate mortality. Most injuries are confined to the cervical trachea, resulting from direct blunt trauma, where the larynx is compressed against the cervical spine. The thyroid and cricoid cartilages may be fractured and the cricoarytenoid joint dislocated.

Separation of the airway may be partial or complete. The points of rupture are most commonly between the cricoid and trachea and in the upper trachea. One or both recurrent laryngeal nerves may be temporarily or permanently

Fig. 2 Computed tomographic scan showing the free space between the orotracheal tube and the surrounding neotrachea.

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Fig. 3 Laryngotracheal disruption is evident, with the cuff of the orotracheal tube completely filling the space between the neo- trachea and the upper end of the distal trachea.

damaged [2]. In complete tracheal transection, the surround- ing tissues may provide a bneotracheaQ; therefore, intubation is very hazardous because the lower end of the endotracheal tube may pass into a false track at the site of the tracheal separation, and hence, not only obstruct the airway completely but also exacerbate any mediastinal or pleural air leak [3].

Clinical signs are nonspecific [4,5], but the diagnosis of any laryngeal injury is suspected on the presence of subcutaneous emphysema. Computed tomographic scan is the imaging modality of choice in demonstrating the various

findings in laryngeal trauma [4,6,7]: fractures, dislocations, hemorrhage, and laryngotracheal separation.

Airway management must be the highest initial priority in the unstable patient. Once stable, the damaged larynx and trachea should be repaired surgically.

Rony Aouad MD Homere Moutran MD Simon Rassi MD

Department of Otolaryngology-Head and Neck Surgery Hotel Dieu de France Hospital, Saint Joseph University PO BOX 70-056, Antelias, Beirut, Lebanon

E-mail address: [email protected] doi:10.1016/j.ajem.2007.02.048

References

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