Laryngeal Fractures Workup

  • Author: Samir S Pancholi, DO; Chief Editor: Arlen D Meyers, MD, MBA   more...
 
Updated: Jan 9, 2010
 

Laboratory Studies

  • General trauma (Advanced Trauma Life Support [ATLS]) protocol is indicated for any individual who is severely injured. The airway must be secured, and other organ systems (eg, cardiac, pulmonology, vascular) must also be stabilized. Before any diagnostic study can be performed, life-threatening injuries, such as vascular injuries or internal bleeding, must be corrected.
  • Generally, in the setting of a laryngeal fracture, chest and cervical spine radiographs are obtained to exclude associated cervical injuries. Other nonroutine studies that may be helpful are cervical arteriography and water-soluble contrast studies of the esophagus and pharynx.
  • Laryngeal fractures are usually suspected based on symptoms and physical findings, but direct visualization of the larynx is critical to define the extent and location of injury. Endoscopy is the mainstay for direct visualization of the larynx and its surrounding structures. Abnormalities such as edema, hematomas, tears, exposed cartilage, vocal cord avulsion, vocal cord paralysis, and arytenoid dislocation can be assessed via endoscopy. Transnasal fiberoptic laryngoscopy is the procedure of choice in this setting because this procedure can assess the airway in the dynamic state and identify any abnormalities. Indirect laryngoscopy is usually avoided because of the gagging and coughing it elicits in a patient with an already compromised airway.
  • When the cause of laryngeal injury is not readily apparent, histological studies can help to determine the cause of injury and detect other macroscopic overlooked injuries.[7]
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Imaging Studies

  • CT scanning is the imaging modality of choice to assess laryngeal anatomy.[8, 9] A clear understanding of the Schaefer classification of laryngeal injuries is required to prevent morbidity and mortality. This classification system is based on a combination of the CT and endoscopic findings, which dictate treatment modalities.
    • CT scanning can help detect laryngeal fractures in a patient with no clinical signs or symptoms. In patients with minor injuries and minimal symptoms (eg, edema, ecchymosis, small hematomas), a CT scan is unlikely to provide new information that would alter treatment. Similarly, a patient with airway compromise and clinically obvious fractures requires aggressive surgical treatment regardless of CT findings.
    • Used judiciously, information gained from a CT scan will guide proper management of the patient's condition and prevent unnecessary surgical exploration; thus, the CT scan is a cost-effective means of assessing laryngeal anatomy.[8]
    • CT devices capable of spiral technique and subsecond scan times, specifically those that can reconstruct 2-dimensional axial sections, 2-dimensional coronal and sagittal images, and 3-dimensional images, can provide optimal imaging results.[10] Interest in the use of 3-dimensional CT images is currently growing. This innovative and highly useful tool can provide useful information when attempting to diagnose a laryngeal fracture. Because of the complexity of laryngeal anatomy, 3-dimensional CT imaging is especially useful when conventional CT, MRI, and fibroscopy are unable to reveal laryngeal trauma.[11]
  • MRI has not gained acceptance as an evaluative tool for laryngeal fractures or trauma because of the length of time required to complete the scan and the increased physical demands placed on the patient (eg, holding breath for a long period).[12] In addition, MRI is not helpful for imaging skeletal structures.
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Diagnostic Procedures

  • The procedures below are used to evaluate patients with suspected laryngeal trauma.
    • Fiberoptic nasopharyngoscopy: This procedure is performed in a conscious patient, with topical anesthesia. The goal of the procedure is to evaluate vocal cord function and to perform a preliminary assessment of the extent of trauma.
    • Direct laryngoscopy: This procedure provides a detailed visual examination of the larynx. Instrumentation such as the Dedo or Pilling laryngoscope provides excellent visualization; however, complete examination of the anterior commissure may require special instrumentation.
    • Bronchoscopy: This procedure may be performed with either a flexible or rigid bronchoscope, depending on the experience of the operator. Examination allows observation of the subglottic larynx and supporting structures.
    • Esophagoscopy: This procedure allows visualization of the esophageal mucosa for traumatic lacerations. It may be performed with either a flexible or rigid esophagoscope, depending on the experience of the operator. Traumatic injury is common in the retrolaryngeal esophagus; therefore, close evaluation is required.
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Contributor Information and Disclosures
Author

Samir S Pancholi, DO  Consulting Surgeon, Cosmetic Surgery of Las Vegas; Adjunct Assistant Professor of Cosmetic Surgery, Touro University; Assistant Professor of Otolaryngology-Facial Plastic Surgery, Michigan State University

Samir S Pancholi, DO is a member of the following medical societies: American Academy of Cosmetic Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, and American Osteopathic Association

Disclosure: Nothing to disclose.

Coauthor(s)

Wayne K Robbins, DO, FAOCO  Program Director, Department of Otolaryngology-Facial Plastic Surgery, Genesys Regional Medical Center

Wayne K Robbins, DO, FAOCO is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, and American Osteopathic Association

Disclosure: Nothing to disclose.

Alpesh Desai, DO  Program Director, South Texas Dermatology Residency Program, Adjunct Clinical Professor, University of North Texas Health Science Center; Associate Professor, Department of Dermatology, Western University of Health Sciences

Alpesh Desai, DO is a member of the following medical societies: American Osteopathic College of Dermatology

Disclosure: Nothing to disclose.

Tejas Desai, DO  Staff Physician, Department of Dermatology, Western University of Health Sciences

Tejas Desai, DO is a member of the following medical societies: Texas Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

John Schweinfurth, MD  Professor, Department of Otolaryngology, University of Mississippi Medical Center

John Schweinfurth, MD is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American Laryngological Association, American Medical Association, and Triological Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Erik Kass, MD  Chief, Department of Clinical Otolaryngology, Associates in Otolaryngology of Northern Virginia

Erik Kass, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Association for Cancer Research, American Medical Association, and American Rhinologic Society

Disclosure: Nothing to disclose.

Christopher L Slack, MD  Private Practice in Otolaryngology and Facial Plastic Surgery, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders

Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA  Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society

Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation Unrestricted gift Unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo Consulting; Medvoy Ownership interest Management position; Cerescan Imaging Honoraria Consulting; GYRUS ACMI Honoraria Consulting

Additional Contributors

I would like to thank Drs. Alpesh Desai and Tejas Desai for their hard work, long hours, initiative, dedication, and assistance in getting this article off the ground and into publication.

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Thyroid fracture.
Hematoma of the false vocal fold.
Stent placement.
Posterior view of the laryngeal cartilages and ligaments.
Sagittal view of the laryngeal cartilages and ligaments.
Management protocol for laryngeal trauma.
Fractured thyroid cartilage closed with wires.
Laceration repair.
Various methods for laryngeal cartilage stabilization.
Table 1
GroupSymptomsSignsManagement
Group 1Minor airway symptomsMinor hematomas



Small Lacerations



No detectable fractures



Observation



Humidified air



Head of bed elevation



Group 2Airway compromiseEdema/hematoma



Minor mucosal disruption



No cartilage exposure



Tracheostomy



Direct laryngoscopy



Esophagoscopy



Group 3Airway compromiseMassive edema



Mucosal tears



Exposed cartilage



Vocal cord immobility



Tracheostomy



Direct laryngoscopy



Esophagoscopy



Exploration/repair



No stent necessary



Group 4Airway compromiseMassive edema



Mucosal tears



Exposed cartilage



Vocal cord immobility



Tracheostomy



Direct laryngoscopy



Esophagoscopy



Exploration/repair



Stent required



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