Pearls and pitfalls in blunt laryngotracheal injuries—a case series

Introduction

Tracheal injury refers to any damage to the trachea, the main airway conducting air from the throat to the lungs. In blunt trauma, tracheal injuries occur when a sudden, forceful impact causes either partial or complete disruption of the trachea. This includes injuries like lacerations, fractures, contusions, and even transections of the tracheal wall (1). The incidence of tracheal injury is very rare accounting for less than 0.5% in trauma patients (2). Though laryngotracheal injuries account for <1% of all trauma injuries, they have high mortality and morbidity both on-scene as well as in-hospital. Mortality varies from 4% to 44% depending on severity of injury, pre-hospital transfer, and early intervention (3).

Patients with neck injury may manifest with numerous signs and symptoms, however many are non-specific and during early assessment there may be minimal external evidence of injury, despite serious underlying injuries (4). Identifying tracheal injuries in penetrating neck trauma is easy, but identifying tracheal injury in blunt trauma is challenging due to varying clinical findings. So, one should have a high level of suspicion in managing airway in blunt trauma patients. Symptoms and signs of significant concern are dyspnoea, dysphonia, pneumomediastinum, pneumothorax, subcutaneous emphysema, stridor, drooling, hematoma, significant external bleeding, bruit, neurological deficit, or shock (5). In our cases, two patients with complete tracheal transection presented with acute airway compromise needing urgent airway management, which ended up in unanticipated failed airway and subsequent surgical airway. There is a wealth of information about iatrogenic tracheal damage and management guidelines (6). However, the knowledge on blunt trauma-induced tracheal damage is limited in the literature.

This series highlights that tracheal injuries in blunt trauma can present with subtle clinical findings to obvious external signs. The severity of clinical signs is not always correlated with severity of injury. And also emphasises on key management strategies in managing tracheal injuries in blunt trauma. We present this article in accordance with the AME Case Series reporting checklist (available at https://jxym.amegroups.com/article/view/10.21037/jxym-24-80/rc).

Case presentation

This is a retrospective case series, reported from the emergency department (ED) of a single level 1 trauma center in South India. Patients with blunt trauma-associated laryngotracheal injuries were included in this study. All patients were followed up till discharge or in-hospital death. The patients were managed either conservatively or surgically based on the severity of laryngotracheal injuries and clinical presentation. We describe six patients with blunt trauma-associated laryngotracheal injuries, who presented to the ED within the first few hours of trauma.

Case 1

A 50-year-old patient was brought to our ED after 90 minutes of sustaining a high-velocity motor vehicle collision (MVC). He was gasping, unconscious, and had unstable vital parameters with heart rate of 40 beats per minute; saturation 46% room air; with peripheral pulses not palpable. There was diffuse subcutaneous emphysema over neck, chest, and abdomen. As he was in peri-arrest state, we proceeded for crash endotracheal (ET) intubation with manual in-line stabilization. During direct laryngoscopy, vocal cords were visualized, but the tip of ET tube couldn’t be advanced beyond the level of vocal cords. Rescue bag-mask ventilation (BMV) was provided, during which it was noticed that subcutaneous emphysema over neck increased with each positive pressure ventilation. This led to suspicion of blunt laryngotracheal injury, and we proceeded with emergency surgical airway. After incising vertically and dissecting over lower anterior neck, the tip of ET tube was found lying out of trachea with complete transection at crico-tracheal level. The lower tracheal end was held with forceps, and a new ET tube was introduced through the transected distal tracheal end. Within a few seconds, he went into cardiac arrest. High-quality cardiopulmonary resuscitation (CPR) was started as per advanced cardiac life support (ACLS) guidelines, and bilateral needle thoracentesis followed by tube thoracostomy was performed due to massive subcutaneous emphysema. Return of spontaneous circulation (ROSC) was achieved after 4 minutes of CPR. Imaging revealed multiple rib fractures, pneumothorax, and pneumomediastinum. Intra-operatively, thyroid and cricoid cartilages were found to be fractured along with complete crico-tracheal transection. All fractured segments were anastomosed, and end tracheostomy was done on the second tracheal ring. Later, he passed away due to hypoxic brain injury on day 4.

Case 2

A 32-year-old man sustained road traffic accident while driving two-wheeler and was brought to our ED 4 hours later. He was tachypneic with 50% saturation and had a blood pressure of 130/80 mmHg. In view of airway compromise and severe respiratory distress, rapid sequence intubation (RSI) was done. On direct laryngoscopy, the tip of ET tube couldn’t be passed beyond the level of vocal cords. With rescue BMV, gurgling was noted along with development of subcutaneous emphysema over neck with each ventilatory effort. Upon suspecting laryngotracheal injury, we proceeded with emergency tracheostomy. After dissecting over lower anterior neck, we noticed air and blood bubbling out with each Ambu^® mask ventilation (Figure 1) with a rent in the 7^th and 8^th tracheal rings. The distal trachea was held using Kocher’s forceps, and a gum-elastic bougie was inserted into the distal tracheal end. A 6.0 size ET tube was guided over bougie and position was confirmed using wave form capnography. Within a few hours, he developed extensive subcutaneous emphysema which was evident on chest X-ray (Figure 2). Computed tomography (CT) imaging revealed a subtle disconnection at left thyroid lamina with extensive subcutaneous emphysema with pneumothorax and pneumomediastinum. Bilateral tube thoracostomy was done in view of pneumothorax and extensively progressing subcutaneous emphysema. Intra-operatively, 7^th tracheal ring was found lacerated and a near complete tracheal separation was observed at the level of 8^th tracheal ring. All of the injuries were repaired and there was no great vessel injury noted. He later succumbed to Klebsiella pneumoniae sepsis in the critical care unit (CCU).

Figure 1 After giving vertical skin incision for emergency surgical airway in case 2, bubbling of air with blood via the tracheal tear with each BMV, as pointed by the red arrow. BMV, bag-mask ventilation.

Figure 2 Chest X-ray of case 2 showing extensive emphysema over the chest and neck dissecting through the muscular planes (black stars), right clavicle fracture (red arrow), bilateral ICD tubes (yellow arrows) in situ. ICD, intercostal drainage.

Case 3

A 28-year-old man on maintenance hemodialysis for chronic kidney disease, encountered a high-velocity MVC with a tree. He presented with dysphonia, dyspnoea, and a non-expanding hematoma over anterior neck. He had a respiratory rate of 36 per minute, room air saturation of 98%, and no stridor. Point of care ultrasound (POCUS) revealed moderate circumferential pericardial effusion and bilateral moderate pleural effusion. CT neck with 1 mm cuts demonstrated collection at thyroid cartilage level compressing the airway. Indirect laryngoscopy in the ED showed gross supraglottic oedema. He was provided repeated adrenaline nebulisations and intravenous hydrocortisone. Intra-operatively, thyroid gland was found lacerated with non-pulsatile hematoma. After evacuating hematoma, laceration was sutured and tracheostomy was performed. No other vascular injury. Post-operatively, he was dialysed and discharged on day 2.

Case 4

An 11-year-old adolescent was abused by his father by throttling his neck. He manifested with pain over neck, dysphonia, pain during swallowing, and subcutaneous emphysema over neck. He was hemodynamically stable without stridor or respiratory distress. Examination was positive for Hamman’s crunch. CT imaging exhibited pneumomediastinum, pneumopericardium and left pneumothorax. In the ED, intercostal drainage (ICD) tube was inserted on the left side using a 24-Fr tube. CT with 1 mm cuts and oral-contrast esophagography did not identify any significant aero-digestive tract injury. ICD was removed on day 5 and he was discharged home on day 7.

Case 5

A 34-year-old male with known psychiatric illness attempted intentional self-harm by throttling himself. He had dysphonia, dyspnoea, and rapidly progressive subcutaneous emphysema involving face, chest, and abdomen. He maintained saturation of 95% with high-flow oxygen. In the ED, bilateral tube thoracostomy was performed. Imaging was positive for massive subcutaneous emphysema, pneumomediastinum, and bilateral pneumothorax. Laryngoscopy and CT neck with 1 mm cuts did not find any evident injury to aero-digestive tract. He was managed with antibiotics and analgesics, with oxygen supplementation. and discharged after 5 days with psychiatric follow-up.

Case 6

A 55-year-old road traffic accident victim presented with pain and bruises over neck. He was breathing comfortably, did not have any noisy breath sounds. CT neck imaging unveiled an undisplaced fracture of thyroid cartilage without gross disruption to the laryngotracheal anatomy. He was managed with analgesics and discharged after 24 hours of observation in the ED.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent for publication of this case series and accompanying images were not obtained from the patients or their relatives after all possible attempts were made.

Discussion

We report six cases of blunt trauma neck with laryngotracheal injuries, out of which three patients required surgical airway, two were done in the ED and one in the operating room (OR). The two patients who had complete tracheal transection had fatal outcome. Four patients mandated tube thoracostomy for extensive subcutaneous emphysema, pneumothorax, and pneumomediastinum. Four patients who had a successful outcome did not have a major disruption in the laryngotracheal framework. Patients’ characteristics are summarized in Table 1.

Majority of tracheal injuries in blunt trauma were due to direct blunt force from MVCs, in which the extended neck strikes the dashboard or steering wheel, and the larynx is compressed between the fixed blunt force and the cervical spine. Other mechanisms include clothesline injuries, near hanging, assaults, improperly fitting shoulder harnesses, athletic events, attempted strangulation, and iatrogenic wounds (7). Shear forces on the trachea will produce injury at the carina and the cricoid cartilage, which are its relatively fixed points. It has also been suggested that if the glottis is closed at the time of impact, the sudden increase in airway pressure will rupture the laryngo-tracheo-bronchial tree (7).

In cases 1,2, the mechanism was a high-velocity injury with no direct impact/external injuries over neck, while the other cases had direct impact on the neck. The mechanism of tracheal injury in cases 1,2 was not clear. The possible theory would be rapid deceleration producing a shear force at trachea, as the lungs were more mobile in the pleural space but are fixed at the carina causing shearing force to trachea. Other four cases had direct force towards the trachea.

Not all surgically significant laryngotracheal injuries will manifest clinically at the time of initial evaluation in the ED, particularly in case of blunt trauma (8). Presentation ranges from asymptomatic, to severe respiratory distress or death. In our patients, the presentation was not typical of airway injury in the first two cases, and we did not suspect laryngotracheal injury. Research on this topic of tracheal injuries is minimal as it is a life-threatening injury, most patients may die on scene or during prehospital transfer. Clinical features suggestive of laryngotracheal injury are bubbling of air from a neck wound, massive subcutaneous air, laryngeal crepitus caused by laryngeal fracture, dysphonia, aphonia, dyspnoea, stridor, haemoptysis, neck tenderness or pain over larynx, or loss of anatomic landmarks secondary to hematoma (9). However, each individual finding occurs in fewer than 50% of cases (10). Soft tissue surrounding the injury can act as a seal, and minimise clinical findings, even with complete laryngotracheal separation (11). This theory could have been the reason in our case 2, even though he had tracheal transection, he didn’t manifest any clinical signs of tracheal injury. Because blunt laryngotracheal injuries are often seen in association with multisystem trauma, they can be easily overlooked.

CT scan can provide detailed information about laryngeal integrity and the surrounding region (12). When anterior neck soft tissue injury is suspected, 1-mm cuts of the larynx should be obtained with multiplanar reconstructions. CT is useful for assessing airway diameter and vocal cord integrity, as well as for detecting fractures in laryngotracheal tree. It is of less use to identify mucosal perforations, degloving injuries of the cartilage with denuded mucosa, certain types of minor laryngotracheal separation, particularly when there are poorly calcified paediatric cartilaginous structures. In our cases 4,5, in spite of having obvious clinical findings, CT could not detect site of the laryngotracheal injury. Typically, injuries missed by CT are unlikely to require surgical management (13). Widespread access to ultrasound has led to an increase in its use for trauma patients. Airway ultrasound may detect blunt laryngotracheal injuries such as laryngotracheal separation, provided in the absence of subcutaneous emphysema (14). Endoscopic assessment of the airway will help in assessing the endolaryngeal haematomas/other pathology in the larynx which might alter the management planning. Fibreoptic bronchoscopy is both gold standard in diagnostic and of therapeutic value, and it also offers an advantage in evaluating the distal airway injuries (5).

Despite a stable initial appearance, airway compromise can occur rapidly in laryngotracheal injury, and intervention is essential at the first sign of airway threat, ideally before respiratory symptoms develop. If available, an awake, fibreoptic-guided oral intubation is likely the best route (15,16). If this is not feasible, “awake” intubation using a video laryngoscope is a good alternative. If an awake technique is not feasible, the only option left is a single attempt at orotracheal intubation under a “double set-up”, using RSI, but with preparations in place to move immediately to secure airway surgically (cricothyroidotomy or tracheostomy) (17).

In select patients with mild injuries, conservative management can be superior to surgical treatments. Small tracheal wounds typically heal spontaneously within 48 hours (6). It is imperative that this management is considered only when the patient is hemodynamically stable, without an associated oesophageal, arterial, or other concomitant neck injury requiring repair (8). Conservative management typically consists of head elevation, neck flexion, steroids, antibiotics, humidification, voice rest, and antireflux medications. They should be administered with humidified oxygen and observed in a critical care setting. Antibiotic prophylaxis is indicated for a week (18).

In our cases, we didn’t anticipate that cases 1,2 had trachea injury. As we don’t have fibreoptic bronchoscope in our ED, we routinely practice double set-up using RSI. In both patients, ET tubes were not passing beyond vocal cords, which led to suspicion of laryngotracheal injury and we immediately performed emergency tracheostomy. When the airway is managed in the OR, tracheostomy is preferred. In the ED, management is often more time pressured, and cricothyroidotomy is preferred, because it is easier and faster to perform. BMV may be hazardous because it may force air into tissue planes, resulting in huge subcutaneous emphysema and successive airway distortion or, rarely, air embolus (2). Our cases 1,2 also developed huge subcutaneous emphysema after rescue BMV.

In our cases 1,2, various rescue techniques could have failed, such as video laryngoscope, BMV, and extraglottic device. Even cricothyrotomy might have been unsuccessful, given the complete tracheal injury of the cervical trachea. A fibreoptic bronchoscope might have helped in identifying the injury, but it is not readily available in most EDs. Considering cricothyrotomy as the ultimate rescue technique may have disastrous consequences. In both of our cases, we preferred emergency tracheostomy over cricothroidotomy. The reason behind this decision was that, as the ET tube was not negotiable beyond the vocal cords, we suspected distal tracheal injuries. Tracheostomy is technically a better option compared to cricothroidotomy when dealing with distal tracheal injuries, but tracheostomy is usually less preferred due to complexity and time taken for the procedure. When the tracheal injury is intrathoracic, then emergency thoracotomy might be needed to secure the ET tube cuff distal to injured trachea. Fibreoptic bronchoscopy is the gold standard for securing airway in distal tracheal injuries (15,16).

Ventilation strategies for tracheal injuries include low tidal volume, low positive end-expiratory pressure. An Indian study suggests that 2 cm infraclavicular incisions bilaterally can reduce further subcutaneous expansion (19). In a case report, a patient with extensive subcutaneous emphysema following thoracostomy had successful treatment with a subcutaneous drain placed superficial to the pectoral fascia on low suction (20). Placement of percutaneous angiocatheter needles has also been ventured for treatment of severe subcutaneous emphysema (21).

In our case series, four patients with signs of air leak needed ICD, out of which three needed bilateral and one needed unilateral. Four patients who had no major disruption of laryngotracheal framework had a favourable outcome. Our case series highlights that the patient who presented in respiratory arrest due to compromised airway had a poor outcome; and also shows that the external clinical signs cannot predict the severity of internal tracheal injury, patients who presented in a relatively stable state had a favourable outcome.

The study’s limitations include the inability to generalize therapeutic recommendations due to the patients’ varying degrees of tracheal damage. The prognostication of tracheal injuries cannot be objective because two individuals experienced polytrauma while others had isolated laryngotracheal injuries. We did not secure the airway using fibreoptic bronchoscopy, which may be a limitation in the case series.

Conclusions

Possibility of airway injury should be considered when managing high-velocity polytrauma victims even without obvious external signs. Patients can present with subtle external signs in spite of having severe tracheal injury. Hypoxia, sepsis, severity of injury, and stability of airway on presentation were important factors in determining patient outcome. Intubation should be performed under bronchoscopic guidance whenever feasible to minimize additional airway damage.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the AME Case Series reporting checklist. Available at https://jxym.amegroups.com/article/view/10.21037/jxym-24-80/rc

Peer Review File: Available at https://jxym.amegroups.com/article/view/10.21037/jxym-24-80/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://jxym.amegroups.com/article/view/10.21037/jxym-24-80/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent for publication of this case series and accompanying images were not obtained from the patients or their relatives after all possible attempts were made.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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