Injury Extra (2006) 37, 425—427

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CASE REPORT

Diagnostic findings in laryngeal fracture

Athanasios Portinos a,*, Zinovia Alatzidou b, Konstantinos Skevis c,Konstantinos Christodoulidis d

aDepartment of Thoracic and Vascular Surgery, Evaggelismos General Hospital of Athens,45-47 Ipsilantou, 10676 Athens, Greeceb ENT Department of General Hospital of Kavala, 61 Erythrou Staurou, 65201 Kavala, GreececThoracic Surgery, Evaggelismos General Hospital of Athens, 45-47 Ipsilantou, 10676 Athens, Greeced First Surgical Department of General Hospital of Kavala, 61 Erythrou Staurou, 65201 Kavala, Greece

Accepted 9 May 2006

Introduction

Laryngeal trauma is a rare type of injury. Epidemio-logically, its incidence is estimated at 1 in 30,000emergency room visits.13,18,19 While laryngotra-cheal injuries have accounted for 0.04% of all trau-matic lesions,13 it is reported as the third mostcommon cause of death due to head and neck injuryafter cranial and cervical spine trauma.8,12,21 Thereare three major etiological groups: traffic acci-dents, blunt injuries, and penetrating injuries.15,26

The most common cause of laryngeal injury is blunttrauma suffered in a motor vehicle accident.7 It iscommonly associated with multisystem trauma andoften unrecognized initially due to minimal symp-tomatology and overshadowing by more obviousinjuries.8,12,21 Virtually all laryngeal fractures arelongitudinally oriented.10,11

We report the diagnosis and the management of acase of blunt neck trauma associated with a seriouslaryngeal fracture, highlight the clinical symptomsand signs, and discuss the importance of the correctevaluation of simple imaging methods, including X-ray findings.

* Corresponding author. Tel.: +30 2106395405.E-mail address: sportinos@hotmail.com (A. Portinos).

1572-3461/$ — see front matter # 2006 Elsevier Ltd. All rights resedoi:10.1016/j.injury.2006.05.009

Case report

A 68-year-old male car driver, without the use of asafety belt was transferred emergently to our hos-pital after a traffic accident. He complained of painover his left arm, left side of his chest and theanterior right side of his neck, as well as dysphagia,and mild dyspnoea. The clinical examinationrevealed an extensive bruising and oedema of hisleft arm, hoarseness, dysphagia, mild inspiratorystridor, tenderness over the larynx, and haemopty-sis. He had normal vital signs and the rest of hisclinical examination was unremarkable. Plain X-raysof the cervical spine, chest, and left arm werenegative. Fiber optic laryngoscopy revealed a hae-matoma of the right piriform fossa and of the righttrue and false vocal cords. No exposed cartilage ormucosal tears were seen. CT scan of the neckrevealed the presence of air in the soft tissue inthe retropharyngeal space (Fig. 1).

A more concentrated examination of the lateralneck X-ray revealed two important findings: a frac-ture of an osteophytic ridge between the anteriorsurfaces of theC4andC5 vertebrae and theexistenceof a strip-like region of air in the retropharyngealspace (Fig. 2). These twofindings, alongwith those oftheCTscanestablished thediagnosis of ruptureof the

rved.

426 A. Portinos et al.

Figure 1 Presence of air in the soft tissue of the retro-pharyngeal space in cervical CT tomography.

Figure 2 Lateral cervical spine X-ray; on original reportabnormal findings not indentified. Re-evaluation of X-rayrevealed fracture of an osteophytic ridge between theanterior surfaces of C4 and C5 vertebrae and a strip-likeregion of air at the prevertebra space.

Figure 3 Fracture of the thyroid cartilage on the right.

upper respiratory tract. AnewCTscanwith 2 mmcutsrevealed a non-displaced paramedian fracture of thethyroid cartilage (Fig. 3). The patient was admittedand treated with i.v. steroids and antibiotics, mon-itored for 24 h in the I.C.U. and discharged 7 dayslater. Follow up at 6 months revealed an unremark-able hoarseness of his voice.

Discussion

Laryngeal fractures are said to have been increasingfor the past several years. This is due in part to

improved early care of trauma patients and thus anincrease in the number of the survivors brought tothe emergency room.7

Thyroid cartilage fractures due to external blunttrauma have been typically thought to occur inpatients over the age of 40. Lack of mineralizationof the cartilage has been considered to be theprotective mechanism.2 Associated fractures or dis-location of the cervical vertebra should be sought onthe lateral radiographs of the neck.22

The main presenting symptoms and signs arehoarseness, neck tenderness, dysphagia and subcu-taneous neck emphysema.20 Stridor is the mostcommon presenting symptom and the thyroid car-tilage is the most common site of fracture.7

The diagnosis of laryngeal blunt trauma is notalways easily accomplished.5 The location and typeof thyroid cartilage fracture is directly related tothe mechanism of trauma.6,10,14 X-ray does play arole in the evaluation of laryngeal fractures.17,24,25

Lateral radiographs of the neck may show subcuta-neous emphysema not recognized on palpation,22

and the presence of air in the prevertebral perithyr-oid space. The diagnosis can thus be established byconventional X-ray examination.9

CT is an excellent noninvasive technique forexamining the laryngeal skeleton.23 It is extremelysensitive for the detection of even small amounts ofsubcutaneous emphysema.8,13,22,23 Laryngeal CTmay be successfully used to define the extent ofinjury and determine the need for open explorationand repair in selected cases of blunt trauma to thelarynx when clinical findings are equivocal for car-tilagious damage.23 Cervical vertebral fractures anddislocations, perforation of the pharynx and oeso-phagus, and vascular injury must be excluded.22

Trauma of the throat should never be underesti-mated even though the patient may initially appearwell. This is not only because of the development of

Rare diagnostic radiological findings in laryngeal fracture 427

oedema of the airway, but also because of the risk ofhaemorrhage into the soft tissues, which couldrapidly prove to be fatal.26,27 The sequela of thismissed or delayed diagnosis and treatment is lar-yngeal stenosis, which often requires prolongedtracheostomy and multiple reconstructive proce-dures.1,4,12,16,24

The aim of therapy for the patient with an injuredlarynx includes two goals: the maintenance of anadequate airway and the restoration of a sociallyacceptable voice for communication.20

Conservative treatment includes observation,delivery of humidified air, voice rest, elevation ofthe head of the bed, antibiotics, and steroids.3

Fractures of the larynx are difficult to recognize,especially in the patientwithmultiple injuries. Hoar-seness of the voice and inspiratory dyspnoea mayindicate injury to the larynx, but not necessarilyfracture. The presence of subcutaneous emphysemais nota standardfinding. The strip-likepresenceof airin the retropharyngeal space seen on a plain lateralneckX-ray is very important for thediagnosis. Furtherevaluation by CT scan imaging is necessary.

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