Laryngeal Trauma - Causes, Symptoms, Diagnosis, and Management.

Introduction

Laryngotracheal injuries are rare but have high mortality rates. These injuries can be blunt or penetrating and occur in the supraglottic, glottic, and infraglottic regions. Prompt diagnosis is essential; different injury patterns and severity can be seen in penetrating and blunt laryngeal trauma. A thorough examination and history are taken when a patient presents with a history of anterior neck trauma for laryngeal injury, and a safe airway is confirmed or established emergently before proceeding with any other procedure. Motor vehicle accidents primarily cause laryngeal trauma and are not frequent.

What Is Laryngeal Trauma?

Laryngeal trauma is an injury to the larynx or voice box in the neck and plays a vital role in breathing, swallowing, and speaking. Injury to the larynx and trachea has significant and potential consequences and can be fatal. It is associated with intracranial injuries, penetrating neck injuries, cervical spine fractures, and facial fractures.

What Are the Symptoms of Laryngeal Trauma?

The symptoms include:

• Hoarse or loss of voice.

• Difficulty speaking or breathing.

• Stridor (a high-pitched, wheezing sound during breathing).

• Pain or discomfort in the throat or neck area.

• Coughing up blood or a persistent cough.

• Swelling or tenderness in the neck or throat region.

• Difficulty swallowing or a feeling of choking or something stuck in the throat.

• Blue tinge to the lips or nails, indicating lack of oxygen.

What Are the Causes of Laryngeal Trauma?

The causes of laryngeal trauma are:

• Motor vehicle accidents.

• Penetrating trauma.

• Assault.

• Strangulation.

• Hanging

• Clothesline-type injuries such as tree-branch or fence wire.

• Iatrogenic causes such as bronchoscopy, percutaneous tracheostomy, and emergent intubation.

How Is Laryngeal Trauma Classified?

The laryngeal trauma is classified based on the degree of injury:

• Type 1 - Minor hematoma of endolarynx or fracture, less laceration.

• Type 2 - Extreme edema, hematoma, a fracture that is not dislocated or breaks in the mucosa in which cartilage is not exposed.

• Type 3 - Extensive edema, extensive break in the mucosa, dislocated fractures or exposed cartilage, immobility of vocal cord,

• Type 4 - Serious interruption of the anterior larynx, unsteady fractures, fracture lines, and severe mucosa trauma.

• Type 5 - Total isolation of trachea and larynx.

What Is the Pathophysiology of Laryngeal Trauma?

Pathophysiology of Blunt Trauma:

The severity of an injury is often related to the amount of force applied and the area of impact. Injuries caused by high-velocity impacts can result in fractures of the laryngeal and tracheal cartilages, which can cause structural deformities. The most severe type of injury is known as a "clothesline" injury, which typically occurs when a motorcycle or snowmobile rider collides with a stationary object such as a fence wire or tree branch, resulting in a crushing injury to the laryngeal or tracheal cartilage and potentially obstructing the airway. Blunt laryngeal injuries during sports or physical altercations may not be immediately apparent on external examination but can cause endolaryngeal injuries or hyoid fractures due to shearing forces. Airway obstruction can occur immediately following the injury or develop later as edema increases and symptoms worsen.

Penetrating Laryngeal Trauma:

The severity of a laryngeal injury depends on the type of injury sustained. Injuries caused by low-velocity penetrating objects such as knives may not present with severe symptoms initially, but swelling or accumulation of blood may eventually compromise the airway. On the other hand, high-velocity injuries caused by firearms, especially hunting or military rifles, are extremely severe, resulting in the fragmentation and destruction of laryngeal and surrounding tissues. This can lead to long-term scarring and devascularization of these tissues, causing significant stenosis. In addition to immediate concerns related to tissue damage and swelling, airway obstruction may occur due to post-injury edema.

What Is the Diagnosis of Laryngeal Trauma?

The initial history plays a vital role in evaluating the laryngeal injury. Any patient with a history of neck trauma is susceptible to a high degree of laryngeal injury. It includes the mechanism of injury, time since injury, and other associated injuries. An essential potential for laryngeal injury is an automobile accident in poly-trauma patients. Some worrisome symptoms of laryngeal injury are:

• History of anterior neck trauma.

• Hoarseness or voice change.

• Pain in the neck.

• Dyspnea.

• Dysphagia.

• Subcutaneous emphysema.

Physical examination involves the overall assessment of a patient's respiratory status. ABCs of trauma is noted.

• Stridor may be expiratory or inspiratory, based on the level of injury and accompanied by voice changes. Cervical spinal injuries are to be ruled out in all neck trauma patients.

• Neck palpation for tenderness over thyroid cartilage and trachea ecchymoses over the anterior neck and voice assessment for hoarseness is done.

• A flexible laryngoscopy is performed if the patient's airway is stable to visualize the larynx and pharynx.

• A CT (computed tomography) is advised for a definitive diagnosis and presentation of laryngeal and tracheal structures, specifically for patients with problematic symptoms.

Evaluation of laryngeal injury:

• Flexible Laryngoscopy: an initial examination method to evaluate the airway, internal mucosal structures of the larynx, and upper aerodigestive tracts. It also helps identify edema, laryngeal lacerations, hematomas, mucosal tears, or other structural abnormalities that may proceed to complications. It also evaluates mucosal injury extent, cartilage exposure, or vocal cords mobility.

• Computed Tomography: it is used if necessary, is safe, and aids in treatment strategy. It is not required in patients with proper history, clinical picture, routine review, or laryngoscopy. A non-contrast CT helps visualize the cartilaginous and bony structures of the larynx and hyoid and any minor or nondisplaced fractures that need stabilization.

• Esophagram: esophageal injury is associated with four to six percent laryngeal fractures and is used if persistent esophageal injury is suspected.

• Chest X-ray: it is used as a routine in poly-trauma patients with a suspected neck injury. It is usually obtained using a portable roentgenogram if the patient is stable and protecting their airway.

What Is the Management of Laryngeal Trauma?

The primary management of laryngeal injuries includes evaluating and establishing a stable airway.

Secure the Airway: Ensure that the airway is properly secured using the appropriate method, such as intubation, cricothyrotomy, or tracheostomy.

Monitor the Patient: Observe the patient's breathing and vital signs closely to ensure that the airway remains open and the patient is adequately oxygenated.

Manage Any Complications: If there are any complications, such as bleeding, swelling, or trauma to the airway, appropriate measures should be taken to manage them promptly.

Administer Appropriate Medications: Depending on the patient's condition, medications such as bronchodilators, steroids, or antibiotics may be necessary to manage underlying conditions or prevent infection.

Consult With Specialists: Consult with specialists such as anesthesiologists, otolaryngologists, or critical care physicians to ensure the best possible outcome for the patient.

Plan For Further Management: Based on the findings of the laryngoscopy and esophagoscopy, a plan should be developed for further management, such as surgical intervention or continued medical management.

What Is the Differential Diagnosis of Laryngeal Trauma?

The differential diagnosis:

• Vascular Injury - Produces hemorrhage or hematoma, hypertension, and stroke symptoms.

• Pharyngoesophageal Injury - Produces blood in saliva, hematemesis, dysphagia or odynophagia, and hemoptysis.

• Pneumothorax - Respiratory distress.

Conclusion

Laryngeal trauma is a severe condition that results from various causes, such as blunt or penetrating injuries, intubation, or foreign body aspiration. It causes airway obstruction and compromises breathing, leading to life-threatening consequences. Early recognition and prompt management are crucial in preventing complications and positive outcomes.