Diagnostic findings in laryngeal fracture

Injury Extra (2006) 37, 425—427 www.elsevier.com/locate/inext CASE REPORT Diagnostic findings in laryngeal fracture Athanasios Portinos a,*, Zinovia Alatzidou b, Konstantinos Skevis c, Konstantinos Christodoulidis d a Department of Thoracic and Vascular Surgery, Evaggelismos General Hospital of Athens, 45-47 Ipsilantou, 10676 Athens, Greece b ENT Department of General Hospital of Kavala, 61 Erythrou Staurou, 65201 Kavala, Greece c Thoracic Surgery, Evaggelismos General Hospital of Athens, 45-47 Ipsilantou, 10676 Athens, Greece d First Surgical Department of General Hospital of Kavala, 61 Erythrou Staurou, 65201 Kavala, Greece Accepted 9 May 2006 Introduction Case report Laryngeal trauma is a rare type of injury. Epidemiologically, its incidence is estimated at 1 in 30,000 emergency room visits.13,18,19 While laryngotracheal injuries have accounted for 0.04% of all traumatic lesions,13 it is reported as the third most common cause of death due to head and neck injury after cranial and cervical spine trauma.8,12,21 There are three major etiological groups: traffic accidents, blunt injuries, and penetrating injuries.15,26 The most common cause of laryngeal injury is blunt trauma suffered in a motor vehicle accident.7 It is commonly associated with multisystem trauma and often unrecognized initially due to minimal symptomatology and overshadowing by more obvious injuries.8,12,21 Virtually all laryngeal fractures are longitudinally oriented.10,11 We report the diagnosis and the management of a case of blunt neck trauma associated with a serious laryngeal fracture, highlight the clinical symptoms and signs, and discuss the importance of the correct evaluation of simple imaging methods, including Xray findings. A 68-year-old male car driver, without the use of a safety belt was transferred emergently to our hospital after a traffic accident. He complained of pain over his left arm, left side of his chest and the anterior right side of his neck, as well as dysphagia, and mild dyspnoea. The clinical examination revealed an extensive bruising and oedema of his left arm, hoarseness, dysphagia, mild inspiratory stridor, tenderness over the larynx, and haemoptysis. He had normal vital signs and the rest of his clinical examination was unremarkable. Plain X-rays of the cervical spine, chest, and left arm were negative. Fiber optic laryngoscopy revealed a haematoma of the right piriform fossa and of the right true and false vocal cords. No exposed cartilage or mucosal tears were seen. CT scan of the neck revealed the presence of air in the soft tissue in the retropharyngeal space (Fig. 1). A more concentrated examination of the lateral neck X-ray revealed two important findings: a fracture of an osteophytic ridge between the anterior surfaces of the C4 and C5 vertebrae and the existence of a strip-like region of air in the retropharyngeal space (Fig. 2). These two findings, along with those of the CTscan established the diagnosis of rupture of the * Corresponding author. Tel.: +30 2106395405. E-mail address: [email protected] (A. Portinos). 1572-3461 # 2006 Elsevier Ltd. Open access under the Elsevier OA license. doi:10.1016/j.injury.2006.05.009 426 A. Portinos et al. Figure 3 Figure 1 Presence of air in the soft tissue of the retropharyngeal space in cervical CT tomography. Figure 2 Lateral cervical spine X-ray; on original report abnormal findings not indentified. Re-evaluation of X-ray revealed fracture of an osteophytic ridge between the anterior surfaces of C4 and C5 vertebrae and a strip-like region of air at the prevertebra space. upper respiratory tract. A new CTscan with 2 mm cuts revealed a non-displaced paramedian fracture of the thyroid cartilage (Fig. 3). The patient was admitted and treated with i.v. steroids and antibiotics, monitored for 24 h in the I.C.U. and discharged 7 days later. Follow up at 6 months revealed an unremarkable hoarseness of his voice. Discussion Laryngeal fractures are said to have been increasing for the past several years. This is due in part to Fracture of the thyroid cartilage on the right. improved early care of trauma patients and thus an increase in the number of the survivors brought to the emergency room.7 Thyroid cartilage fractures due to external blunt trauma have been typically thought to occur in patients over the age of 40. Lack of mineralization of the cartilage has been considered to be the protective mechanism.2 Associated fractures or dislocation of the cervical vertebra should be sought on the lateral radiographs of the neck.22 The main presenting symptoms and signs are hoarseness, neck tenderness, dysphagia and subcutaneous neck emphysema.20 Stridor is the most common presenting symptom and the thyroid cartilage is the most common site of fracture.7 The diagnosis of laryngeal blunt trauma is not always easily accomplished.5 The location and type of thyroid cartilage fracture is directly related to the mechanism of trauma.6,10,14 X-ray does play a role in the evaluation of laryngeal fractures.17,24,25 Lateral radiographs of the neck may show subcutaneous emphysema not recognized on palpation,22 and the presence of air in the prevertebral perithyroid space. The diagnosis can thus be established by conventional X-ray examination.9 CT is an excellent noninvasive technique for examining the laryngeal skeleton.23 It is extremely sensitive for the detection of even small amounts of subcutaneous emphysema.8,13,22,23 Laryngeal CT may be successfully used to define the extent of injury and determine the need for open exploration and repair in selected cases of blunt trauma to the larynx when clinical findings are equivocal for cartilagious damage.23 Cervical vertebral fractures and dislocations, perforation of the pharynx and oesophagus, and vascular injury must be excluded.22 Trauma of the throat should never be underestimated even though the patient may initially appear well. This is not only because of the development of Rare diagnostic radiological findings in laryngeal fracture oedema of the airway, but also because of the risk of haemorrhage into the soft tissues, which could rapidly prove to be fatal.26,27 The sequela of this missed or delayed diagnosis and treatment is laryngeal stenosis, which often requires prolonged tracheostomy and multiple reconstructive procedures.1,4,12,16,24 The aim of therapy for the patient with an injured larynx includes two goals: the maintenance of an adequate airway and the restoration of a socially acceptable voice for communication.20 Conservative treatment includes observation, delivery of humidified air, voice rest, elevation of the head of the bed, antibiotics, and steroids.3 Fractures of the larynx are difficult to recognize, especially in the patient with multiple injuries. Hoarseness of the voice and inspiratory dyspnoea may indicate injury to the larynx, but not necessarily fracture. The presence of subcutaneous emphysema is not a standard finding. The strip-like presence of air in the retropharyngeal space seen on a plain lateral neck X-ray is very important for the diagnosis. Further evaluation by CT scan imaging is necessary. References 1. Alonso WA, Pratt LL, Zollinger WK, Ogura JH. Complications of laryngotracheal disruption. Laryngoscope 1974;84(8): 1276—90. 2. Austin JR, Stanley RB, Cooper DS. Stable internal fixation of fractures of the partially mineralized thyroid cartilage. Ann Otol Rhinol Laryngol 1992;101:76—80. 3. Bent III JP, Silver JR, Porubsky ES. Acute laryngeal trauma: a review of 77 patients. Otolaryngol Head Neck Surg 1993;109 (3 Pt 1):441—9. 4. Chasin WD. Pediatric otolaryngologic crises. Hosp Pract 1977;12(3). 89—96, 101—2. 5. Cozzi S, Gemma M, De Vitis A, Piccoli S, Frascoli C, Beretta L. Difficult diagnosis of laryngeal blunt trauma. J Trauma 1996;40:845—6. 6. Curtin HD. The larynx. In: Som PM, Bergeron RT, editors. Head and neck imaging. 2nd ed, St. Louis, MO: Mosby Year Book; 1991. p. 17. 427 7. Ganzel TM, Mumford LA. Diagnosis of acute laryngeal trauma. Am Surg 1989;55:303—6. 8. Harris HH, Tobin HA. Acute injuries of the larynx and trachea in 49 patients. Laryngoscope 1970;80:1376—84. 9. Kolodziej M, Tyc M. Extensive cervical emphysema as a result of laryngeal injury. Otolaryngol Pol 1993;47(3):286—90. 10. Lee SY. Experimental blunt injury to the larynx. Ann Otol Rhinol Laryngol 1992;101:270—4. 11. LeMay Jr SR. Penetrating wounds of the larynx and cervical trachea. Arch Otolaryngol 1971;94(6):558—65. 12. Leopold DA. Laryngeal trauma. A historical comparison of treatment methods. Arch Otolaryngol Head Neck Surg 1983;109:106—11. 13. Lupetin AR, Hollander M, Rao VM. CT evaluation of laryngotracheal trauma. Semin Musculoskel Radiol 1998;2:105— 16. 14. Mancuso AA, Hanafee WN. Computed tomography of the head and neck Baltimore: Williams and Wilkins; 1982. 15. Maran AG, Murray JA, Stell PM, et al. Early management of laryngeal injuries. J R Med 1981;74:656. 16. Miles WK, Olson NR, Rodriguez A. Acute treatment of experimental laryngeal fractures. Ann Otol Rhinol Laryngol 1971;80 (5):710—20. 17. Ogura JH, Powers WE. Functional restitution of traumatic stenosis of the larynx and pharynx. Laryngoscope 1964;74: 1081—110. 18. Schaefer SD, Close LG. Acute management of laryngeal trauma: update. Ann Otol Rhinol Laryngol 1989;98:98— 104. 19. Schaefer SD, Close LG, Mickey BE. Axial subcutaneous scalp flaps in the reconstruction of the anterior cranial fossa. Arch Otolaryngol Head Neck Surg 1986;112:745—9. 20. Schild JA, Denneny EC. Evaluation and treatment of acute laryngeal fractures. Head Neck 1989;11(6):491—6. 21. Schild JA, Deenneny EC. Evaluation and treatment of acute laryngeal fractures. Head Neck Surg 1992;118:598—604. 22. Snow Jr JB. Diagnosis and therapy for acute laryngeal and tracheal trauma in otolaryngologic clinics of North America, vol 17, No 1, February 1984. 23. Stanley Jr RB. Value of computed tomography in management of acute laryngeal injury. J Trauma 1984;24(4):359—62. 24. Wesirow G, Luning M, Baudisch B. X-ray diagnosis of a laryngeal fracture. Radiol Diagn (Berlin) 1977;18(2):181—4. 25. Whited RE. Laryngeal fracture in the multiple trauma patient. Am J Surg 1978;136:354—5. 26. Yarley MP, Parker AJ, Durham LH. Traumatic laryngeal fracture. Injury 1991;22:335—6. 27. Yen PT, Lee HY, Tsai MH, Chan ST, Huang TS. Clinical analysis of external laryngeal trauma. J Laryngol Otol 1994;108: 221—5.