External laryngeal trauma is reportedly rare, occurring in approximately 1 in every 30,000 emergency room visits. 36 However, the actual number of laryngeal injuries is probably underestimated, since many cases go unrecognized, and the victims of the most severe laryngeal trauma frequently die at the scene of the accident. Several authors suggest that an increase in the incidence of laryngotracheal injury patients reaching the emergency room alive is a result of improved prehospital care and the development of specialized regional trauma units.3637
Blunt trauma to the larynx occurs primarily as the result of motor vehicle accidents (dashboard), personal assaults, or sports injuries. The basic mechanism for blunt external injury to the laryngotracheal skeleton is compression of the larynx on the anterior cervical bodies. The varying densities of the hard and soft tissues of the larynx and the rotation of these elements around fixed points cause tearing of the cartilage and mucosa. Injuries range from mucosal tears, to cartilaginous fractures of the hyoid, cricoid, or thyroid, to dislocation of the cricoarytenoid joints or vocal cords. The so-called clothesline injury is a form of blunt laryngeal trauma that deserves special attention due to its severity. This typically occurs when the victim is riding a motorcycle or snowmobile and the neck strikes a stationary object, such as a wire fence or tree limb. The transfer of such a large amount of force to the neck crushes the laryngeal cartilage and may cause laryngotracheal separation. Asphyxiation often occurs at the scene, and survivors of such injuries may have an airway held together precariously by mucous membranes bridging the cartilage.
The larynx of a child responds to blunt trauma differently than does that of an adult. The pediatric larynx is situated higher in the neck and is protected by the mandible. Although the larynx of a child has relatively smaller dimensions, fractures are less common due to the elasticity of the pediatric cartilaginous skeleton. However, the lack of fibrous tissue support and the loose attachments of the mucous membranes increase the likelihood of soft-tissue damage in children. 38
An upper airway injury should be suspected in any patient with anterior neck trauma. The classic symptoms associated with laryngeal trauma are listed in Table... 235-6.. With the exception of a subtle change in voice, injuries may be initially asymptomatic. With more significant or worsening injury, the patient may become increasingly aware of pain. Dyspnea, cough, and hemoptysis are common symptoms of tracheobronchial injury. Subcutaneous emphysema of varying degrees is a common finding. When the laryngeal lumen is severely compromised, aphonia and apnea may occur, signaling the need for immediate establishment of an alternative airway.36
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