If the airway is stable, a thorough physical examination of the neck and larynx is required. Bleeding, expanding hematomas, bruits, and loss of pulses are signs associated with vascular injury.3738 Other signs of laryngeal trauma include stridor, hemoptysis, subcutaneous emphysema, and tenderness or deformity of the laryngeal skeleton. The type of stridor may suggest the location of the lesion. Inspiratory stridor is typically indicative of partial supraglottic airway obstruction, as might occur from edema, hematoma, foreign body, soft-tissue injury, or cartilaginous fractures. Expiratory stridor may portend lower airway pathologic conditions in the trachea. Inspiratory and expiratory stridor suggest partial obstruction at the level of the glottis.
Flexible fiberoptic nasopharyngolaryngoscopy is the examination of choice, since it allows immediate assessment of airway integrity while maintaining cervical spine immobilization. In stable patients, CT is helpful in defining the extent of injury and need for structural repair. 36 In cases of massive blunt trauma, CT scanning is not indicated, since patients require immediate tracheostomy, direct laryngoscopy, and open exploration. Cervical spine radiographs should be performed to rule out vertebral injury, and soft-tissue anteroposterior and lateral radiographs of the neck should be obtained. Deep cervical and prevertebral air is the most common finding on radiographs of the cervical spine and on CT (Fig 235-5 and Fig...235-6).
FIG. 235-5. Lateral radiograph demonstrating air in the retropharyngeal space after blunt laryngeal trauma.
FIG. 235-6. Two axial computed tomographic (CT) cuts demonstrating air in the retropharynx after blunt laryngeal trauma.
The two primary goals in the management of acute laryngeal trauma are preservation of life by maintaining the airway and restoration of function. There is controversy regarding the best way to establish an alternative airway in blunt laryngeal trauma. Some authors believe that intubation following laryngeal trauma is hazardous, since the endotracheal intubation of a traumatized larynx may cause iatrogenic injury as well as the loss of an already precarious airway. "i?7,,39 Other authors suggest that orotracheal intubation is a safe method of establishing an airway in this setting if it is done with a small tube under direct visualization. 40 If the lumen of the laryngeal airway is compromised by ecchymosis and edema but there is no gross disruption of the laryngeal mucosa or displacement of the arytenoids and the tracheal lumen can be identified, then the airway may be secured with an endotracheal tube advanced over the bronchscope. 40 When the laryngeal lumen cannot be visualized because of gross anatomic disruption or edema and hemorrhage, urgent tracheostomy is the preferred method of controlling the airway and avoiding further injury to the larynx.41 An emergent tracheotomy is performed through a midline vertical skin incision, and the trachea should be entered at a level lower than usual (fourth or fifth tracheal ring.) Cricothyrotomy may be difficult because of cervical emphysema and swelling, and should be avoided if possible in suspected laryngeal trauma, since it may further injure the subglottis.39 Retrograde intubation should not be attempted.
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