Operative Techniques in Otolaryngology (2007) 18, 140-143

Blunt and penetrating trauma to the larynx and

upper airway
Todd Preston, MD, Fred G. Fedok, MD, FACS

From the Department of Surgery, Division of Otolaryngology–Head and Neck Surgery, Penn State College of Medicine,
Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania.

KEYWORDS Larynx and upper airway trauma are uncommon but potentially devastating injuries. These injuries may
Larynx; rapidly progress with lethal consequences. In the United States, the incidence of laryngeal trauma is
Laryngeal trauma; estimated to be between 1 in 5,000 to 1 in 137,000 emergency room visits. The most common etiology
Laryngeal fractures; of airway trauma is a blunt force impact to the anterior neck. With penetrating wounds there may be
Laryngeal associated tissue loss, injury to the nearby carotid sheath structures, or injury to the esophagus and
emergencies; pharynx. There is an overall mortality of 40% for blunt injuries and 20% for penetrating injuries.
Stridor Evaluation and treatment are directed at preserving life and maintaining and restoring laryngeal
function.
© 2007 Elsevier Inc. All rights reserved.

Larynx and upper airway trauma are uncommon but
potentially devastating injuries. These injuries may rapidly
progress to lethal consequences in a somewhat unpredict-
able fashion. In the United States, the incidence of laryngeal
trauma is estimated to be between 1 in 5,000 to 1 in 137,000
emergency room visits.1,2 The most common etiology of
airway trauma is a blunt force impact to the anterior neck.1
Laryngeal trauma also occurs by penetrating injuries to the
neck, carrying a greater degree of urgency for control of
the patient’s airway as the amount of tissue injury is
usually greater than that occurring by blunt force im-
pact.3,4 With penetrating wounds, there may be associ-
ated tissue loss, injury to the nearby carotid sheath struc-
tures, or injury to the esophagus and pharynx.4 Care must
be taken not to overlook the extent of injury during
evaluation and management as the size of the external
wound may not reflect the overall degree of injury. There
is an overall mortality of 40% for blunt injuries and 20%
for penetrating injuries.5
Address reprint requests and correspondence: Fred G. Fedok, MD,
FACS, Otolaryngology–Head and Neck Surgery, H091, Penn State Milton
S. Hershey Medical Center, 500 University Drive, PO Box 850, Hershey,
PA 17033-0850.
E-mail address: ffedok@psu.edu.
1043-1810/$ -see front matter © 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.otot.2007.05.005
Initial evaluation and treatment
Patients should be evaluated in accordance with basic trauma
principles, as delineated by the American College of Surgeons’
Advanced Trauma Life Support protocol.6 There should be
special attention paid to the evaluation of the airway in patients
with a history of trauma to the anterior or anterolateral regions
of the neck. A significant injury should be suspected in patients
with hoarseness, shortness of breath, pain, or a globus sensa-
tion. Physical examination findings include the presence of
subcutaneous air, a change of the contour of the thyroid carti-
lage, hematoma, hemoptysis, and the presence of lacerations or
ecchymosis. The physical examination of the patient who is
suspected of having significant laryngeal injury should include
an examination of the endolarynx. Depending on the clinical
situation, this can be done via fiberoptic laryngoscopy. This
can also be performed during the establishment of a definitive
airway.
For patients with an unstable airway, priority must be given
to the establishment of a definitive one by performing a tra-
cheotomy.2 This typically should be done with a minimum of
sedation as sedation may decrease the patient’s ability to cough
and may lead to aspiration or respiratory collapse. In most
cases, cricothyroidotomy should be avoided as this may com-
plete a partial cricotracheal separation injury, leading to the
loss of the airway.2 In stable patients with normal anatomic
landmarks, a trial of endotracheal intubation may be cautiously
performed under direct fiberoptic visualization.3
Preston and Fedok Trauma to the Larynx and Upper Airway
Figure 1 Noncontrasted axial computed tomography scan demon-
strating a left paramedian fracture of the thyroid cartilage, with sig-
nificant amounts of air present within the soft tissues of the neck.
Imaging
Typically, computed tomography without contrast may be per-
formed to establish the extent and location of injury and pro-
vide information for definitive treatment planning7,8 (Figure 1).
In cases of suspected great vessel injury, however, contrast
may be added to investigate these injuries. It also may reveal
occult injuries in the case of penetrating wounds or foreign
bodies.3
Definitive treatment
For patients with type I injuries consisting of a greenstick
fracture or a nondisplaced fracture of the thyroid cartilage and
Figure 2 Subperichondrial dissection showing the exposed thyroid cartilage fracture.
141
without significant mucosal tear, conservative treatment may
be considered, consisting of observation for at least 24 hours
with continuous oxygen saturation monitoring.3,4,8 This group
of patients may be managed with the administration of cool air
or supplemental oxygen and treated with a brief course of IV
steroids, antibiotics, H2 blockers, and a soft diet.3,4,8
Type II injuries consist of patients with a linear fracture of
the thyroid cartilage and, without evidence of significant en-
dolaryngeal injury, should be explored via an open approach to
best expose, reduce, and fixate the fractured airway skeleton.
This can be done through a horizontal skin incision at the level
of the cricothyroid membrane, with the creation of subplatys-
mal soft-tissue flaps. The lateral limits of these soft-tissue flaps
may be extended to explore the pharynx, esophagus, and ca-
rotid sheath structures. Exposure of the thyroid cartilage then
proceeds in a subperichondrial plane (Figure 2). Once expo-
sure of the fracture is complete, titanium plates are used to
rigidly fixate the fracture segments.1 It is thought that the use
of plate and screw fixation produces better fracture stabiliza-
tion, especially during speaking and swallowing and in youn-
ger, more pliable cartilage. Some authors recommend the use
of a 4-hole miniplate (Figure 3) or titanium mesh stabilization
over a fracture.1 The use of low-profile plates of 1.3 mm or 1.5
mm is generally recommended.1 After completion of this sta-
bilization, the wound is irrigated and closed in layers over a
drain, with careful approximation of the perichondrium.
For type III injuries, including significant injury to the
endolaryngeal mucosa, involvement of the anterior commis-
sure, or extensive comminution of the thyroid cartilage,
open exploration by laryngofissure is indicated. This expo-
sure is performed in the same way as described above but
includes a vertical thyrotomy made in midline, extending
through the entire thyroid cartilage (Figure 4). Via this
approach, the entire endolarynx can be exposed, evalu-
ated, and treated. Through this exposure, evacuation of
142 Operative Techniques in Otolaryngology, Vol 18, No 2, June 2007

Figure 3 Fixation of thyroid cartilage fracture using 4-hole plate and screw technique.

hematomas and repair of significant lacerations should be Discussion and controversies

performed. Coverage of all exposed cartilage should be
performed through primary repair if possible or via ad- Large areas of exposed cartilage should be avoided because
vancement flaps by using 5-0 or 6-0 absorbable suture.3,4 of the risk of granulation or subsequent scar and synechiae

Figure 4 Surgical thyrotomy with exposure of the airway lumen.

Preston and Fedok Trauma to the Larynx and Upper Airway
Figure 5 Schematic depicting the placement and securing of soft endolaryngeal stent as might be used in the management of extensive
endolaryngeal laceration or grafting. (A) Anchoring suture placement through stent before closure of thyrotomy. (B) The positioning of
anchoring sutures through skin and secured over buttons. (All to be removed several weeks after primary operation.)
formation. Free grafts consisting of buccal mucosa, dermis,
or split-thickness skin grafts may be used where mucosal
advancement is impossible but may themselves lead to the
increased formation of granulation tissue.
Thyroid cartilage loss and fractures with comminution
should generally be corrected or supported because of the risk
of a poor voice or difficulty with decannulation. Correction of
loss of skeletal support may be performed with autogenous
cartilage grafts, alloplastic stents, or titanium mesh. Some
authors recommend simply using titanium mesh to span gaps,
thus stabilizing the cartilage without the use of stents and their
associated risk of granulation tissue formation.1 Injuries at the
level of the cricoid ring may be repaired by using mesh,
permanent suture,7 or keel placement. Stents may be placed at
the level of the thyroid cartilage for additional support and to
stabilize soft-tissue grafts. It is recommended that stents placed
for the correction of loss of skeletal support be left in place for
14 days, and for the support of grafts, 8 days.4 Longer periods
of time may promote granulation formation. Stents are secured
in place by passing at least 2 transcutaneous permanent sutures
through the stent and securing it over skin buttons (Figure 5).
Some authors also recommend placing additional superior and
inferior sutures for additional security.3 Stents should be de-
signed to be easily removed using endoscopic techniques.
143
The above principles of evaluation and treatment are
designed to give an overview of safe and effective treat-
ments for both preserving life and maintaining and restoring
function in patients suffering from blunt and penetrating
injury to the larynx.
References
1. de Mello-Filho FV, Carrau RL: The management of laryngeal fractures
using internal fixation. Laryngoscope 110:2143-2146, 2000
2. Bent JP 3rd, Silver JR, Porubsky ES: Acute laryngeal trauma: a review
of 77 patients. Otolaryngol Head Neck Surg 109:441-449, 1993
3. Schaefer SD, Stringer SP: Laryngeal Trauma (ed 3). Philadelphia, PA,
Lippincott, Williams and Wilkins, 2001
4. Lucente FE, Mitrani M, Sacks SH, et al: Penetrating injuries of the
larynx. Ear Nose Throat J 64:406-415, 1985
5. Atkins BZ, Abbate S, Fisher SR, et al: Current management of laryn-
gotracheal trauma: case report and literature review. J Trauma 56:185-
190, 2004
6. American College of Surgeons: American College of Surgeons ATLS
Guidelines (ed 7). Chicago, IL, American College of Surgeons, 2007
7. Richardson JD: Outcome of tracheobronchial injuries: A long-term
perspective. J Trauma 56:30-36, 2004
8. Butler AP, Wood BP, O’Rourke AK, et al: Acute external laryngeal
trauma: Experience with 112 patients. Ann Otol Rhinol Laryngol 114:
361-368, 2005