Laryngeal Fractures - Causes, Symptoms, Diagnosis, and Treatment

Introduction:

The larynx (voice box) is a tube that connects the throat (pharynx) to the respiratory system (windpipe and lungs) and performs various functions like breathing and speech. Vocal cords or vocal folds are the bands of smooth muscle which are present in the larynx and help in the speech, so often termed as “voicebox.” Laryngeal injuries can be blunt or penetrating. Blunt injuries to the larynx are more severe compared to the penetrating type of injuries.

What Is the Incidence of Laryngeal Fractures?

Laryngeal fractures are very uncommon and are seen in one among 14,000 patients after trauma.

What Are the Types of Laryngeal Fractures?

Laryngeal fracture types are:

• Group 1: Minor laryngeal injuries with hematoma and without fracture.

• Group 2: Undisplaced fracture with edema, hematoma, soft tissue lacerations with exposed laryngeal cartilage.

• Group 3: Displaced fracture with severe edema, vocal fold immobility, and mucosal damage.

• Group 4: Complex laryngeal fractures (presence of two or more fracture lines) with severe laryngeal mucosal disruption along with group three features.

• Group 5: It involves complete laryngotracheal separation.

What Are the Causes of Laryngeal Fracture?

Blunt laryngeal trauma causes are,

• Motor vehicle accidents.

• Assaults.

• Sports injuries.

Penetrating laryngeal trauma occurs due to,

• Gunshot injuries.

• Trauma from sharp instruments like scalpel or knife (stab injuries).

• Blast injuries.

What Are the Signs and Symptoms of Laryngeal Fractures?

Clinical signs and symptoms associated with laryngeal fractures are:

• Pain in the larynx.

• Hoarseness of voice.

• Difficulty or pain in swallowing.

• Stridor (sign observed on upper airway obstruction).

• Breathing difficulties.

• Coughing of blood.

• Reddish or bluish discoloration of overlying cervical skin.

• Loss of normal thyroid prominence.

• Displacement or deviation of the larynx.

• Subcutaneous emphysema (entrapment or escape of air into the tissues under the skin).

• Neck pain.

• Neck hematomas (due to rupture of blood vessels ).

• Loss of consciousness.

How to Diagnose Laryngeal Fractures?

Diagnosis of laryngeal fractures can be made by:

• Evaluate the Airway: The first step for the diagnosis is evaluation of the airway and maintenance of the patent airway so that further diagnostic procedures to identify laryngeal fractures can be performed. Evaluation of the airway can be done by using a flexible fiberoptic laryngoscope carefully. If the airway is still compromised, an emergency tracheostomy (opening window made in the trachea surgically) should be performed.

• Evaluation of Trauma: After achieving a stable airway, an evaluation of the extent and severity of laryngeal trauma is done.

• Direct Laryngoscopy: In case of huge trauma, direct evaluation of the larynx is done using a laryngoscope after the fiberoptic laryngoscopy is done.

• Radiographic Assessment: Radiographic assessment procedures used to identify laryngeal fractures are :

1. Chest X-Ray: It helps in identifying any deviation or displacement in the trachea and larynx and any escape of air into the spaces between the lungs (pneumothorax).

2. Computed Tomography (CT) Scan: It helps in the identification of laryngeal fractures and planning the treatment to repair and reconstruct the damaged larynx accordingly.

3. Computed Tomography (CT) Scan of the Cervical Spine: It should be done as mandatory in all cases of laryngeal fractures.

4. Computed Tomography (CT) Scan of the Neck: It should be performed by using the contrast medium to identify the damaged organs of the upper airway like the throat, larynx, tonsils, adenoids, thyroid, and other glands.

• Evaluation of Soft Tissues: Evaluation of soft tissue injury should be done to rule out the symptoms of edema and hematoma. It is one of the crucial steps as hematomas and edema tends to spread quickly, involving the potential spaces around the larynx progressing into airway obstruction.

What Is the Treatment Plan For Laryngeal Fractures?

After achieving a secure airway, it is important to restore the normal anatomy of the larynx to treat the underlying signs and symptoms due to laryngeal damage. Various modalities to treat laryngeal fractures are:

• Securing Airway: The first step in the management of the laryngeal fracture is managing the compromised airway and achieving stable airway patency. An emergency tracheostomy can be performed if required.

• Medicinal Therapy: Medications are prescribed to control the underlying symptoms of pain, edema, and hematoma like:

1. Steroids.

2. Antibiotics.

3. Antacids.

• Soft Tissue Repair: Any damage to the soft tissues of vocal folds, laryngeal cartilage, laryngeal soft tissue lacerations, and displacement or deviation of the larynx should be visualized carefully and repaired.

• Complex Laryngeal Fractures: In cases of unstable and multiple fractures of the larynx, emergency tracheotomy is performed, and surgical repair of the injuries is done, followed by the placement of an intra-laryngeal silicone stent to maintain the rigidity and stability of the larynx. A stent is removed after two weeks by the endoscopic procedure in the operating room.

• Miniplate Fixation: The use of titanium mini plates and screws is done to stabilize the fractured cartilages after reducing them back into normal anatomical positions. Thyroid fractures are stabilized by wiring or sutures. Bioresorbable plates are the latest plates that can be used for the fixation of laryngeal fractures.

What Measurements Are Taken After the Surgery of Laryngeal Fracture?

• Observation of Airway: After the surgery, monitoring of the patient airway is done for about 24 hours as there are chances of edema after surgery which can compromise the airway.

• Head-End Elevation of Bed: It is done to minimize laryngeal edema (swelling of epiglottis and vocal folds).

• Systemic Steroids: Patients are kept on steroids to treat the post-surgical swelling of the larynx.

• Speech Therapy: Speech therapy is provided by the speech pathologist to the person who suffered from vocal cord dysfunction after a laryngeal fracture.

• Antireflux Medications: It is given to prevent acid reflux.

What Are the Complications That Can Occur After Laryngeal Fracture Surgery?

• Injury to the laryngeal nerve.

• Vocal cord paralysis.

• Tracheal stenosis (abnormal narrowing of the trachea).

• Altered voice.

• Hoarseness.

• Swallowing disorder.

• Post-surgical hematoma due to damage to adjacent blood vessels during surgery.

• Infection.

• Necrosis of the adjacent tissues and flap with compromised blood supply may occur after surgery.

Conclusion:

Laryngeal fractures are very uncommon but an emergency clinical condition that needs urgent attention. Laryngeal fractures have an increased death ratio because of airway compromise. It often gets undiagnosed, or there is a delay in the diagnosis of fractures because of lack of awareness making the condition worse to manage. The laryngeal fractures affect the voice, speech, and swallowing significantly. So early diagnosis and intervention are key to preventing serious complications due to laryngeal fracture.