Acute external laryngotracheal trauma: diagnosis and management.
ABSTRACT Laryngotracheal trauma may result in lifelong complications or even death if diagnosis or treatment is delayed. Emergency room physicians, trauma surgeons, anesthesiologists, and especially otolaryngologists should maintain a high level of awareness of and suspicion for laryngotracheal trauma whenever a patient presents with multiple trauma in general or with cervical trauma in particular. Although there is some controversy regarding care, treatment in experienced hands will usually result in a favorable outcome. In this article, we review and update the diagnosis and management of acute external laryngotracheal trauma.
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ABSTRACT: Survival following tracheoesophageal transection is uncommon. Establishing a secure airway has the highest priority in trauma management. Understanding the mechanism of the incident can be a useful adjunct in predicting the likelihood and severity of specific anatomical patterns of injuries. We discuss published literature on combined tracheoesophageal injuries after blunt neck trauma and their outcome. A search of MEDLINE for papers published regarding tracheoesophageal injury was made. The literature search identified 14 such articles referring to a total of 27 patients. Age ranged from 3-73 years. The mechanism of injury was secondary to a rope/wire in 33%, metal bar in 4% of cases and unspecified in 63%. All of the patients were managed surgically. A number of tissues were used to protect the anastomosis including pleural and sternocleidomastoid muscle flaps. There were no reported mortalities. Patients with combined tracheoesophageal injury after blunt neck trauma require acute management of airway along with concomitant occult injuries.Journal of Emergencies Trauma and Shock 04/2013; 6(2):117-22.
- Injury Extra 12/2012; 43(12):144–147.
- European Journal of Intensive Care Medicine 04/2014; · 5.17 Impact Factor
Volume 85, Number 3
ACUTE EXTERNAL LARYNGOTRACHEAL TRAUMA: DIAGNOSIS AND MANAGEMENT
Acute external laryngotracheal
trauma: Diagnosis and management
From the Head and Neck Institute, The Cleveland Clinic (Dr. Lee and Dr.
Eliachar), and the Department of Otolaryngology–Head and Neck
Surgery, Hadassah University Hospital, Jerusalem (Dr. Eliashar).
Reprint requests: Walter T. Lee, MD, Head and Neck Institute, The
Cleveland Clinic, 9500 Euclid Ave., Desk A-71, Cleveland, OH
44195. Phone: (216) 444-6695; fax: (216) 445-9409; e-mail:
Walter T. Lee, MD; Ron Eliashar, MD; Isaac Eliachar, MD
Laryngotracheal trauma may result in lifelong com-
plications or even death if diagnosis or treatment is
delayed. Emergency room physicians, trauma surgeons,
anesthesiologists, and especially otolaryngologists should
maintain a high level of awareness of and suspicion for
laryngotracheal trauma whenever a patient presents with
multiple trauma in general or with cervical trauma in
particular. Although there is some controversy regarding
care, treatment in experienced hands will usually result
in a favorable outcome. In this article, we review and
update the diagnosis and management of acute external
Laryngotracheal trauma has been reported to account for
1 in every 5,000 to 30,000 emergency room visits in the
United States.1-3 Its rarity notwithstanding, it is second
to only intracranial injury as the most common cause of
death among patients with head and neck trauma.4 A blunt
or penetrating laryngotracheal injury can result in acute
airway obstruction and death at the scene of an accident
or crime. In recent years, advances in emergency services,
including better evacuation procedures and heightened
training, have improved survival rates.
The scarcity of laryngeal trauma is primarily attribut-
able to the protected position of the larynx. It is shielded
inferiorly by the sternum, superiorly by the mandible,
posteriorly by the cervical spine, and laterally by the ster-
nocleidomastoid muscles. The laryngeal complex is also
supported by muscular and tendinous attachments, which
can deflect trauma in all directions except posteriorly. The
muscular attachments disperse most external forces during
impact.5 However, an anterior force may traumatize the
larynx against the cervical spine.6
Because of the infrequency of laryngeal injuries among
surviving trauma patients, laryngeal and tracheal trauma
may too often be ignored or overlooked.1,2,7 Performing
an initial intubation or tracheostomy in a patient with
respiratory compromise may pose a risk of injury or may
contribute to a more protracted course. In fact, trauma is
the most common cause of laryngeal stenosis.6
Otolaryngologists are the guardians of the upper aerodi-
gestive tract in general and of the larynx and trachea in
particular. As such, we are responsible for the thorough
evaluation, prompt treatment, and adequate follow-up of
patients with laryngotracheal trauma. In addition, we must
develop a strong and ongoing working relationship with
anesthesiologists in order to plan and manage a laryngeal
injury. In this article, we review and update the manage-
ment of acute external laryngotracheal trauma.
Diagnosis and classification of injuries
Successful treatment of laryngotracheal trauma requires
the incorporation of a spectrum of clinical, physical, and
radiographic data. Classification and grading systems
proposed by the senior author (I.E.) years ago provide an
organizational framework as well as a wide spectrum of
management options for physicians. These guidelines are
general; evaluation and treatment must be individualized.8
Also, there is no substitute for good clinical judgment.
Management begins with an assessment of the mecha-
nism of injury, the level of injury, and the severity of
Mechanism of injury. The two main classifications of
trauma are blunt and penetrating:
Blunt trauma. The most common cause of blunt laryngo-
tracheal trauma is motor vehicle accidents. In most accidents,
the driver is thrust against the steering wheel or windshield
with the neck extended. This can result in thyroid cartilage
fracture, mucosal disruption, edema, arytenoid dislocation,
and/or torn laryngeal ligaments.7,9 Fortunately, the incidence
of blunt laryngotracheal injuries associated with automobile
accidents is declining as a result of improved dashboard
designs, passenger restraints, air bags, and other safety
devices.1 Other etiologic considerations in blunt trauma
are sports injuries and acts of violence.10,11
LEE, ELIASHAR, ELIACHAR
ENT-Ear, Nose & Throat Journal March 2006
Presenting symptoms include dyspnea, dysphonia, neck
pain, dysphagia, odynophagia, and hemoptysis. The two
most common are respiratory distress and dysphonia.3
Physical findings may include subcutaneous emphysema,
tenderness, edema, hematoma, ecchymosis, and distortion
or loss of laryngeal landmarks. Laryngotracheal injury is
sometimes overlooked because the severity of the symp-
toms does not always correspond with the extent of injury.12
Coincidental involvement of adjacent anatomic structures
may go unrecognized as a result of the delayed clinical
Age is a factor in the pattern of laryngeal fractures.5 The
thyroid and cricoid cartilages ossify during early adulthood.
In adults, a calcified laryngeal complex tends to fracture in
more than one place, whereas a cartilaginous larynx tends
to fracture at a single site.4 The more elastic properties of a
nonossified larynx afford some protection against avulsion
and rupture. The pediatric anatomy also confers protec-
tion. In a child younger than 3 years, the cricoid cartilage
is at the level of C4; in adults, it is at the level of C7. The
higher position affords children more laryngeal protection,
although it leaves the trachea more exposed.
Penetrating trauma. It is imperative to identify the source
of a penetrating injury, assess the entry and exit wounds,
and search for displaced skin, broken bone, and cartilage
fragments. A failure to remove foreign bodies may lead to
complications. Moreover, penetrating objects are likely to
cause injuries to adjacent structures. When the trachea is
involved, the clinical picture may be dominated by sub-
cutaneous emphysema, simple or tension pneumothorax,
or pneumomediastinum, which might delay detection of
the laryngeal injury. A thorough discussion of the charac-
teristics of different penetrating objects (e.g., bullets and
knives) is beyond the scope of this overview.
Level of injury. For classification purposes, the head and
neck is divided into three trauma zones: zone 1 includes
the area below the sternal notch, zone 2 extends between
the sternal notch and the mandibular angle, and zone 3
includes the area above the mandibular angle. Radiography,
endoscopy, angiography, and surgical exploration may be
indicated, depending on the nature of the clinical signs
and symptoms. Injury to the throat can also be classified
according to the anatomic level as either hypopharyngeal,
supraglottic, glottic, subglottic, and tracheal. Multiple ana-
tomic levels may be involved in laryngotracheal trauma.
Severity of injury. Injuries can be clinically classified
into five types according to the degree and extent of the
patient’s presenting symptoms and signs (table 1).1,2 The
type of injury determines the management strategy (table
2).1-3 Continual reassessment is essential at every stage
of hospital care, beginning in the emergency department,
until the patient’s safety is assured.
As is the case with every trauma patient, the first step in
the management of a patient with laryngotracheal trauma
is to secure an adequate airway by the most practical and
effective means available.13 In addition, every effort must
be made to assure that the cervical spine is secured and
immobilized to prevent serious neural injury. Once these
steps have been taken, treatment of injuries can take place.
Interdisciplinary triage may dictate that laryngeal repair
Table 1. Classification of laryngotracheal trauma according to the degree of the injury
Type Degree Symptoms Signs (in order of their incidence)
Mild voice change,
mild dyspnea, cough
Minor hematomas, small lacerations, no fractures
Obstructing hematoma, edema, minor mucosal
disruption, nondisplaced fractures
Severe airway compromise,
Massive edema and hematoma, deep mucosal tears,
exposed cartilage, aspiration, displaced fractures,
unilateral vocal fold immobility
Impending airway obstruction
Massive edema, mucosal avulsion, fragmented
cartilage, aspiration, displaced arytenoids,
bilateral vocal fold immobility
Complete airway obstruction
Skeletal collapse, structural disruption and breakdown,
complete laryngotracheal separation
Source: Modified from data included in references 1 and 2.
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ACUTE EXTERNAL LARYNGOTRACHEAL TRAUMA: DIAGNOSIS AND MANAGEMENT
be postponed while injuries to other organ systems are
Cricothyroidotomy and tracheotomy. Emergency cri-
cothyroidotomy and tracheotomy with local anesthesia
are the two most commonly used procedures for cases
of severe trauma.3 Cricothyroidotomy is the more direct,
simple, and safe way of bypassing upper airway obstruc-
tion, but it carries potential risks to the vocal folds, even
in experienced hands. Most cricothyroidotomies should
be converted to conventional tracheotomies in order to
reduce potential complications.1,2
Tracheotomy, even when expertly performed and man-
aged, is the primary cause of long-term laryngotracheal
complications. Therefore, tracheotomy should be performed
and maintained only when medically indicated.1,14 The
tracheotomy incision should be made as low in the neck
as possible to avoid further injury to the laryngotracheal
complex.1,2 The cervical incision should be vertical, which
allows for inferior extension if it becomes necessary to
achieve better anatomic exposure.2 In some cases of open
soft-tissue injuries, a tracheotomy can be performed through
the existing wounds in the neck.15 When an open surgical
laryngotracheal reconstruction is considered (i.e., in a patient
with a type 3, 4, or 5 injury), it may be wise to establish a
long-term, self-sustaining, tube-free tracheostoma and to
include it in the reconstructive procedure. This will create
a circumferential mucocutaneous junction that may prevent
further laryngotracheal damage caused by infection, granu-
lation tissue, or a prolonged foreign-body effect.1
Endotracheal intubation. Intubation may be difficult
in the presence of spinal, facial, or cervical trauma. Even
in cases of only limited intraluminal injury, intubation
may exacerbate the situation, so tracheotomy is preferred
(figure 1).3 Tracheotomy is generally preferred for patients
with a severe laryngeal injury. Finally, some concomitant
injuries––such as those to the tongue, jaw, or spine––may
preclude safe intubation. In these cases, a controlled tra-
cheotomy over a laryngeal mask airway or over a rigid
ventilating bronchoscope can be performed.1
Intubation is best performed in the context of a panen-
doscopy so that the injury is evaluated under direct vision.
A smaller tube with a high-volume, low-pressure cuff is
recommended. Fiberoptic or rigid endoscopy may be used
to both plan and perform intubation. Consideration may be
given to fiberoptically guided intubation rather than flexible
bronchoscopy if the intubation can be carried out promptly
and safely.12 Examination by an otolaryngologist during
the course of an intubation and panendoscopy and prior
to the placement of the tube is essential because once the
patient is intubated, it is difficult to examine and monitor the
larynx and trachea. These structures may become affected
by secondary inflammation, infection, and further damage
secondary to the superimposed presence of the tube. Pro-
longed intubation poses a significant risk of complications
that must not be overlooked or underestimated.
Fiberoptic and direct endoscopy. The best method of
examining the larynx during all stages of the workup is to
use a flexible fiberoptic nasopharyngoscope with suction
capability.1-3 However, this instrument may not be useful in
a patient with a severely traumatized upper aerodigestive
Table 2. Suggested management for each type
Observation, humidification, antibiotics, steroids,
Tracheotomy/intubation, panendoscopy, antibiot-
Panendoscopy, open surgical repair with or with-
out stenting and with or without tracheotomy or
Panendoscopy, open surgical repair with stent-
ing, with or without tracheotomy or tracheostomy
Tracheotomy/intubation, panendoscopy, recon-
struction, restoration, or resection with end-to-
end anastomosis with or without stenting (a long-
term tube may serve as a stent)
Source: Modified from data included in references 1, 2, and 3.
Figure 1. Intubation can exacerbate a preexisting laryngeal
LEE, ELIASHAR, ELIACHAR
ENT-Ear, Nose & Throat Journal March 2006
tract that is restricted by edema or tissue hemorrhage and
flooded with blood or secretions.1 In such instances, rigid
endoscopy, preferably with a rigid Hopkins rod telescope,
has no substitute. Endoscopic photographs may be useful
for documentation and follow-up.2
Imaging studies. Computed tomography (CT) is the im-
aging procedure of choice for the initial evaluation.1,2,3,7,11,16
Some authors have suggested that CT be employed on a
selective basis––that is, that it not be ordered for patients
with very mild injuries and for those with severe injuries
that require immediate surgical exploration.12,17,18 Other
authors routinely obtain CT once the patient is stabilized
and able to leave the emergency room or operating room.1,2,7
Obtaining a CT generally causes no significant delay in the
management of stable patients. A thin-slice axial CT may
be useful not only for demonstrating the extent of cartilagi-
nous and soft-tissue injuries, but for defining the anatomic
limits of the injury and the degree of airway obstruction,
as well. Axial CT also allows the physician to assess any
concomitant injuries involving adjacent structures in the
neck, skull, spine, and chest.1 A sagittal projection may
further enhance the three-dimensional perception of the
trauma. A spiral (helical) CT with “virtual bronchoscopy”
capability may provide additional valuable information.
Magnetic resonance imaging (MRI) allows for multiple-
axis imaging of the larynx and trachea, thereby providing
valuable information regarding the extent and configuration
of soft-tissue trauma. MRI is also useful for evaluating the
long-term complications of laryngotracheal trauma, such
as tracheal stenosis. For best results, an MRI should be
T1-weighted, and the echo and repetition time should be
short. High-resolution images should be obtained in the
direct sagittal plane, and the oblique axial and coronal
planes should be oriented both perpendicular to and paral-
lel to the longitudinal axis of the laryngotracheal airway.
One advantage that CT has over MRI is that CT requires
less time to complete.19
If a patient cannot be transferred from the emergency
room or the operating room because his or her condition
is unstable, routine x-ray studies of the cervical spine and
cervical soft tissues and plain films of the chest and skull
may be the only practically available options.
In penetrating injuries, there is always a possibility
of a pharyngoesophageal perforation and a laryngeal or
tracheoesophageal fistula. A meglumine diatrizoate (Gas-
trografin) contrast study should be performed whenever a
perforation cannot be completely confirmed or ruled out
by endoscopic examination.2
Panendoscopy. Direct rigid laryngoscopy, bronchoscopy,
and esophagoscopy are essential to assessing the trauma-
tized aerodigestive tract and the larynx.1,3 These procedures
should be performed only after the cervical spine has been
thoroughly examined for fractures. Once cervical spine
integrity has been confirmed, panendoscopy should be
performed on any patient with a type 2, 3, 4, or 5 injury.
Panendoscopy should precede surgical exploration and
repair. At the completion of the procedure, the patient may
be carefully intubated or undergo a tracheotomy performed
over a ventilating bronchoscope. The rigid Hopkins rod
telescope provides magnification, straight and angulated
exposures, and assistance in obtaining photographic and
The ultimate goals of long-term treatment are to maintain
an adequate airway, to prevent aspiration, and to restore
ventilation, deglutition, and phonation to pretrauma qual-
ity.9 Restoration or reconstructive management can be
undertaken conservatively (patients with type 1 trauma) or
invasively (all others). Patients with a type 1 injury usually
recover completely with minimal sequelae.1,2,3,15
Surgical intervention can be performed as either a closed
endoscopic procedure or as an open surgical exploration
and repair.3 Again, the decision rests on the severity of the
injury (table 2).1-3 A temporary tracheotomy with the small-
est safe and effective tube placed for the shortest possible
amount of time is recommended for patients with moderate
injuries in order to secure and maintain the airway while
hematoma and edema subside.1,9 A long-term, tube-free,
flap tracheotomy in conjunction with laryngotracheal
reconstruction is recommended for more severe cases
in order to avoid a tube’s adverse effects on the healing
processes.20 Surgical intervention should be carried out
as a direct continuation of panendoscopy of the pharynx,
esophagus, larynx, and trachea.
When irreparable segmental damage of the upper trachea
or cricoid arch is encountered, primary resection followed
by cricotracheal or tracheothyroidal anastomosis may be
the treatment of choice. This approach may also be used
to manage concomitant esophageal tears or fistulae.
Closed operative interventions. Closed reductions of
arytenoid dislocations or minimally displaced fractures
of the laryngeal skeleton, occasionally followed by en-
doscopically introduced stents, have been suggested as
alternatives to open reductions. However, experience is
limited and the success rate is low.1-3 Therefore, most
surgical interventions are open procedures.
Open surgical techniques. Jewett et al reviewed a
trauma database of 392 patients in 11 states and found
that open surgical intervention was required in 32% of
patients with external laryngeal trauma.14 The purpose
of an open intervention is to stabilize significant skeletal
fractures and to repair any associated soft-tissue injuries
(figure 2, table 3).1,21 Special attention should be given
to covering all exposed cartilage with mucosa to prevent
the formation of granulation tissue and the development
of chondritis. This can be accomplished with grafting and
Volume 85, Number 3
ACUTE EXTERNAL LARYNGOTRACHEAL TRAUMA: DIAGNOSIS AND MANAGEMENT
A review of the details of each open surgical procedure
is beyond the scope of this article. Instead, the following
four principles may be helpful:
• The treating otolaryngologist should be well trained,
experienced, and versatile.
• Each case must be approached individually. A dogmatic
approach should be avoided, and experimentation should
be condemned. Prioritize every step of the treatment. At-
tention should be directed not only to securing the airway
but to preventing aspiration and preserving voice quality,
• The operation should be kept as simple as possible,
and every step must be planned.
• Proper steps to guaranteeing the
airway postoperatively without addi-
tional risks or trauma must be achieved
Adherence to the dictate “Primum
non nocere” is critical when operating
on an injured larynx because mistakes
may be very difficult to correct. It is
important to realistically and candidly
discuss the risks of surgery––as well
as the indications, expectations, and
benefits––with the patient if possible
and with the family prior to surgery.
Stenting. Stents are predominately
used to manage severely displaced
laryngeal fractures that may cause
skeletal instability or breakdown.
Besides providing internal support
to the cartilage, stents bolster the
soft tissues and arytenoids; prevent
hematomas, web formation, and aspiration; and promote
flap and graft adherence.1,3 Many types of stents are avail-
able, including molded, tubed, hollow, and balloon-like
variations. Yet because no stent is free of limitations or
the risk of complications, controversy still surrounds the
indications for stenting and the length of time that a stent
should remain in place. Many authors believe that stenting
should be reserved for severe cases and should not exceed
2 weeks.1-3 Any surgeon who expects to become involved
in the management of acute laryngotracheal trauma or its
long-term consequences must have immediate access to a
variety of stent designs and sizes at all times.22
The essentials of postoperative care are similar to the
conservative treatment strategy (table 2). Surgeons should
keep in mind a few possible complications:
• Gastroesophageal reflux can undermine even the
best of reconstructive techniques. Therefore, it should
by controlled by head elevation, antacids, H2 blockers,
and proton-pump inhibitors. Nasogastric tubes should be
avoided if possible. If feeding by mouth is to be prohib-
ited for a prolonged period of time, a gastrostomy or an
enterostomy should be considered.1
• Aspiration following laryngotracheal trauma can occur
as a result of different mechanisms. A tracheotomy will
usually worsen aspiration rather than prevent it, primarily
because of the deleterious effect it has on swallowing.1,23
Uncontrolled, life-threatening aspirations––as well as in-
fections––may require radical measures such as prolonged
stenting, diversion, occlusion, and even total laryngectomy
in severe cases.1
Table 3. Ten steps to performing an open reduction
1. Assess the injury.
2. Secure the airway at all stages.
3. Prevent and control infection.
4. Define the injury.
5. Debride and perform immediate grafting if indicated.
6. Restore soft tissues and skeletal cartilages by reduc-
tion, repositioning, grafting, and/or resecting anasto-
7. Immobilize and fix fractures with internal support by
stenting, wiring, or miniplating.
8. Close any fistulae.
9. Stent to provide internal support, bolster grafts and
flaps, prevent webs, and aspirate.
10. Include management of tracheotomy/tracheostomy in
the surgical plan.
Source: Modified from data included in reference 1.
Figure 2. Illustrations show a laryngeal cartilage fracture (A) that has been stabilized
with a plate (B).
ENT-Ear, Nose & Throat Journal March 2006
LEE, ELIASHAR, ELIACHAR
• Some extensive reconstructive procedures––for exam-
ple, laryngofissure, arytenoidectomy, vocal fold resection,
and cordotomy––may result in a secure airway and closure
of the tracheotomy site at the expense of voice quality.
• Long-term treatment and close follow-up are necessary
in cases where scarring may progress and persist.24
In conclusion, although there is some controversy re-
garding the management of acute laryngotracheal trauma,
treatment in experienced hands will usually result in a
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