Laryngeal Fracture

Aka: Laryngeal Fracture, Laryngeal Trauma, Larynx Injury, Laryngotracheal Trauma

1. See Also
   1. Tracheal Laceration
2. Epidemiology
   1. Common cause of death in blunt head and neck Trauma (second only to Intracranial Hemorrhage)
   2. Rare overall
      1. Incidence: 1 in 30,000 Emergency Department encounters
      2. Found in 0.5% of overall blunt Trauma patients
3. Causes
   1. Head and Neck Trauma
   2. Rare overall and especially rare in children (elastic necks)
   3. Sports Injury
      1. Football
      2. Soccer
4. Symptoms
   1. Dyspnea
   2. Dysphagia
   3. Hemoptysis
   4. Hoarseness or Dysphonia
   5. Neck Pain
5. Signs
   1. Stridor
   2. Cyanosis
   3. Subcutaneous Emphysema (typically massive)
      1. Persistent air leak despite Chest Tube
   4. Laryngeal palpation with crepitation
   5. Tracheal tenderness
6. Precautions
   1. Easily unrecognized in multisystem Trauma patients
   2. Airway compromise can develop quickly
      1. May be delayed if airway obstruction is due to soft tissue edema and bleeding
7. Imaging
   1. CT Soft Tissue Neck
      1. Evaluate Larynx as well as esophagus and vascular structures
   2. CT Cervical Spine
      1. Evaluate for concurrent Cervical Spine Injury as indicated
   3. Other diagnostics
      1. Flexible fiberoptic Laryngoscopy
      2. Flexible bronchoscopy
8. Grading: Schaefer Classification System of Laryngeal Injury
   1. Grade 1
      1. Minor endolaryngeal hematoma
      2. No detectable Fracture
   2. Grade 2
      1. Edema, hematoma or mucosal disruption
      2. Nondisplaced Fractures
      3. No exposed cartilage
   3. Grade 3
      1. Massive Edema
      2. Mucosal disruption
      3. Displaced Fracture
      4. Exposed cartilage
      5. Vocal Cord Immobility
   4. Grade 4
      1. Includes Grade III criteria AND
      2. Two or more Fracture lines OR Massive Trauma to laryngeal mucosa
   5. Grade 5
      1. Complete laryngotracheal separation
9. Management: Complete airway obstruction or severe respiratory distress
   1. Emergent Surgical Consultation
   2. Endotracheal Intubation
      1. Video Laryngoscopy or
      2. Flexible Endoscopic Intubation
   3. Cricothyrotomy for failed intubation (Airway double set-up)
      1. May also exacerbate Laryngeal Trauma
10. Management: Airway Initially Stable
    1. Emergent surgical Consultation with otolaryngology or maxillofacial surgery in all cases (regardless of grade)
       1. Grade 1-2 Laryngeal Injuries are medically managed in many cases
       2. Grade 3-5 Laryngeal Injuries are managed surgically
    2. Elevate head of bed
    3. Ice region
    4. Encourage vocal rest
    5. Humidified air
    6. Antibiotics indicated for exposed laryngeal cartilage
    7. Monitor for worsening (secure airway for changes)
       1. Agitation
       2. Altered Level of Consciousness
       3. Oxygen Saturation
       4. Cyanosis, retractions or Stridor
       5. Snoring or unable to speak
11. References
    1. Dreis (2020) Crit Dec Emerg Med 34(7):3-21
    2. Phillips (2021) Crit Dec Emerg Med 35(8): 14-5