Laryngeal Fracture

Laryngeal Fracture and TraumaFew things are more synonymous with pediatric emergency care than “throat pain” and “trauma.” If you are seeing children in the ED right now, I’m sure there is one complaining of sore throat and another has had a recent traumatic injury. We’ve addressed many topics that cause throat pain in children (ex, Strep Pharyngitis, PTA, RPA, Neck Mass, and Lemierre’s) and we have covered numerous traumatic conditions (ex, Thoracic, Abdominal, and Major Head Trauma), but what happens when one patient complains of both issues? Could it be a Cervical Spine Injury or Penetrating Neck Trauma? Perhaps, but let us not overlook the traumatic blow to the anterior neck (the hip kids today talk a lot about “throat punching”… so let’s be hip too). Let’s take a minute to review Laryngeal Injury and Fracture:

 

Laryngeal Injury: Basics

  • Incidence of laryngotracheal injury in children is rare. [Waseem, 2009]
    • When it occurs, it is most often in the context of severe, multi-organ trauma. [Sidell, 2011]
    • Overall mortality rate of ~8-9% [Sidell, 2011]
    • Typically seen in older children. No laryngeal injuries found in children < 2 years of age. [Sidell, 2011]
  • More often associated with blunt force trauma. (~83%) [Sidell, 2011]
    • MVCs are the most common cause.
      • Impact of the anterior neck on dashboard or front seat.
      • Larynx is compressed between that object and the cervical spine.
      • Rapid deceleration injuries can also cause shearing of the airway.
    • Direct impact from fall or “clothesline” event onto an object also seen.
      • Bicycle handlebars are described in the literature as a cause.
      • Being kicked by a horse (horse hoof vs neck – not good) [Kadish, 1994]
      • Strangulation
    • Compressive forces can lead to:
      • Laryngeal fracture (fracture of any of the laryngeal cartilages)
      • Tracheal transection
      • Damage to the recurrent laryngeal nerve

 

Laryngeal Injury: Age & Anatomy Matters

  • The larynx of the young child is more protected from trauma than the adult larynx.
    • It is more cephalad, residing at the level of C4.
    • The position allows for the mandible to be overlying a larger portion of the larynx.
  • The larynx of the young child is more elastic and pliable.
    • More mobile
    • The laryngeal cartilage is the last to ossify.
      • This can lead to the larynx “splaying” open rather than fracturing. [Sidell, 2011]
      • This can be protective, but also can increase risk for avulsion of vocal folds.
  • There is greater risk for soft tissue injuries though. [Shire, 2011; Sidell, 2011]
    • Submucosal tissues are less fibrous and loosely attached to the larynx.
    • Predisposes to edema or post-traumatic fluid collection.
    • May be involved in delayed presentation of respiratory distress.

 

Laryngeal Injury: Presentation

  • Presentation can be subtle or difficult to discern initially. [Shire, 2011; Sidell, 2011; Waseem, 2009]
    • Polytrauma patient may be too injured to convey symptoms suggestive of laryngeal fracture or trauma.
    • Well appearing patients may have minimal symptoms / asymptomatic at first.
    • Be alert for dysfunction of any of the 3 primary functions of the larynx: [Sidell, 2011]
      • Airway
      • Swallowing
      • Speech
  • Red Flags for Laryngeal Fracture or Injury [Sidell, 2011; Waseem, 2009]
    • Hoarseness of voice (hoarse voice after horse hoof to neck?… that could be bad).
    • Palpable crepitance
    • Dysphagia
    • Dysphonia
    • Hemoptysis
    • Stridor
    • Respiratory Distress
  • Be leery of the the patient who has increasing pain with coughing or swallowing as this may indicate a hyoid bone fracture. [Waseem, 2009]

 

Laryngeal Injury: Management

  • The critically ill/injured child needs to have rapid assessment and management of the airway.
    • Bag ventilations need to be done carefully… as you may worsen subQ emphysema. [Shire, 2011]
    • INTUBATE CAREFULLY, but oral intubation can be done successfully in these patients. [Shire, 2011; Kadish, 1994]
  • In clinically stable patient in whom you suspect laryngeal fracture or injury [Waseem, 2009]
    • Flexible fiberoptic laryngoscopy can help visualize possible injuries while remaining at bedside.
    • CT of neck is an option, but only if patient stable enough to leave department.
      • CT is most useful for defining fluid collections or fractures. [Sidell, 2011]
      • CT should not be done if that patient has obvious tracheal injury in need of surgical repair. [Shires, 2011]
      • May want to include CT of Cervical Spine, Soft Tissues, and Chest.
        • Remember that poly-trauma is most common.
        • Cervical spine injuries are often concomitant. [Kadish, 1994]
  • There is wide variation in the management by subspecialists. [Sidell, 2011; Shire, 2011; Waseem, 2009]
    • Patients with minor or non displaced fractures are often managed conservatively. [Sidell, 2011]
      • Close observation
      • Steroids
      • Humidified oxygen
    • Patients with more significant injuries require endoscopic evaluation.
      • Newer endoscopic techniques can also allow for more complex repairs.
      • Stenting may be used.
    • Tracheostomy may still need to be performed to stabilize pediatric patients with laryngeal trauma. [Sidell, 2011]
    • Therapeutic strategies should be tailored for the individual. [Sidell, 2011]

 

Moral of the Morsel

  • While laryngeal injury in kids is rare, it can be deadly!
  • Presentation can be subtle and delayed!
  • Respect any derangement in Speech, Swallowing, or Airway after an injury to the anterior neck.

 

References

Sidell D1, Mendelsohn AH, Shapiro NL, St John M. Management and outcomes of laryngeal injuries in the pediatric population. Ann Otol Rhinol Laryngol. 2011 Dec;120(12):787-95. PMID: 22279950. [PubMed] [Read by QxMD]

Shires CB1, Preston T, Thompson J. Pediatric laryngeal trauma: a case series at a tertiary children’s hospital. Int J Pediatr Otorhinolaryngol. 2011 Mar;75(3):401-8. PMID: 21242005. [PubMed] [Read by QxMD]

Waseem M1, Kane MR. An uncommon cause of throat pain. Pediatr Emerg Care. 2009 Jan;25(1):35-6. PMID: 19148011. [PubMed] [Read by QxMD]

Merritt RM1, Bent JP, Porubsky ES. Acute laryngeal trauma in the pediatric patient. Ann Otol Rhinol Laryngol. 1998 Feb;107(2):104-6. PMID: 9486903. [PubMed] [Read by QxMD]

Kadish H1, Schunk J, Woodward GA. Blunt pediatric laryngotracheal trauma: case reports and review of the literature. Am J Emerg Med. 1994 Mar;12(2):207-11. PMID: 8161397. [PubMed] [Read by QxMD]

Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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1 Response

  1. Health_Kenya says:

    What can be done to avoid long term Voice complications.

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