Primarily, symptoms, direct nasopharyngoscopy, and CT scanning determine the need for treatment of laryngeal fractures. For minor injuries in which edema, hematoma, or certain small, insignificant mucosal tears are identified without evidence of other injury, medical treatment is appropriate. Mucosal tears of less than 2 cm have been treated effectively without surgical intervention.  The goal of medical treatment is to return the patient to preinjury laryngeal function, which includes ventilation, phonation, and protection of the lower airway. Typically, in such minor injuries, tracheotomy is not required; however, close clinical observation is essential in the first 24-48 hours after injury.
Bed rest is recommended for patients treated medically for laryngeal trauma, with the head of the bed elevated 30-45°. Voice rest is recommended to minimize edema, hematoma formation, and subcutaneous emphysema. Humidified air reduces crust formation and transient ciliary dysfunction. Supplemental oxygen is usually not needed and may be harmful in some patients (eg, patients with chronic obstructive pulmonary disease). Arterial blood gas (ABG) testing can be used to determine the need for supplemental oxygen.
Initially, a nothing by mouth (NPO) status is recommended for patients with laryngeal fractures and mucosal tears, followed by a clear liquid diet.  Diet regimens should mirror the severity of injury. Those patients without visible mucosal lacerations or fractures can initiate a clear liquid diet earlier than those patients with more severe injuries. Patients with severe injuries may require total parenteral nutrition supplementation during their NPO period. Avoid the use of nasogastric tubes for suctioning or feeding because of the potential for worsening laryngeal injury that results from local trauma during tube placement.
The benefit of using systemic corticosteroids is controversial. Many otolaryngologists believe that corticosteroids are necessary to retard inflammation, swelling, and fibrosis and to help prevent granulation tissue formation. Systemic corticosteroids are helpful only in the first few days after the injury.
The use of antibiotics is not necessary in the treatment of minor laryngeal trauma in which cartilaginous fractures and mucosal tears are not identified. However, when tears are visualized or with compound fractures of the larynx, systemic antibiotics should be used to reduce the high risk of local infection and perichondritis, which may delay healing and promote airway stenosis.
The use of antireflux medications, such as H2-receptor antagonists and proton pump inhibitors, can help to reduce granulation tissue formation and tracheal stenosis. Use these medications throughout the emergent and convalescent phases of medical treatment for laryngeal fractures.
The surgical management of an unstable patient can be guided by the flow diagram depicted in the image below.
The information gained from the history, physical examination, endoscopic procedures, and imaging studies serves as an important tool when planning a neck exploration. If the airway is compromised, a tracheotomy should be performed, preferably with the patient awake under local anesthesia with mild sedation. Usually, a tracheal incision is made at a position lower than that for standard tracheotomy. An incision below the third or fourth ring is preferred when managing the airway that has laryngeal trauma. This position helps to avoid further injury to the larynx and its supporting structures.
Surgical exploration begins with a horizontal skin incision in a skin crease at the level of the cricothyroid membrane. A subplatysmal apron flap is then elevated superior to the hyoid bone and inferior to expose the cricoid cartilage. Extension of the incision site facilitates examination of neural, vascular, and visceral injuries. The strap muscles are separated in the midline and are retracted laterally so that the laryngeal skeleton can be assessed adequately. At this point, identify and remove fractured pieces of the laryngeal cartilage.
Depending on the injury, the larynx is entered through the thyrohyoid membrane, a midline thyrotomy, or the thyroid cartilage within 2-3 mm of the thyroid notch. If a thyrotomy is needed, a midline, vertical perichondrial incision is made in the thyroid cartilage. A subchondral dissection follows bilaterally. An oscillating saw or a number 15 blade can be used to cut through the thyroid cartilage, with care to avoid trauma to the endolaryngeal mucosa.
After the thyroid cartilage is divided, the endolaryngeal mucosa is sharply divided. The endolarynx is examined in its entirety to identify the full extent of injury. The arytenoids are palpated to evaluate their mobility and position. Vocal cords are repaired using 5-0 or 6-0 absorbable sutures. Suturing the anterior surface of each damaged cord to the external perichondrium with 4-0 absorbable sutures resuspends the vocal cord. Reconstituting the anterior commissure is critical to preserving voice quality.
Great care should be taken to identify and repair all mucosal lacerations with fine absorbable sutures (ie, 5-0, 6-0). Primarily close exposed cartilage with meticulous technique to minimize fibrosis and prevent formation of granulation tissue. Exposed cartilage that cannot be closed primarily may need skin or mucous membrane grafts. In the few circumstances in which a graft is required, mucous membrane, dermis, or split-thickness grafts are suitable. 
Laryngeal cartilage fractures must be reduced and immobilized. Small, isolated cartilage fractures that have no perichondrium are débrided to prevent chondritis and vocal cord dysfunction.
Traditionally, wire sutures have been used to immobilize reduced laryngeal cartilage fractures as seen in the image below.
Recently, however, many surgeons have begun to use metal alloy plates (miniplates) for repairing laryngeal fractures. Miniplates have been shown to effectively stabilize the laryngeal architecture as seen in the image below and reshape the larynx back to its preinjury state. They also decrease the length of hospitalization, insignificantly alter operating time, and usually add no additional discomfort to the patient. [22, 23] The image below depicts stabilization methods.
More recently, the use of absorbable miniplates has been introduced. These plates have been found to be just as safe, effective, and manageable as their alloy counterparts. They also have the advantages of improved cosmesis after resorption, less bone growth restriction, less issue with plate migration, less bony resorption, and negligible image artifact.  Most plates are composed of polylactic acid copolymer material and used for open reduction and stabilization of displaced fractures. Sasaki et al evaluated the efficacy of both MacroPore and Leibinger restorable reconstruction plates in 3 adult male patients and found both plates to be equally easy to use. In addition, adequate skeletal stabilization was achieved, which allowed for early phonation and respiratory function without long-term stenting. 
In Brazil, de Mello-Filho et al performed a retrospective study on the efficacy of adaptation plate fixation (APF) to repair the larynx. This group had no complications with the use of APF, and 19 out of 20 patients recovered their voices. 
Regardless of the method, the goal of surgical intervention is to restore the 3 primary functions of the larynx: breathing, phonating, and swallowing.
Using permanent sutures or wires, the thyrotomy is then closed, and the strap muscles are reapproximated. The nasogastric tube is then placed using direct visualization.
Proper patient positioning is essential when planning a neck exploration and may require hyperextension of the patient's neck after first clearing the cervical spine. The neck and tracheotomy site is prepared and draped in sterile fashion. The midcervical transverse thyrotomy incision is marked and injected with local anesthetic.
Perhaps the most important portion of the surgery is injury assessment. Failure to adequately assess for potential injuries can result in disastrous consequences. Important structures, such as the larynx, cricoid, both recurrent laryngeal nerves, and the esophagus, must be identified and evaluated. Repair esophageal injuries before manipulating the trachea.
When performing the thyrotomy, use electrocautery to make the transverse incision in the cricothyroid membrane. When using the saw or a number 15 blade, exercise extreme caution to avoid entering the lumen. Placing the patient in the Trendelenburg position can sometimes provide better visualization of the subglottic region.
If required, resuspension of the vocal cords must be the last step before closure of the thyrotomy. Prior to this step, all other structures must be stabilized.
See the list below:
If a tracheotomy is performed, the tube is left in place for a minimum of 5 days.
Decannulation depends on several factors and should be performed on a case-by-case basis.
Prophylactic antibiotics are used for at least 5 days. If a stent is used, antibiotics are continued until stent removal (usually 2-3 wk).
Tube feedings are continued for at least 5-10 days.
Facial plastic and reconstructive surgery may be necessary in the future. Other procedures, such as destruction of granulation tissue, stenosis, and webs, may also be required. Patients are monitored closely for the first 6-12 months after the initial injury.
Complications include the following:
- Airway obstruction
- Postoperative complications (eg, hematoma, infection)
Injury to the recurrent laryngeal nerve is a dreaded complication of surgery and may cause vocal fold impairment. Unilateral injuries result in a weak voice, and bilateral injuries can cause respiratory compromise. Unless the recurrent laryngeal nerve is severed during surgery, no intervention is needed. However, if no improvement is noted after 6-12 months, a thyroplasty-type vocal cord medialization procedure can be performed to strengthen the voice. The vocal cord can be injected with Gelfoam if aspiration or dysphonia is present and severe.  This procedure is only a temporary solution.
Cricoarytenoid joint fixation must be excluded before initiating any of these procedures.  To accomplish this goal, assess vocal cord mobility using direct laryngoscopy, and assess arytenoid mobility using direct palpation. If an adequate airway and voice are present, no treatment is needed. Bilateral arytenoid fixation or recurrent laryngeal paralysis with an unstable airway is treated with arytenoidectomy, cordotomy, or vocal cord lateralization.
The most common problem in the immediate postoperative period is the development of granulation tissue and ulceration from exposed cartilage. Granulation tissue may be decreased with the use of antibiotics and stents if the stents are removed in a timely fashion. The main concern with granulation tissue formation is the potential for the development of fibrosis and eventually stenosis. Many techniques have been used to slow the formation of granulation tissue, including systemic and intralesional administration of corticosteroids, long-term splinting, and low-dose radiation. These techniques have resulted in little success.  Debulking granulation tissue through endoscopy is probably the most effective alternative treatment currently available.
Subglottic stenosis is a difficult complication to treat effectively. Incomplete ring and weblike subglottic stenosis can be treated with laser excision or incision and dilation.  More significant stenosis may require anterior or posterior cricoid splits with cartilage grafting. Direct laryngoscopy and bronchoscopy should be performed during the follow-up period to examine the extent of stenosis.
Laryngeal trauma complications can manifest as inadequate voice and failure to decannulate. These can be prevented or treated in the following ways:
- Covering all exposed cartilage to prevent
- Avoiding stents when possible
- Careful excision
- Excision with mucosal coverage
- Stenting selected cases
- Tracheal resection with reanastomosis
Vocal fold immobility
- Vocal fold injection
- Thyroplasty-type vocal fold medialization
- Arytenoidectomy and vocal fold lateralization for bilateral paralysis
Outcome and Prognosis
The overall outcome and prognosis of a patient with a laryngeal fracture depends on several factors, such as extent of injury, timing of repair, and the ability of the otolaryngologist to properly evaluate and treat the patient who has been traumatized. Generally, success is measured in terms of voice and airway function. Minor injuries usually result in return to preinjury airway and voice status. More significant trauma results in voice changes and requires more intensive procedures for airway stabilization.
Certain factors have been identified that correlate with a good outcome. Although controlling some of these factors is virtually impossible, a basic understanding and knowledge of these indicators can help predict the ultimate morbidity or mortality of a patient.
Early repair of injury is essential in obtaining the best outcome. Evidence suggests that ideal timing for the repair of laryngeal fractures is within the first 24-48 hours after injury. [31, 32] If repair occurs later, the rate of complications (dysphonia, aspiration, and tracheotomy dependence) increases considerably. Early repair decreases the complications of chronic airway obstruction, poor voice quality, persistent granulation tissue, wound contractures, and stenosis.
After studying 392 patients with laryngeal trauma, Jewett (1999) found an increased mortality rate (0.78% vs 0.5%) in patients in whom tracheostomy was performed versus those in whom it was not performed.  The reason for tracheostomy was unclear and possibly associated with other common associated injuries (eg, head or chest injury).
Penetrating trauma is prognostically more favorable than blunt trauma. Leopold (1983) found that penetrating trauma resulted in good airway function 93% of the time, and 70% of patients recovered with excellent voice quality. In contrast, 68% of patients who had sustained blunt trauma had good airway function, while 39% of patients recovered with excellent voice quality.
Vocal cord mobility is another documented favorable prognostic sign. Vocal cord dysfunction usually results from recurrent laryngeal nerve injury or arytenoid subluxation. Leopold's study revealed that good airway function was found in 81% of patients with good vocal cord mobility, while good airway function was found in only 72% of patients with vocal cord dysfunction. The data are even more impressive when voice change was compared. Excellent voice quality was found in 56% of patients with normal vocal cords, while excellent voice quality was found in only 17% of patients with vocal cord immobility (1983). 
Much controversy exists regarding the use of laryngeal stents and whether their use improves patient outcome in laryngeal trauma. Inherent difficulties arise when measuring their influence because most injuries that require stent placement are severe and probably will have some complications regardless of stent use. The basic tenet for the use of laryngeal stents requires that they serve as internal fixation devices and as a means of preventing endolaryngeal scarring; however, the use of stents is associated with risks. Stents may increase the prevalence of infection and granulation tissue formation. Specific indications are needed for their use, including multiple cartilaginous fractures, anterior commissure lacerations, and significant distortion of laryngeal architecture.
Stent placement does not serve as a substitute for primary closure of mucosal lacerations and reduction and internal fixation of laryngeal fractures. [21, 34] Patients treated without stents had better resultant airway function (88% of patients without stents vs 71% of patients with stents).  Similarly, patients treated without stents had better voice results (61% of patients without stents had excellent voice results vs 33% of patients with stents). 
Choices of stents range from finger clots with foam rubber to commercially prepared polymeric silicone stents. Place the material in the larynx so that the material moves freely with the larynx during swallowing. Also, contour the stents to the shape of the larynx to avoid mucosal damage. If internal sutures break, use a 4-point fixation device to allow an easier recovery from the stent. Most authors agree that stents should be removed in 10-14 days.
Future and Controversies
Because of the rarity of serious laryngeal trauma, limited clinical research is available to guide treatment decisions. The poor results associated with the use of internal stents remains an obstacle in treatment. Research that describes specific injuries necessitating the use of stents will help to improve outcomes. Recently, investigation and clinical use of adaptation plates to stabilize laryngeal fractures has shown promising results and may reduce future need for internal laryngeal stents. Further investigation into the use of absorbable polyvicryl miniplates or mesh could reduce long-term complications.
Several promising techniques that may be beneficial in the future of laryngotracheal reconstruction have been recently described. Several authors have described the use of autogenous laryngeal cartilage in laryngotracheal reconstruction.  Others have described the use of tracheal homografts from cadavers.  In 1998, at the Cleveland Clinic, the first laryngeal transplant was performed in a patient who lost phonation after a motorcycle accident. Reports of patients with laryngeal transplants suggest good-to-excellent results in phonation and airway.  Perfecting laryngeal transplantation in the future could provide an alternative for patients with poor outcomes resulting from laryngeal fractures.
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