The Laryngoscope

C 2013 The American Laryngological,

V
Rhinological and Otological Society, Inc.

Contemporary Review

Management of Acute Blunt and Penetrating External Laryngeal

Trauma

Steven D. Schaefer, MD, FACS

Objectives/Hypothesis: Improve the care of acute external laryngeal trauma by reviewing controversies and the evolu-
tion of treatment.
Data Source: Internet-based search engines, civilian and military databases, and manual search of references from these
sources over the past 90 years.
Review Methods: Utilizing the above-mentioned sources, electronic and manual searches of primary topics such as la-
ryngeal trauma or injury, emergency tracheotomy, airway trauma, intubation versus tracheotomy, cricothyrotomy, esophageal
trauma, and emergent management of airway injuries in civilian and combat zones. Citations were reviewed, selected reports
analyzed, and the most relevant articles referenced.
Results: Optimal treatment of acute laryngeal trauma includes early identification of injuries utilizing a directed history
and physical examination. Timely management of the wounded airway is essential. The choice of intubation, tracheotomy, or
cricothyrotomy must be individualized. Computed tomography (CT) may assist in differentiating patients who can be
observed versus those who require surgical exploration. In selected patients, laryngeal electromyography and stroboscopy
may also be useful. Surgery should begin with direct laryngoscopy and rigid esophagoscopy to evaluate the hard and soft tis-
sues of the larynx, and to visualize the pharynx and esophagus. Minor endolaryngeal lacerations and abrasions may be
observed, whereas more significant injuries require primary closure via a thyrotomy. Laryngeal skeletal fractures should be
reduced and fixated. Endolaryngeal stenting is reversed for massive mucosal trauma, comminuted fractures, and traumatic
anterior commissure disruption.
Conclusions: Acute external injury to the larynx is both life threatening and a potential long-term management chal-
lenge. Although a rare injury, sufficient experience now exists to recommend specific treatments, and to preserve voice and
airway function.
Key Words: Acute laryngeal trauma; upper airway injury; blunt and penetrating neck wounds; laryngoesophageal
injury.
Laryngoscope, 124:233–244, 2014

INTRODUCTION larynx. The myoelastic contributions to phonation are

Acute blunt and penetrating trauma presents a the consequence of the soft tissues of the larynx, which
myriad of management challenges to both civilian and are supported by the cartilaginous skeleton of this
military medical personnel. External injuries to the lar- organ. Air passing through the glottis is acoustically fil-
ynx threaten both the quality and maintenance of life.1 tered by the vocal tract.2 Essential to preservation of
Essential to the preservation of the phonatory and pro- these two laryngeal functions is early recognition, accu-
tective respiratory functions of the larynx is restoration rate evaluation, and proper treatment of injuries.3
of its skeletal framework, ligaments, muscles, and epi- As external laryngeal trauma is rare, few authors
thelial covering. The quality of phonation is the product have published a large series of patients. The format of
of the aerodynamic and myoelastic properties of the Contemporary Reviews in Laryngoscope permits us to
examine reports and relevant literature over the past 90
years, as well as recent trauma databases. In doing so,
From the New York Head and Neck Institute, Department of Oto- >1400 references in PubMed, Google Scholar, and other
laryngology–Head and Neck Surgery, Lenox Hill Hospital of the North
Shore Long Island Jewish Health System and New York Medical Col- civilian and military databases were reviewed. Pertinent
lege, New York, New York, U.S.A references were obtained from many of these articles,
Editor’s Note: This Manuscript was accepted for publication January which were frequently not identifiable using Web-based
31, 2013. search engines. With the exception of animal investiga-
The author has no funding, financial relationships, or conflicts of
interest to disclose.
tions on laryngeal stenting and external fixation and
Send correspondence to Steven D. Schaefer, MD, FACS, New York one clinical study, level of evidence ranged from cases se-
Head and Neck Institute 110 East 59th Street, Suite 10A, New York, NY ries with and without prospective nonrandomized treat-
10022. E-mail: sschaefer1@nshs.edu
ment (level 4 evidence) to expert opinion (level 5).This
DOI: 10.1002/lary.24068 subject demonstrates a process in which successive

Laryngoscope 124: January 2014 Schaefer: Management of Acute Laryngeal Trauma

233
authors have learned from their predecessors to con-
struct a coherent paradigm for early treatment of blunt
and penetrating laryngeal trauma, and to further refine
treatment as new information becomes available. Given
these considerations, we review: 1) incidence and mecha-
nisms of injury, 2) immediate management of the com-
promised airway secondary to external laryngeal
trauma, 3) evaluation of the injured patient, and 4) de-
finitive treatment. Further, we seek to examine prior
recommendations and controversies, and to draw upon
our own 35 years of experience with this subject.

DISCUSSION
Incidence of Injury
The incidence and demographics of laryngeal trauma
has evolved in post-World War II America; and more recent
international events obligate us to include the consequen-
ces of armed conflict in other regions of the world. In the
immediate post-war decades, the incidence of blunt trauma Fig. 1. Illustration of potential disruption of the airway by the endo-
was greater than penetrating laryngeal injuries due to tracheal tube separating the tenuous continuity afforded by the tra-
automobile designs, which “offered many hazards to the cheal and cricoid ligaments. Patients with such injuries are best
unrestrained occupant.”4,5 Other forms of blunt trauma managed by tracheotomy under local anesthesia. Insert: sagittal
cadaver section showing larynx and trachea—1) epiglottis, 2) thy-
included assaults and sports injuries. As automobile roid cartilage, and 3) first tracheal ring. [Color figure can be viewed
designed improved to better protect the occupants, and vio- in the online issue, which is available at wileyonlinelibrary.com.]
lent crime increased in America, blunt neck injuries
declined and penetrating injuries increased.6 In contrast,
blunt trauma predominated in Great Britain throughout fractured laryngeal skeleton can lead to airway compro-
the same period.7 In the United States, the incidence of mise in these patients.1,3,7 Many such events can be pre-
both forms of injury in the 1980s ranged from one in 5,000 dicted by including a history focused on the mechanism
emergency visits8 to one in 137,000 inpatient admissions,9 of the anterior neck trauma taken from the patient, other
and one in 30,000 emergency visits in the 1990s.3 vehicle occupants, or emergency responders. We believe
In the post-Vietnam era, the management of mili- that these patients should be observed for several hours
tary injuries and their morbidity continued to change. In postinjury and reevaluated as indicated, despite the be-
Vietnam, 6% of the soldiers died from isolated airway nign findings on initial physical examination.
injuries.10 In contrast, current military training manuals Emergent treatment of the compromised airway
and databases show that acute airway compromise is a historically reflects the experiences of individual physi-
significant cause of traumatic death.11–13 This change in cians. More recent reports from the military and civilian
the site of injury may reflect improved body armor cov- databases offer further insight and possible directions
ering the thorax and abdomen, with an estimated 27% for management. Two frequently cited historical experi-
of wounds involving the head, neck, and airway.14 The ences are the reports of Gussack18and Schaefer.3,16,19
lessons learned from the military experience are very The former advocated intubation for more minimal inju-
useful in improving care of both soldiers and civilians. ries of the supraglottic and endolarynx; whereas the lat-
ter preferred to avoid intubation in the emergency
department. having observed a range of injuries. These
Initial Management of Acute External include avulsion of the endolaryngeal mucous mem-
Laryngeal Trauma in the Patient with brane, creation of pseudo-lumens or false passages, dis-
a Compromised Airway ruptions of tenuous airways by the endotracheal tube,
Essential to effective management of the compro- and respiratory arrest (Fig. 1).1,3,19 Subsequent revisions
mised airway is early recognition and treatment of by Schaefer and others have lead to the following intu-
impending airway obstruction. The trajectory of a projec- bation recommendations: 1) the larynx and trachea must
tile or a knife, the location of the neck wound, and the be clearly intact and in continuity versus partial separa-
energy of the projectile all determine the potential com- tion or avulsions of these structures, 2) the airway
promise of the airway. In contrast, the extent of wounding should be visible to direct inspection by endoscopy in the
with blunt laryngeal trauma may be less obvious and pro- emergency department or operating room, and 3) intuba-
gress over hours.1,3–5,7,15 Prior reports include observa- tion requires a highly experienced physician.8,19 The
tions that vehicle occupants who sustain blunt injuries to pitfalls and importance of well-trained personnel per-
the central compartment of anterior neck and present forming endotracheal intubation of the potentially com-
early to the emergency department may initially have an promised airway are illustrated by Wang et al.,20 and
unremarkable airway.16,17 Over several hours, a combina- Adams et al.13 Wang reviewed 2003 Pennsylvania state-
tion of edema, hematoma, or inherent instability of the wide emergency medical services data, finding either no

Laryngoscope 124: January 2014 Schaefer: Management of Acute Laryngeal Trauma

234
benefit or injury to patients undergoing intubation by the initial publication by Xydakis et al., demonstrating
paramedics prior to hospital admission. Jalisis and Zoc- the value of timely involvement of ENT-head and neck
coli found no complications from highly trained para- surgeons in the management of head and neck wounds
medic intubations “in the field” in four of four patients.21 through analyzing the patterns of trauma in Iraq and
Adams et al. reviewed Combat Hospitals’ emergency air- Afghanistan.45
way experience from January 2005 to March 2007, and
also found that a successful outcome was determined by
the skill set of the physician or other health care person- Computed Tomographic Imaging (CT)
nel performing the intubation. In the patient with a stable airway, computed tomog-
Given the variation in civilian and military out- raphy scanning of the larynx is useful if the imaging find-
comes, when the least trained professional provides an ings influence the subsequent treatment of the patient.46
urgent airway via intubation, should cricothyroidotomy Conversely, if the airway cannot be safely managed while
be considered?12 Despite Jackson’s report in 1921 of la- the patient undergoes CT scanning, or the extent of injury
ryngeal stenosis following cricothyroidotomy, more is so apparent to required neck exploration, the risks to
the patient outweigh the benefits of imaging.18,21,41 As the
recent experience suggest a place for this procedure in
degree of wounding varies with the intensity of the kinetic
the rapidly deteriorating airway.22–24 Implicit in consid-
energy to the anterior neck, the severity of injury may be
ering cricothyroidotomy is verification on physical exam-
particularly difficult to ascertain in blunt wounds and
ination of the continuity of the cricoid and tracheal
must be individualized for each patient. Given our own
cartilages (Fig. 1). Although our own policy is to convert
experience and that of others, we now believe CT imaging
emergency cricothyroidotomy to a low tracheotomy in
is beneficial in: 1) patients with a significant history of
the operating room, both Graham25 and Francois26 ques-
blunt force trauma to the anterior neck with or without
tion the need for routine conversion of the airway to a
significant abnormal findings on physical examination,
tracheotomy. In seeking a rational recommendation for
particularly with dysphonia or hemoptysis, 2) the condi-
urgently establishing an airway in the blunt and pene- tion and continuity of the endolarynx and trachea is not
trating neck trauma, we believe that if the above-sum- observable due to edema or hematoma, 3) the physician is
marized conditions for optimal intubation cannot be met, uncertain about the extent of injury, and 4) imaging can
and if tracheotomy is not feasible, cricothyroidotomy be performed under the supervision of a physician profi-
with subsequent revision should be considered. cient in establishing an emergency airway.

Initial Management of External Laryngeal Imaging and Surgical Evaluation of the

Trauma in the Patient Without a Compromised Esophagus
Airway Concurrent injury to the pharynx and/or esophagus
The patient’s history should be directed toward the is infrequent in both penetrating and blunt laryngeal
mechanism of trauma and the temporal evolution of the trauma.40 In retrospective analysis of cervical penetrat-
injury.3 The physical examination should include the ing trauma in 223 patients, Demetriades found a 6.3%
entire body and rule out associated spinal, vascular, and incidence of esophageal injuries and Grewal et al.
neurological injuries. Manipulation of the neck should reported a 4% frequency.40,45 While other authors note a
be avoided until the stability of the cervical spine is higher incidence of such injuries in penetrating trauma,
insured. Flexible fiberoptic laryngoscopy permits direct both agree that esophageal wounds are less common in
inspection of the pharynx and larynx, and should be per- blunt trauma.9,23 Such injuries, particularly in the cervi-
formed whenever the patient’s condition permits. Flexi- cal esophagus, may be difficult to recognize. Weigelt
ble laryngoscopy should assess the patency of the et al. reported identifying 80% of esophageal injuries in
airway, vocal fold mobility, and pharyngeal and endolar- penetrating cervical trauma based on clinical evaluation
yngeal integrity. The range of signs and symptoms of la- and furthering the detection of such wounds with the
ryngeal injuries are reviewed in Table I.1,3,7–9,15–19,21–43 inclusion of esophagography and esophagoscopy.48 A
Paradoxically, with the exception of impending loss of multicenter study of 211 patients with penetrating cervi-
the airway, these findings correlate poorly with the cal esophageal wounds under the sponsorship of the
extent or severity of injury, whereas they do suggest a American Association for the Surgery of Trauma
potential airway injury.3 Employing these observations, included a review of the forms of evaluation of the
Brennan et al. reported assessing airway patency when esophagus.49 In this review, Asensio et al. utilized esoph-
caring for large numbers of casualties in combat hospi- agography in 30% and endoscopy in 40% of their
tals at the time of the primary trauma survey in the patients. Esophagoscopy was further divided into rigid
2004 Fallujah Offensive in Iraq.44 Screening consisted of in 70% and flexible in 30% of the patients. Gonzales
“moving from patient to patient and asking how he or et al. performed a prospective blinded study of 42
she was doing. An intelligible and appropriate reply patients with zone II neck wounds to evaluate the role
indicated a patent airway, enough respiratory effort to of CT contrast esophageal radiography in neck trauma.50
generate voice and a perfusing brain with a Glasgow Patient selection consisted of those with knife or gun
Coma Scale score greater than 8.” If the soldier failed wounds penetrating the platysma between the clavicular
this screening, an emergent airway was secured. Such heads and angle of the mandible without surgically sig-
early battlefield involvement of otolaryngologist followed nificant injuries on physical examination and plain

Laryngoscope 124: January 2014 Schaefer: Management of Acute Laryngeal Trauma

235
 TABLE I.

236
Selected Reports of Management of External Laryngeal Trauma From 1942–2011.
Number Patients/Methodology/
Citation/Publication Date Study Period Form of Injury Signs and Symptoms Management Outcome/Comments

Nach RL et al./194227 13 pts/retrospective Penetrating trauma, pre- Dyspnea, shock TRACH, immediate surgical 1 died of shock; 4 wound
dominately tracheal. repair. infections; 8 uneventful
recovery.
Lynch MG/194728 37 pts/retrospective/3 yrs Not given, military injuries N/A Low TRACH, immediate or 35/37 patients decannu-
Lynch MG/195129 World War II. late repair larynx. lated with resumption of
“normal activities.” Pro-
posed classification
based on 3 forms of la-
ryngeal injuries described

Laryngoscope 124: January 2014

in 1947 report.
Holinger PH et al./195930 82 pts/retrospective/10 yrs 68 blunt; 14 penetrating Hoarseness, dysphonia, Depending on injury, obser- N/A
trauma aphonia, compromised vation, TRACH, early
airway TH 1 ORIF.
Harris HH et al./196531 Har- Sets forth principles used in 39 pts blunt; 10 Indications for surgery Observation only (5 pts); Emphasizes early manage-
ris HH et al./197032 1970 report 49 pts/retro- penetrating. evolved from preoperative observation and ENDO (6 ment of laryngeal injuries.
spective/15 yrs findings in the 1965 pts); TRACH only (3 pts); Observation and endos-
report. TH (10 pts); copy only patients did
TH 1 ORIF 1 STENT (5 well. 2/3 pts TRACH only
pts); laryngeal and tra- died of other injuries. 9/
cheal exploration with 10 TH had a good voice
stent and skin graft. and 5/5
TH 1 ORIF 1 STENT with
skin graft had an
adequate airway and
poor voice.
Curtin JW et al./196633 34 pts/retrospective/7 yrs Blunt trauma; only 2 acute Airway compromise Early repair laryngeal frac- Emphasized need for early
injuries. ture in acute patients; recognition and treatment
reconstruction larynx in to avoid laryngeal
chronic injuries (2 mos to stenosis.
20 yrs old).
Olson NR et al./197134 25 pts/retrospective Blunt trauma Poor correlation of severity 12 patients treated surgi- Airway and voice returned
of injury, except for air- cally, 9 within 12 days to normal in observation
way compromise in the and earlier if emergent only patients. Less severe
crushed larynx. TRACH performed. injuries had better out-
TRACH, exposed carti- comes. Results improved
lage and fractured cricoid with earlier surgical
are primary surgical treatment.
indications.
Shia FT et al./197235 6 pts/retrospective/1 yr 4 blunt trauma; 2 Voice and airway compro- 6/6 patients treated surgi- 5/6 patients had normal air-
penetrating. mise varied with actual cally. TH 1 ORIF 1 STENT way. 1 required repeated
injury to vocal folds. used for complicated surgery for restoration of
injuries. airway. 1 patient died of
pulmonary embolus.
Pennington CL/19725 22 pts/retrospective Blunt trauma Voice and airway TH 1 ORIF fractures. Stent- 18 patients with immediate
compromise. ing used as needed. Fol- repair did well. 4 patients
lowing thyrotomy, vocal with cricotracheal separa-
ligaments fixated to thy- tion had RLN transection
roid cartilage. 18% of had good airway and
patients had cricotracheal poor voice. Describes
separation. biomechanics of blunt
injuries.

Schaefer: Management of Acute Laryngeal Trauma

 TABLE I.
(Continued)
Number Patients/Methodology/
Citation/Publication Date Study Period Form of Injury Signs and Symptoms Management Outcome/Comments

Cohn AM et al./197636 30 pts/retrospective 18 pts blunt; 12 pts Voice and airway more sig- Open surgical exploration in Penetrating trauma (10/12
penetrating. nificantly compromised in all patients with ORIF of pts) had better voice/air-
blunt than penetrating fractures. Stenting with way outcomes than blunt
trauma. and without grafting. (8/12 pts). Careful analy-
sis of injury and manage-
ment. Severity of injury
correlates best with
outcome.
Lambert GE et al./197617 23 pts/12 laryngeal injuries/ Laryngeal: 4 pts blunt; 8 pts Subcutaneous emphysema Immediate management 19 pts hoarseness; 2 pts
11 tracheal injuries/retro- penetrating. Tracheal: 6 (21 pts); hemoptysis (18 with wound exploration tracheal stenosis; 1 pt
spective/10 yrs pts blunt; 5 penetrating. pts); airway obstruction and TH 1 ORIF. tracheosophageal fistula;

Laryngoscope 124: January 2014

(13 pts); aphonia (10 pts). 1 pt laryngeal web; 1
death to airway blunt
trauma.
Trone TH et al./19801 53 pts/retrospective/13 yrs 42 pts blunt; 11 pts pene- 1965-1978 population: ob- 1965-1978 population:
trating. servation only (7 pts); groups patients by 4 types
TRACH 1 ENDO (5 pts); of injury and principles.
immediate TH 1 ORIF Stratifies airway manage-
fractures (14 pts), imme- ment by injury. Voice and
diate TH 1 ORIF 1 stent airway normal in groups 1
(27 pts). and 2. Airway good in 7/7
pts and voice good in 5/7
pts in TH 1 ORIF group
(group 3). Airway and
voice normal in TH 1,
ORIF 1 stent group in
>90% and 60% respec-
tively (group 4). Above
stratification becomes
standard nomenclature for
laryngeal trauma.
Schaefer SD/198216 35 pts/prospective/4 yrs 1978 to 1992 population 1978 to 1992 population: 1965 to 1992 population: 1978–1992 population,
Schaefer SD et al./199119 26 pts/prospective/5 yrs (Laryngeal): 42 pts blunt; aphonia (30 pts); pain (20 Observation only (20 pts); voice and airway normal
Schaefer SD/19923 19 pts/prospective/4 yrs 45 pts penetrating. pts); hemoptysis (5 pts); TRACH 1 ENDO (51 pts); in groups 1 and 2. Voice
dysphagia (6 pts); subcut immediate TH 1 ORIF and airway normal
emphysema (18 pts); fractures (29 pts); imme- in > 90% in groups 3 and
impaired respiration (39 diate TH, ORIF 1 STENT 4.
pts); hematoma (4 pts). (39 pts).
Maran AGD et al./19817 44 pts/retrospective/4 yrs 18 pts blunt; 14 pts MVA; Dysphonia and dyspnea pri- 17/18 pts with blunt trauma Voice good in the blunt
12 penetrating. mary symptoms followed observed; 8/14 accident trauma observed group; 8/
by dysphagia and pain. patients underwent surgi- 14 MVA patients had a
cal exploration. 12/12 good airway and voice; 5
penetrating trauma had a mixed result with one
patients had surgical tracheotomy dependent. 9/
repair. Surgical treatment 12 penetrating patients had
was within 1 wk. a good result. Authors
compared results of early
versus late treatment.
Gussack GS et al./198818 21 pts/prospective per pro- 9 pts blunt; 12 penetrating. N/A 6 pts TRACH; 18 pts intuba- 13/21 pts good voice; 16/
tocol/3 yrs ted with early manage- 21 pts good airway and 1
ment advocated. Blunt death. Stratifies intuba-
trauma tended to be more tion and CT imaging
complex and more likely to based on injury. Advo-
require TRACH rather than cates intubation over
intubation. Stents in 4 TRACH.

237
Schaefer: Management of Acute Laryngeal Trauma
blunt patients and 2 pene-
trating trauma patients.
 TABLE I.

238
(Continued)
Number Patients/Methodology/
Citation/Publication Date Study Period Form of Injury Signs and Symptoms Management Outcome/Comments

37
Leopold DA/1983 36 pts/retrospective/14 yrs N/A N/A 9 prior reports were Historical review combined
reviewed to examined with retrospective series
treatment and results in of 36 patients. Conclude
various forms of laryngeal best results with treat-
injuries and management. ment within 24 hrs, with-
out use of stenting, with
initial mobile vocal folds
and limiting stenting to
2.1 to 3.5 wks.

Laryngoscope 124: January 2014

Fuhrman GM et al./199038 10 pts/retrospective/1.5 yrs 10 pts blunt Pts neck tenderness: 9 pts 8 pts TRACH; 1 pts Adds laryngotracheal sepa-
subcutaneous air; 6 pts TH 1 ORIF; 1 pt ration as fifth category of
neck contusion; 4 pts tra- TH 1 ORIF 1 STENT; 1 laryngeal trauma. Voice
cheal deviation; 2 pts pts reapproximation lar- and airway poor to fair
hemoptysis. yngotracheal separation. with laryngotracheal sep-
aration due to transection
RLN.
Bent JP et al./19938 77 pts/retrospective/18 yrs 45 pts blunt; 32 pts 11 pts minor hematomas 61/75 pts managed within 40/55 pts good voice and
penetrating. and edema; 10 pts hema- 48 hrs; 11 pts observed; 50/55 pts good airway.
toma, minor lacerations; 10 pts underwent ENDO Poor airway and voice
36 pts massive edema with or without TRACH; results associated with
and mucosal lacerations 36 pts had TH and ORIF late management and se-
and fractures; 14 pts fractures. Complexity of verity of injury. Advocates
massive lacerations and treatment based on TRACH over intubation.
multiple fractures; 4 pts injury.
laryngotracheal
separation.
Yen PT et al./199439 30 pts/retrospective/10 yrs 25 pts blunt; 5 pts 26 pts hoarseness; 18 pts 16 pts observed; 4 pts Airway restoration good in
penetrating. dysphagia; 17 pts subcu- TRACH; 2 pts intubation; all patients, with 60% fair
taneous emphysema; 11 8 pts TH 1 ORIF. voice. Authors conclude
pts hemoptysis; 11 pts results can be improved
dyspnea . by earlier surgical inter-
vention and more aggres-
sive surgical restoration
of normal anatomy.
Grewal H et al./199540 57 pts/24 laryngeal/33 tra- 57 pts penetrating 22 pts subcutaneous em- 14 pts observed or repair of Airway stenosis in 3 pts
cheal/11 pts airway and physema; stridor; 19 pts injuries without TRACH; without TRACH depend-
digestive tract injuries/ret- respiratory distress; 2 pts 10 pts TH 1 ORIF. ent; 10 pts with less than
rospective/15 yrs hematemesis; and 2 pts normal voice. Advocates
dysphonia. selective use of intuba-
tion, TRACH or cricothyr-
oidotomy, and careful
examination of
esophagus.
Jewett BS et al. /19999 392 pts in a 11-state data 392 pts blunt 139 pts underwent TRACH TRACH associated with
base with diagnosis of and 96 pts TH, of which greater mortality and
external laryngeal trauma/ 140 were treated within length of hospital
retrospective/5 yrs 24 hrs. Direct laryngos- admission.
copy or bronchoscopy
performed in 45% of
patients.

Schaefer: Management of Acute Laryngeal Trauma

 TABLE I.
(Continued)
Number Patients/Methodology/
Citation/Publication Date Study Period Form of Injury Signs and Symptoms Management Outcome/Comments

41
Francis S et al./2002 23 pts/12 pts laryngeal, 8 4 pts blunt; 19 pts 7 pts subcutaneous emphy- 2 blunt trauma patients 2 penetrating injury patients
pts tracheal, 3 pts com- penetrating. sema; 12 pts lacerations; observed and 2 under- had a poor voice; 1
bined injuries/retrospec- 6 pts respiratory distress; went intubation; 12/19 patient died of a concur-
tive/6 yrs 4 pts dysphonia. penetrating trauma rent esophageal wound.
patients had surgery,
including TRACH in 9
patients.
Kennedy TL et al./200242 40 pts/retrospective/20 yrs 40 pts blunt 15 pts minor edema or lac- Suggest videostroboscopy
erations were observed; 6 could improve manage-

Laryngoscope 124: January 2014

pts required TRACH or ment of lesser injuries
intubation without further and avoid surgery.
surgery; remainder
TH 1 ORIF. Laryngeal
stroboscopy useful in
evaluating minimal
injuries.
Bhojani RA et al./200523 71 pts/15 pts laryngeal, 26 19 pts blunt; 52 pts 12 pts cervical ecchymosis All penetrating trauma Blunt trauma (P 5.0021)
pts tracheal, 30 pts com- penetrating. or hematomas; 12 pts patients required emer- and need for emergency
bined/retrospective/8 yrs stridor; 10 pts cardiopul- gency airways; 44 airway (P 5.0352) were
monary arrest; 8 pts patients required further independent predictors of
aphonia; 8 pts neurologi- surgical procedures. mortality. Blunt trauma
cal deficits. patients more frequently
required emergency air-
ways than penetrating.
Danic D et al./200643 65 pts/37 pts laryngeal; 2 Peacetime trauma: 16 pts 12 pts edema, minor hema- Minor injuries observed, Airway was good in 32 pts
tracheal; 8 pts combined blunt; 10 pts penetrating tomas, and minimal air- and intermediate injuries and phonation good in
trachea and larynx injuries. War trauma: 2 way obstruction; 11 pts treated by TH 1 ORIF. 28/36 pts. Data not avail-
pts blunt; 21 penetrating mucosal lacerations, frac- able in 12 patients. War
injuries. tures without displace- wounds were more
ment, and respiratory severe than civilian, mor-
obstruction; 25 pts with tality, 3.8% vs. 9%, and
large lacerations, dislo- distribution of wounds
cated fractures, and similar in both groups.
severe respiratory
obstruction.
Jalisi S et al./201121 12 pts/retrospective/10 yrs 10 pts blunt; 2 pts 1 pt hematoma; 2 pts 7/12 pts required a TRACH; Recommends selective
penetrating. hemoptysis; 1 pt dyspho- 6 pts with comminuted TRACH based on endo-
nia; 6 pts airway insuffi- fractures underwent laryngeal findings. 4/6 pts
ciency requiring TH 1 ORIF. 1 pt with lar- undergoing early
intubation “in the field”; 2 yngotracheal separation TH 1 ORIF laryngeal frac-
pts neck pain and sore was treated with primary tures had return of good
throat. repair and stent. voice and airway. Found
CT with contrast very
useful.

CT 5computed tomography; ENDO 5 direct laryngoscopy with or without esophagoscopy; N/A 5 information not included in report; pts 5 patients; ORIF 5 open reduction and internal fixation of laryngeal
skeletal fractures; RLN 5 recurrent laryngeal nerve; STENT 5endolaryngeal stent placed at time of thyrotomy; TH 5 thyrotomy with primary closure of mucosal lacerations; TRACH 5 tracheotomy.

239
Schaefer: Management of Acute Laryngeal Trauma
radiography. Utilizing 0.5 cm CT sections from the skull injuries.42 Stroboscopic examination is also useful in fol-
base to the first thoracic vertebrae after the patient lowing the recovering patient after surgery. Laryngeal
swallowed 250 ml of intravenous contrast, imaging sen- electromyography of the traumatized larynx is uncom-
sitivity was equivalent to standard barium swallow. mon, but allows for the evaluation of potential paresis or
Small esophageal lacerations were missed in the same paralysis of the external branch of the superior laryngeal
patients and only identified at surgery. nerve or the recurrent nerve. The former condition may
Summarizing the above reports and those in Table mimic arytenoid dislocation, and the latter condition
I, we offer the following observations: 1) esophageal inju- presents with a spectrum of vocal fold findings and dys-
ries are rare in both penetrating and blunt laryngotra- phonia.54 As stated by Nahum, observation is appropriate
cheal trauma but potentially catastrophic; 2) barium for “reversible injuries” due to blunt trauma, including
swallow and contrast CT esophagography using an iodi- endolaryngeal “edema, hematoma, contusion, abrasion,
nate intravenous contrast agent are equivalent studies non-displaced fractures, and small lacerations.”52 The
in patients without surgically obvious esophageal inju- most common finding in these patients has been dyspho-
ries, although both are inferior to esophagoscopy; and 3) nia and pain/tenderness of the larynx.3 These patients
rigid esophagoscopy is the most sensitive procedure to should be observed for 12 to 24 hours postinjury to insure
identify esophageal wounds but requires general anes- that their airway is not further compromised, and they
thesia. These observations have led us to recommend may benefit from steroids and inhaling cool mist.
rigid esophagoscopy in all patients undergoing surgical We are unaware of a systematic investigation of the
treatment of their external airway injuries. role of proton pump inhibitors to promote satisfactory re-
covery after external larynx trauma. Prospective com-
parisons of patients with documented laryngopharyngeal
Treatment of Acute Laryngeal Trauma reflux undergoing surgery for vocal fold polyps or Reinke
Following World War II, Lynch sought to improve edema do show a statistically better outcome in treated
laryngeal trauma treatment by classifying injuries as patients, and we utilize proton pump inhibitors to mini-
“lacerating, penetrating, contusions and crushing mize reflux.55 Contrary to Nahum’s recommendation to
wounds.”29 He proposed classifying the injuries as: 1) observe nondisplaced thyroid and cricoid cartilage frac-
“wounds from without, involving the cartilages or hyoid tures, and our own previously published experi-
bone without intrinsic injury; 2) wounds injuring the ence,3,27,52 we now prefer fixation of any fracture using
endolarynx; 3) wounds with little or no external injury adaptation plates.57,58 We believe such fixation is benefi-
but causing displacement or lacerations of the interior cial because we have observed distraction of CT imag-
surfaces; and 4) a combination of the these injuries.”29 ing-documented nondisplaced fractures separating days
In 1969 Nahum used several of the earlier reports noted to weeks postinjury. Further, using cadaveric larynges
in Table I29–31,33 to analyze the biomechanics of blunt Stanley et al. showed the importance of realignment of
trauma to the larynx. He described specific sites and nondisplaced angulated thyroid cartilage fractures on
types of injuries, and recommended treatment based on the aerodynamic performance of the larynx.56 Patients
the likely outcome being “reversible, intermediate, or ir- with minimal endolaryngeal mucosal injuries and
reversible if not treated.”51 The genesis of considering without cartilage fractures should be observed, and
outcome as a consequence of the airway injury can be recovery of a normal airway and voice is uniformly
found in the literature as early as 1922, when Zeuch excellent (Fig. 2).3,8,9,16,18,19,21
described subcutaneous rupture of the trachea and
reviewed the 1922 world literature on airway trauma.52
As referenced by DeSanto,“Lynch’s classification of types Surgical Management of Acute Laryngeal
of laryngeal trauma provides a useful framework for the Trauma
application of surgical principles in the repair of injuries Surgical management is directed toward preserva-
of the upper airway.”53 As additional trauma patients tion of the airway and maintenance of normal, func-
were managed, observations and treatment were further tional anatomy. Such restoration includes the repair of
refined and continue to reflect the original recommenda- injuries to the endolarynx and fracture stabilization of
tions of Lynch, Holinger, Harris, and Nahum the laryngeal framework. Curtin and Holinger summar-
(Fig. 2).1,3,5,7–9,16–19,21,23,30,31,34–43,51 ized the goals of the latter as “fractures of the larynx
just as fractures elsewhere in the body, require adher-
ence to the basic principles of all trauma surgery;
Nonsurgical Management of Acute Laryngeal namely, restore the parts to as nearly normal positions
Trauma as possible and splint them in positions of function.”30,33
The initial evaluation of blunt trauma should be per- In addition to Curtin and Holinger’s principles, the ben-
formed as outlined above, including flexible fiberoptic lar- efits of early surgical treatment have also become appa-
yngoscopy and judicious CT scanning of the larynx. rent. As summarized in Table I, the timing of “early”
Evaluation of penetrating trauma depends on the mecha- surgical management ranges from within 24 hours to
nism and path of the injury. If available and permitted several days. However, the excellent outcomes in a large
by the condition of the patient, video stroboscopic laryn- number of patients reported by Herbert Harris in 1965
goscopy provides an excellent assessment of vocal fold and 1970 demonstrated the benefits of surgery within 24
mobility and integrity, and potential reversibility of hours of injury.31,32 Few authors have compared their

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240
Fig. 2. Algorithm for early treatment of acute external laryngeal trauma. CT 5computed tomography; Ctomy 5 cricothyrotomy;
EMG 5 electromyography of the larynx; ORIF 5 open reduction and internal fixation of laryngeal skeletal fractures; STENT 5endolaryngeal
stent or lumen keeper; TRACH 5 tracheotomy; VS 5 videostroboscopy of larynx.

results in early versus delayed surgical management. In actual publications suggests that early repair is prefera-
1981, Maran et al. analyzed outcomes based on the tim- ble and that their delayed surgery was the consequence
ing of treatment. They stated: “by recognizing and treat- of the patient’s health and availability for surgery rather
ing the severe injuries early (defined as within 1 week than physician’s choice.34,59 Given the weight of outcomes
post injury), there is a 40% better chance of a good evidence, we strongly recommend surgical treatment
result and three times less chance of having to wear a within 24 hours, or as soon as the patient can be brought
tracheotomy tube permanently.”7 to the operating room.1,3,8,17,19,23,31–33,43
Further insight is provided by Bent et al., who found
a 25% incidence of poor voice and/or airway results after
late treatment compared to a 2% incidence of voice and Surgical Management of Acute Laryngeal
airway problem for those patients treated within 48 hours Trauma: Airway Maintenance and
of injury.8 Additional support for immediate surgery is Endoscopy Only
implicit in Leopold’s review of nine laryngeal trauma pub- Impending airway obstruction requires immediate
lications in which he concludes that 87% of patients attention and the various opinions on tracheotomy, crico-
undergoing treatment within 24 hours achieved a good thyroidotomy, or intubation have been reviewed. Once
airway compared to 69% after 2 to 7 days, and 27% after the airway is stabilized, direct laryngoscopy and esopha-
7 days.37 Voice results showed a similar decline with goscopy should be performed in the operating room.60
delay beyond 1 day. While some authors have extrapo- Patients with reversible findings such as edema, hema-
lated delaying treatment based on animal experiments, a tomas without mucosal disruption, and small lacerations
few authors have been cited by others as advocating post- not involving the glottis can be observed provided that
poning surgery for a week or more to permit resolution of they have a secure airway (Fig. 2). As many of these
soft tissue edema. Our own reading of these authors’ patients often undergone tracheotomy prior to

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241
endoscopy, further preservation of the airway simply
requires routine posttracheotomy care. In those patients
intubated, the next step is to perform either a tracheot-
omy or sedation with the endotracheal tube managed in
an intensive care unit. This decision should consider the
likelihood of further injury to the larynx by the endotra-
cheal tube, and the experience of the intensive care unit
with both tracheotomy and intubation care. Patients
managed in this way do well, with more than 90% hav-
ing a normal airway and voice.3,8

Surgical Management of Acute Laryngeal

Trauma: Airway Maintenance, Endoscopy,
Thyrotomy and ORIF Laryngeal Fractures
Following stabilization of the airway and endoscopy,
patients with mucosal lacerations involving two or more
anatomic sites, the free margin of the vocal folds, or
skeletal fractures are likely to benefit from surgical
treatment (Fig. 2). Midline thyrotomy for repair of endo-
laryngeal lacerations rather than alternatives such as
transoral endoscopic placement of a lumen keeper or
stent has been the prescribed treatment for the past 40
years.3,8,34,61 Paramedian thyrotomy via a vertical frac-
ture adjacent to the midline, with incision of mucous
Fig. 3. Primary closure of laryngeal lacerations via a midline thyro-
membrane at the anterior commissure, can also be uti- tomy. Enlargement shows suturing anterior margin of true vocal
lized to expose the endolarynx.34,61 Both approaches per- fold to outer perichondrium of thyroid cartilage to reconstitute the
mit direct exposure of the injury, realignment of injured normal anatomy and phonatory qualities of this structure. (With
mucous membrane, and primary approximation of lacer- permission from Schaefer SD. The acute surgical treatment of the
fractured larynx. Oper Techniq Otolaryngol–Head and Neck Surg
ations with 5-0 or 6-0 absorbable suture. We advocate
1990: 1:64–70.) [Color figure can be viewed in the online issue,
conservation of anatomy; that is, preservation and which is available at wileyonlinelibrary.com.]
realignment of mucous membrane and laryngeal muscles
instead of skin or mucosal grafts, or various partial or
the stabilization of fractures with wires or sutures
total laryngeal resection procedures.62
through cartilage to the approximation of perichon-
Repair of displaced or dislocated arytenoid cartilages
drium. In 1990, Woo reported laryngeal framework sur-
varies with the degree of injury. Isolated lacerations
gery using miniplates.54 Subsequently, Pou et al. utilized
involving these cartilages can be treated with reapproxi-
adaptation miniplates to stabilize laryngeal fractures in
mation of mucous membrane. Complete dislocation of the
10 patients.53 As described by Pou et al., the laryngeal
arytenoids from the cricoid requires traumatic avulsion of cartilages may not be well calcified and care must be
the cricoarytenoid joint ligaments. In the latter injuries, a taken to avoid stripping the screw threats in the carti-
pseudarthrosis of the joint is created and mobility of the lage. Macroporous biodegradable plates, an alternative
arytenoids is variable and therefore phonation.63 Follow- to metal plates, are reabsorbed in 18 to 36 months.64,65
ing closure of lacerations, the scaphoid shape of the ante- These devises are malleable after placement in 55 C
rior commissure provided by the insertion of anterior water; they may be shaped to conform to the laryngeal
commissure tendon (a.k.a.,Broyle’s ligament) on the mid- cartilages; and they maintain their strength for 6 to 12
line thyroid cartilage should be reconstituted. We recom- months. Independent of type of plate, we agree with Pou
mend bilaterally suturing the most anterior margin of the et al. that 2-point fixation on each side of the fracture
true vocal fold and vocal ligament to the outer thyroid car- permits maximum fragment alignment and stability,
tilage perichondrium because: 1) this permits primary which potentially reduces the need for laryngeal
repositioning and re-tensioning the vocal folds; 2) stenting stents.57 Such fixation has now become our procedure of
or keels are avoided by reconstituting a mucous mem- choice to stabilize laryngeal skeletal fractures, whether
brane lined anterior commissure; and 3) the pre-injury or not they are displaced.
configuration of the anterior larynx is best preserved, as
is vocal quality (Fig. 3). If the larynx is entered through a
paramedian thyrotomy, the anterior commissure can be Surgical Management of Acute Laryngeal
reconstructed using the above technique, with passage of Trauma: Airway Maintenance, Endoscopy, Thy-
nonabsorbable suture from the vocal fold through a mid- rotomy, ORIF Laryngeal Fractures and Stenting
line drill hole in the thyroid cartilage. The myoelastic aerodynamic properties of the lar-
Reports outlined in Table I offer various methods to ynx are compromised by: 1) avulsion of the anterior com-
reduce and fixate laryngeal skeletal fractures after missure from the thyroid cartilage; 2) mucosal injuries
repair of laryngeal mucosal injuries. These range from to the anterior vocal folds leading to adhesions that alter

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242
the scaphoid shape of the commissure; 3) obliteration of post-World War II period. Within the United States, the
the laryngeal lumen by synechia secondary to large or frequency and distribution of blunt and penetrating
multiple lacerations crossing multiple anatomic sites; trauma reflects regional variations and safety improve-
and 4) severely comminuted, unstable skeletal fractures. ments in automobile design. The high quality of emer-
The former can be managed by a laryngeal keel, gency personnel, and developments in fiberoptic
whereas the latter three diminish both voice and airway endoscopy and CT imaging have combined to improve
and may require a lumen keeper or stent. Sufficient ex- overall early diagnosis. Early diagnosis and stratification
perience has matured with stenting to permit general of treatment based on the initial history, physical find-
statements about their use: 1) soft stents are preferable ings, and the various aforementioned refinements has
to hard stents34,66; 2) prolonged stenting produces gran- improved outcomes. Our goal remains preservation of
ulation tissue, and most surgeons today prefer limiting life with restoration of a normal airway and voice.
their application to several weeks67; 3) stents should be
immobilized within the larynx by passage of monofila- BIBLIOGRAPHY
ment synthetic sutures through the laryngeal ventricle
1. Trone TH, Schaefer SD, Carder HM. Blunt and penetration laryngeal
and a second suture through the cricothyroid membrane. trauma: a 13-year review. Otolaryngol Head Neck Surg 1980;88:257–
Fixation with wire is not recommended because wire can 261.
2. Van de Berg J. Myoelastic theory of voice production. J Speech Hear Res
break and permit the stent to migrate into the trachea1; 1958;1:227–244.
4) the superior end of the stent should be closed to pre- 3. Schaefer SD. Acute management of external laryngeal trauma: a 27 year
experience. Arch Otolaryngol Head Neck Surg 1992;118:598–604.
vent aspiration of liquids through the stent66; 5) multi- 4. Nahum AM, Siegel AW. Biodynamics of injury to the larynx in automobile
ple, comminuted laryngeal skeletal fractures often collisions. Ann Otol Rhinol Laryngol 1967;76:781–785.
5. Pennington CL. External trauma of the larynx and trachea. Ann Otol Rhi-
require both internal stenting and external fixation nol Laryngol 1972;81:546–554.
because of the movement of the larynx during swallow- 6. Administration NHTSA. Traffic safety facts: 2002, p. 12.
7. Maran AGD, Stell PM, Murray JAM, Tucker A. Early management of la-
ing, and contraction of the intrinsic and extrinsic laryn- ryngeal injuries. J Royal Society Medicine 1981;74:656–660.
geal muscles further separates the fragmented cartilage 8. Bent JP, Silver JR, Porubsky ES. Acute laryngeal trauma: a review of 77
and; 6) if the laryngeal fractures can be stabilized with- patients. Otolaryngol Head Neck Surg 1993;109:441–449.
9. Jewett BR, Shockley WW, Rutledge R. External laryngeal trauma analysis
out an internal lumen keeper, and the endolaryngeal of 392 patients. Arch Otolaryngol Head Neck Surg 1999;125:877–880.
mucosal injuries are minimal, stenting should be 10. McNamara JJ, Stremple JF. Causes of death following combat injury in an
evacuation hospital in Vietnam. J Trauma 1972;12:1010–1012.
avoided.37 Various forms of laryngeal stents are now 11. Mabry RL, Holcomb JB, Baker AM, Baker AM, Cloonan CC, Uhochak JM,
available. Perkins DE, Canfield AJ, Hagmann JH, Cann C, Hirsch EF. United
States Army Rangers in Somalia: an analysis of combat causalities on
As referenced in the articles listed in Table I, the an urban battlefield. J Trauma 2000;49:515–529.
finger cot, rolled silastic sheet, and molded Portex endo- 12. Mabry RL, Cuniowski P, Frankfurt A, Adams BD. Advanced airway man-
agement in combat casualties by medics at the point of injury: a sub-
tracheal tube stents have been used for many decades; group analysis of the Reach Study. J Spec Oper Med 2011;11:16–19.
when other stents are not available, we will use the Por- 13. Adams BD, Cuniowski P, Muck A, DeLorenzo RA. Combat airway manage-
ment: the registry of emergency airways arriving at combat hospitals. J
tex tube. Newer commercial stents include the Aboulker Trauma 2008;64:1548–1554.
stent,68 the Montgomery T-tube,69 the Montgomery la- 14. CoTCCC. Tactical Combat Casualty Care Manual. Washington, DC; 2005.
ryngeal stent,70 the Eliachar laryngotracheal stent,71 15. O’Keeffe LJ, Maw AR. The dangers of minor blunt laryngeal trauma. J
Laryngol Otol 1992;106;372–373.
and the LT-Mold stent.72 The LT-Mold stent has the 16. Schaefer SD. Primary management of laryngeal trauma. Ann Otol Rhinol
“virtues” of being made of soft silicone, conforms to the Laryngol 1982;91:399–402.
17. Lambert GE, McMurry GT. Laryngotracheal trauma: recognition and
endolaryngeal-tracheal contours, may be shortened in management. JACEP 1976;5:883–887.
the operating room, and is available in various adult 18. Gussack GS, Jurkovich J. Treatment dilemmas in laryngotracheal trauma.
J Trauma 1988;28:1439–1444.
and pediatric sizes.72 A final consideration is the proxim- 19. Schaefer SD. State of the art: the acute treatment of external laryngeal
ity of the stent relative to the true vocal folds. Ko et al. injuries. Arch Otolaryngol Head Neck Surg 1991; 117:35–39.
20. Wang HE, Abo BN, Lave JR, Yealy DM. How would minimum experience
analyzed 40 adult and pediatric patients undergoing tra- standards affect the distribution of out-of-hospital endotracheal intuba-
cheal stenosis stenting, employing either the Montgom- tions? Ann Emerg Med 2007;50:246–252.
21. Jalisis S, Zoccoli M. Management of laryngeal fractures—a 10-year experi-
ery T-tube or Dumon prosthesis (Novatech, Grasse, ence. J Voice 2011;25:473–479.
France) following surgery for various forms of injury to 22. Jackson C. High tracheostomy and other errors–the chief cause of laryn-
geal stenosis. Surg Gynecol Obstet 1921;32:392–398.
the trachea, glottis, and supraglottis.73 Logistic regres- 23. Bhojani RA, Rosenbaum DH, Dikmen E, Paul M, Zane B, Zonies D,
sion analysis revealed a significant (LR 1 4.630, Estrera AS, et al. Contemporary assessment of laryngotracheal trauma.
J Thorac Cardiovasc Surg 2005;130:426–432.
P 5 0.042) increased risk of granulation tissue the closer 24. Desjardins G, Varon AJ. Airway management for penetrating neck inju-
the superior end of stent approximated the true vocal ries: the Miami experience. Resuscitation 2001;48:71–75.
folds, and the greater aspiration with placement above 25. Graham DB, Eastman AL, Aldy KN, Carroll EA, Minei JP, Brakenridge
SC, Phelan HA. Outcomes and long term follow-up after emergent crico-
the glottis (LR 5 26.050, P <, 0.001). Although one might thyroidotomy: Is routine conversion to tracheotomy necessary? The
question the applicability of Ko’s report to laryngeal Amer Surg 211;77:1707–1711.
26. Francois B, Clavel M, Desachy A, Puyraud S, Roustan J,Vignon P. Compli-
injuries, all will agree that the quality of the stent, and cations of tracheostomy performed in the ICU: Subthyroid tracheostomy
its position, duration, and fixation are practical vs. surgical cricothyroidotomy. Chest 2003;123:151–158.
27. Nach RL, Rothman M. Injuries to the larynx and trachea. Surg Gynecol
considerations. Obstet 1943;76:614–622.
28. Lynch MG. Traumatic lesions of the larynx. Arch Otolaryngol
1947;73:413–420.
29. Lynch M. Repair of the traumatized larynx. Laryngoscope 1951;61:51–65.
CONCLUSION 30. Holinger PH, Johnston KC. Laryngeal trauma and its complications. Am J
Surg 1959;97:513–517.
The evaluation and treatment of acute external la- 31. Harris HH, Ainsworth JZ. Immediate management of laryngeal and tra-
ryngeal trauma has improved considerably during the cheal injuries. Laryngoscope 1965;75:1103–1115.

Laryngoscope 124: January 2014 Schaefer: Management of Acute Laryngeal Trauma

243
32. Harris HH, Tobin HA. Acute injuries of the larynx and trachea. Laryngo- 54. Schroeder U, Motzko M, Wittekindt, Eckel HE. Hoarseness after laryngeal
scope 1970;80:1376–1383. blunt trauma: a differential diagnosis between an injury to the external
33. Curtin JW, Holinger PH, Greeley PW. Blunt trauma to the larynx and branch of the superior laryngeal nerve and arytenoid subluxation. A
upper trachea: immediate treatment, complications and late reconstruc- case report and literature review. Eur Arch Ortorhinolaryngol
tive procedures. J Trauma 1966;6:493–502. 2003;260:304–307.
34. Olson NR, Miles WK. Treatment of acute blunt laryngeal injuries. Ann 55. Kantas I, Balatsouras DG, Kamargianis N, Katotomichelakis M, Riga M,
Otol Rhinol Laryngol 1971;80:704–709. Danielidis V. The influence of laryngopharyngeal reflux in the healing of
35. Shia FT, Cassady CL. Laryngeal trauma. Arch Otolaryngol 1972;95:104–108. laryngeal trauma. Eur Arch Otorhinolaryngol 2009;266:253–259.
36. Cohn AM, Larson D. Laryngeal injury: a critical review. Arch Otolaryngol 56. Stanley RB, Cooper DS, Florman SH. Phonatory effects of thyroid carti-
1976;102:166–170. lage fractures. Ann Otol Rhinol Laryngol 1987;96:493–496.
37. Leopold DA. Laryngeal trauma: a historical comparison of treatment 57. Pou AM, Shoemaker DL, Carrau RL, Synderman CH, Eibling DE. Repair
methods. Arch Otolaryngol 1983;109:106–111. of laryngeal fractures using adaptation plates. Head Neck 1998;20:707–
38. Fuhrman GM, Stieg FH, Buerk CA. Blunt laryngeal trauma: classification 713.
and management protocol. J Trauma 1990;30:87–92. 58. Woo P. Laryngeal framework reconstruction with miniplates. Ann Otol
39. Yen PT, Lee HY, Tsai MH, et al. Clinical analysis of external laryngeal Rhinol Laryngol 1990;99:772–777.
trauma. J Laryngol Otol 1994;108:221–225. 59. Potter CR, Sessions DG, Ogura JH. Blunt laryngotracheal trauma. Otol
40. Grewal H, Prakashchandra MR, Mukerji S, Ivatury RR. Management of AAOO 1978;86:909–923.
penetrating laryngotracheal injuries. Head Neck 1995;17:494–502. 60. Krekorian EA. Laryngopharyneal injuries. Laryngoscope 1975;85:2069–
41. Francis S, Gaspard DJ, Rodgers N, Stain SC. Diagnosis and management 2086.
of laryngotracheal trauma. J Natl Med Assoc 2002;94:21–24. 61. Schaefer SD. The acute surgical treatment of the fractured larynx. Oper
42. Kennedy TL, Gilroy PA, Greene JS, Pelliteri PK, Harlor M. Strobovideo- Techniq Otolaryngol Head Neck Surg 1990;1:64–70.
laryngoscopy in the management of acute laryngeal trauma. J Voice 62. Harrison DFN. Bullet wounds of the larynx and trachea. Arch Otolaryngol
2004;18:130–137. 1984;110:203–205.
43. Danic D, Prgomet D, Sekelj A, Jarkovina A, Danic A. External laryngotra- 63. Schaefer SD, Close LG, Brown OE. Mobilization of the fixated arytenoid
cheal trauma. Eur Arch Otorhinolaryngol 2006;263:228–232. in the stenotic posterior commissure. Laryngoscope 1986;96:656–659.
44. Brennan J, Gibbons MD, Lopez M, Hayes D, Faulkner J, Eller RL, Brown 64. Bhanot S, Alex JC, Lowlich RA, Ross DA, Sasaki CT. The efficacy of
C. Traumatic airway management in operation Iraqi Freedom. Otolaryn- resorbable plates in head and neck reconstruction. Laryngoscope
gol Head Neck Surg 2011;144:376–380. 2002;112:890–898.
45. Xydakis MS, Fravell MD, Nasser KE, Casler JD. Analysis of battlefield 65. Sasaki CT, Marotta JC, Lowlicht RA, Ross DA, Johnson M. Efficacy of
head and neck injuries in Iraq and Afghanistan. Otolaryngol Head Neck resorbable plates for reduction and stabilization of laryngeal fractures.
Surg 2005;133:497–504. Ann Otol Rhinol Laryngol 2003;112:745–750.
46. Schaefer SD, Brown OE. Selective application of CT in the management of 66. Schaefer SD, Carder HM. Fabrication of a simple laryngeal stent. Laryn-
laryngeal trauma. Laryngoscope 1983;93;1473–1475. goscope 1981;90:1561–1563.
47. Demetriades D, Velmahos GG, Asensio JA. Cervical pharyngoesophageal 67. Thomas GK, Stevens MH. Stenting in experimental laryngeal injuries.
and laryngotracheal injuries. World J Surg 2001;25:1044–1048. Arch Otolaryngol 1975;101:217–221.
48. Weigelt JA, Thal ER, Snyder WH, Fry RE, Mier DE, Kilman WJ. Diagnosis 68. Aboulker P, Demaldent JE. Clinical aspects and treatment of tracheal and
of penetrating cervical esophageal injuries. Am J Surg 1987;154:619–622. laryngotracheal stenosis after tracheotomy. Ann Chir Thorac Cardiovasc
49. Asensio JA, Chahwan S, Machersie R, et al. Penetrating esophageal 1967;6:1095–1102.
injury: multicenter study of the American Association for the Surgery of 69. Montgomery W. T-tube tracheal stent. Arch Otolaryngol 1965;82:320–321.
Trauma. J Trauma 2001;50:289–296. 70. Montgomery WW, Montgomery SK. Manual for use of Montgomery laryn-
50. Gonzales RP, Falimirski M, Holvar MR, Turk B. Penetrating zone II geal tracheal and esophageal prostheses: update. Ann Otol Rhinol Lar-
injury: Does dynamic computed tomographic scan contribute to the diag- yngol 1990;150:2–28.
nostic sensitivity of physical examination for surgically significant 71. Eliachar I, Nguyen D. Laryngotracheal stent for internal support and con-
injury? A prospective blinded study. J Trauma 2003:54:61–65. trol of aspiration without loss of phonation. Otolaryngol Head Neck
51. Naham AM. Immediate care of acute blunt laryngeal trauma. J Trauma Surg 1990;103:837–840.
1969;9:112–125. 72. Monnier P. Airway stenting with the L-T Mold: experience in 30 pediatric
52. Zeuch LH. Sub-cutaneous rupture of the trachea. Illinois Med J 1922 cases. International J Ped Otolaryngol 2007;71:1351–1359.
June;451–454. 73. Ko PJ, Liu CY, Wu YC, Chao YK, Hsieh MJ, Wu CY, Wang CJ, Liu YH,
53. DeSanto LW, Brown AK. Acute laryngeal trauma. Minn Med 1972;55: Liu HP. Granulation formation following tracheal stenosis stenting:
328–332. Influence of stent position. Laryngoscope 2009;119:2331–2336.

Laryngoscope 124: January 2014 Schaefer: Management of Acute Laryngeal Trauma

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