INTRODUCTION

Laryngeal injuries are uncommon, occurring in approximately 1 out of every 5,000 to 1 out of every 137,000 visits to the emergency department (ED). These injuries may be accompanied by a range of associated conditions, including intracranial injuries (17%), penetrating neck injuries (18%), cervical spine fractures (13%), and facial fractures (9%) [1]. Laryngotracheal injuries are associated with significant mortality, as death may occur rapidly after trauma. Therefore, immediate and appropriate care is essential for patients who present to the ED. We present a rare case of isolated blunt trauma to the neck, which was evaluated in our ED and ultimately diagnosed as a laryngeal injury. This case underscores the importance of recognizing the diverse potential presentations of laryngeal injuries and highlights the evidence-based management strategies that every emergency physician should consider when treating such trauma.

CASE REPORT

A 45-year-old male motorcyclist, under the influence of alcohol, was involved in a road traffic accident after colliding with a truck. During the incident, he fell from his motorcycle, striking his neck against the handlebars. Initially, the patient experienced neck pain and returned home overnight. The following morning, he awoke with significant breathlessness, rated as grade 4 on the modified Medical Research Council scale, persistent neck pain, and difficulty speaking. Upon arrival at the ED, the patient exhibited hoarseness of voice with visible abrasions and swelling in both zones 1 and 2 of the neck (Fig. 1). There were no signs of pulsatile swelling, expanding hematoma, or external air leaks. Palpation revealed subcutaneous emphysema extending from the mandible to the supraclavicular area, along with tenderness over the thyroid cartilage. Stridor was present, more pronounced during inspiration. There was no midline cervical spine tenderness. The patient maintained an oxygen saturation of 100% on room air, with a respiratory rate of 24 breaths per minute. Chest examination revealed no tenderness, subcutaneous emphysema over the anterior chest, equal bilateral air entry, and normal vesicular breath sounds. There were no signs of chest wall injury, and chest expansion was symmetrical. Circulation assessment was unremarkable, and the patient was fully conscious, oriented, and had pupils that were equal and reactive to light. Given the presence of an unstable airway, the decision was made to proceed with endotracheal intubation, with preparation for a double setup for front-of-neck access in case of difficulties with tube placement. Direct laryngoscopy was performed with manual inline stabilization, revealing a Cormack-Lehane grade I view without apparent edema of the vocal cords or mucosal injury. A 7.5 mm endotracheal tube was successfully placed and secured. The patient remained hemodynamically stable after intubation. The remaining components of the primary survey were then completed. There were no signs of external trauma to the chest, no tenderness on palpation, and an extended focused assessment with sonography for trauma revealed no free fluid in the abdomen, no pneumothorax, and no pericardial effusion. The patient was then transferred for computed tomography (CT) imaging of the head, cervical spine, and neck. CT of the head revealed no injury to the brain parenchyma or skull, and no abnormalities were noted in the cervical spine. However, a small, minimally displaced fracture of the thyroid cartilage was identified, accompanied by subcutaneous emphysema in the myofascial planes of the neck and chest wall (Fig. 2).

After 3 hours of mechanical ventilation, reexamination revealed that the subcutaneous emphysema in the neck had completely resolved, likely due to the endotracheal tube bypassing the laryngeal rent. Given the presence of a minimally displaced fracture and the absence of significant endolaryngeal damage, the surgical team opted for conservative management. The patient remained on mechanical ventilation for 1 week, after which he was extubated and subsequently discharged 2 days later. He fully recovered with no complaints following extubation and was doing well at the time of writing this manuscript. The timeline of events from trauma occurrence to the preparation of this case report is shown in Fig. 3.

Ethics statement

Written informed consent for publication of the research details and clinical images was obtained from the patient. The study was conducted in accordance with the principles of the 1964 Declaration of Helsinki and its later amendments.

DISCUSSION

Laryngeal injuries account for less than 1% of all traumatic injuries [2]. This case represents a rare instance of isolated laryngeal injury in which the patient presented to the ED in a timely manner for appropriate management. Previous reports have highlighted the potential for a latency period following such injuries. Thus, patients presenting with apparently benign neck trauma should be closely monitored for the development of delayed complications. It has been documented that edema, hematoma, or instability of the damaged laryngeal structure may result in airway compromise in these scenarios [3,4]. Given our patient’s symptoms of hoarseness, shortness of breath, stridor, subcutaneous emphysema in the neck, and tenderness over the thyroid cartilage, the airway was classified as unstable. In cases where the airway is relatively stable, the next step would typically involve flexible fiber-optic laryngoscopy to assess the extent of endolaryngeal injury and to identify mucosal damage or exposed cartilage. However, due to airway instability, our patient was intubated with preparations for a possible cricothyrotomy if surgical intervention became necessary. Direct laryngoscopy revealed no evidence of mucosal injury or cartilage exposure. Intubation in the context of laryngeal injury carries various risks, including avulsion of the endolaryngeal mucosa, creation of false passages or pseudo-lumens, disruption of fragile airways by the endotracheal tube, and potential for respiratory arrest [3,5]. Schaefer et al. [3] recommend the following for intubation in such cases: (1) the larynx and trachea must be intact and in continuity, rather than partially separated or avulsed; (2) the airway should be directly visualized via endoscopy in the ED or operating room; and (3) intubation should be performed by a highly experienced physician. The literature further indicates that immediate intubation is the first priority in cases of tracheobronchial injuries. However, intravenous paralysis should be avoided, as the transected airway may be supported only by the surrounding musculature. Therefore, intubation using a flexible bronchoscope is preferred. It is critical that the endotracheal tube bypass the injured segment, with the cuff inflated distal to the site of injury, to prevent further disruption or transection. Accordingly, the resolution of subcutaneous emphysema 3 hours after endotracheal tube placement in our patient suggested that the injured airway segment had been successfully bypassed. Low-volume or low-pressure ventilation may also help minimize additional trauma. Tracheostomy is rarely necessary but is indicated in patients with severe maxillofacial trauma, unstable facial fractures, palpable tracheal deformities, or extreme edema or hemorrhage. Additional indications include severe airway obstruction and inability to intubate. The tracheostomy site must always be positioned caudal to the level of injury [6]. Further assessment of the laryngeal skeletal framework was conducted using CT imaging of the neck. Given the presence of an undisplaced or minimally displaced fracture of the larynx, a decision was made to manage the patient conservatively. In view of the Schaefer stage II injury (Table 1), the patient was scheduled for conservative management, with open reduction and internal fixation and thyrotomy deferred [7]. An example of a possible approach to the definitive management of laryngeal injuries is provided in Fig. 4 [3].

Our case adequately illustrates the potential for delayed manifestations of airway injury in patients with seemingly benign neck trauma. Presentation of airway injury to the ED is uncommon, and isolated airway injury is even rarer; thus, awareness of the correct approach enables the trauma team to manage such cases effectively. Although the management of our patient was straightforward, unfamiliarity with the classification of laryngeal injuries and the appropriate management algorithm can create uncertainty regarding comprehensive care for these patients. Our discussion focuses on the emergency management of the airway in patients with laryngeal injuries, as surgical intervention was not required in this case.

In this case, the definitive airway was secured promptly, and early identification of the type of laryngeal injury was critical in determining the appropriate management strategy. The endotracheal tube cuff was passed distal to the site of injury, resulting in resolution of subcutaneous emphysema within a few hours. Although laryngeal injuries are rarely encountered in the ED, a thorough understanding of emergency airway management, including key considerations when securing a definitive airway and the protocol for further evaluation and classification based on the Schaefer classification, is essential for ensuring timely and effective patient care.

ARTICLE INFORMATION

Author contributions

Conceptualization: NM; Investigation: all authors; Resources: SP, AM; Visualization: NM, AS, SP; Writing–original draft: NM; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Conflicts of interest

The authors have no conflicts of interest to declare.

Funding

The authors received no financial support for this study.

Data availability

Data sharing is not applicable as no new data were created or analyzed in this study.

Fig. 1.

Abrasions in zone 1 (clavicles to cricoid cartilage) and zone 2 (cricoid cartilage to angle of the mandible) of the neck. (A) Anterior view. (B) Lateral view.

Fig. 2.

Computed tomography images show a comminuted fracture involving the inferior horn of the thyroid cartilage on the left side with minimal displacement and adjacent air foci (arrows). (A) Coronal view (bone window). The cuff of the endotracheal tube is shown inflated distal to the site of laryngeal injury (arrowhead). (B) Axial view.

Fig. 3.

Timeline of events. CT, computed tomography.

Fig. 4.

Algorithm for early treatment of acute external laryngeal trauma. CT, computed tomography; CTomy, cricothyrotomy; EMG, electromyography of the larynx; ORIF, open reduction and internal fixation of laryngeal skeletal fractures; STENT, endolaryngeal stent or lumen keeper; TRACH, tracheotomy; VS, videostroboscopy of larynx. Adapted from Schaefer [3], with permission from John Wiley and Sons.

REFERENCES

• 1. Jewett BS, Shockley WW, Rutledge R. External laryngeal trauma analysis of 392 patients. Arch Otolaryngol Head Neck Surg 1999;125:877–80.ArticlePubMed
• 2. Shaker K, Winters R, Jones EB. Laryngeal injury. In: StatPearls [Internet]. StatPearls Publishing; [updated 2023 Jul 4; cited 2025 Feb 9]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK556150/
• 3. Schaefer SD. Management of acute blunt and penetrating external laryngeal trauma. Laryngoscope 2014;124:233–44.ArticlePubMedLink
• 4. Lambert GE, McMurry GT. Laryngotracheal trauma: recognition and management. JACEP 1976;5:883–7.ArticlePubMed
• 5. Bent JP, Silver JR, Porubsky ES. Acute laryngeal trauma: a review of 77 patients. Otolaryngol Head Neck Surg 1993;109(3 Pt 1):441–9.ArticlePubMedLink
• 6. Rieth A, Varga E, Kovacs T, Ottlakan A, Nemeth T, Furak J. Contemporary management strategies of blunt tracheobronchial injuries. Injury 2021;52 Suppl 1:S7–14.ArticlePubMed
• 7. Elias N, Thomas J, Cheng A. Management of laryngeal trauma. Oral Maxillofac Surg Clin North Am 2021;33:417–27.ArticlePubMed

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