The protection afforded by the maxilla and the sternum, coupled with the elastic nature of the cartilage makes laryngeal fractures relatively uncommon in occurrence. However, due to the risk of severe airway obstruction and impending multiorgan failure emanating from these fractures, proper and quick identification of this condition becomes necessary [1] [2].

Laryngeal fractures need to be suspected in all patients with trauma to the neck, as well as in patients presenting with respiratory distress, stridor, subcutaneous emphysema or hoarseness. Neck hematomas, hemoptysis, tenderness over the larynx and the loss of visible anatomical markers over the neck also constitute indications for a thorough clinical assessment, performed in view of a suspected laryngeal fracture [3] [4].

The most common symptoms encountered in a laryngeal fracture are odynophagia and pain at the site of trauma. Dysphasia, aphonia and dyspnea are also highly prevalent in such patients. Some individuals may suffer from subcutaneous emphysema or unconsciousness arising from these fractures.

The physical examination of such patients must begin with a complete assessment of the cervical spine. Acute fractures may present with tenderness over the larynx, whilst stridor, hematomas, ecchymosis and vocal cord abnormalities are some of the other clinical signs that may be seen in such patients [5]. Airway injury or obstruction, crepitus over bony structures and loss of palpable landmarks in the neck may also be seen in these individuals.

• Hoarseness

  Her physical examination was normal except subcutaneous emphysema, edema and tenderness in the cervical area, hoarseness, facial and extremity abrasions and ecchymoses. [ncbi.nlm.nih.gov]

  If the child's voice is hoarse then a flexible laryngoscopy can be used in the emergency room to visualize the vocal cords for hematomas or disruption. If the child's condition is stable, they may have a CT scan of the neck and chest. [chop.edu]

  Studies suggest that hoarseness is the most common presenting symptom of laryngeal trauma. Juutilainen et al reviewed 33 cases of external laryngeal trauma, and 28 (85%) of those cases presented with hoarseness. [brownemblog.com]

• Laryngeal Pain

  Laryngeal trauma is uncommon in the setting of external blunt or penetrating trauma. The larynx may also be injured internally, for example during endotracheal intubation. Symptoms include hoarseness, laryngeal pain, dyspnea, and/or dysphagia. [radiopaedia.org]

  Diagnosis is made based on clinical findings (for example, hoarseness, laryngeal pain, aphonia, asymmetry, bleeding and subcutaneous emphysema) in the laryngeal area. CT is recommended to evaluate the extent of laryngeal fractures [8]. [jmedicalcasereports.biomedcentral.com]

• Difficulty Vocalizing

  Chronic airway obstruction Fistula formation Cosmetic deformitiesChronic aspiration difficulties Vocal cord paralysis or vocal cord fixation Injury to the recurrent laryngeal nerve Granulation tissue formation (if antibiotics are not used) Subglottic [autoaccident.com]

• High Pitched Voice

  In phoniatric evaluation most (six of eight) patients with fair voice outcome could not produce high pitched voices because of inability to stretch the vocal folds. [researchportal.helsinki.fi]

• Ulcer

  Cartilage • most injuries : superficial irritation / minor ulceration : heal quickly • More severe injuries : edema, granulation tissue / ulcerations 40. [slideshare.net]

  The most common problem in the immediate postoperative period is the development of granulation tissue and ulceration from exposed cartilage. [emedicine.medscape.com]

Before proceeding to any diagnostic tests, the Advanced Trauma Life Support (ATLS) protocol needs to be followed. Securing the airway and optimizing the cardiorespiratory status of the individual are of great importance. Other life-threatening injuries, if present, need to be managed accordingly.

Laryngeal fractures are suspected primarily based on the clinical findings. However, direct observation of the laryngeal anatomy helps in delineating the severity and extent of injury. For this purpose, transnasal fiberoptic laryngoscopy needs to be performed in these patients to identify any airway abnormalities. Dislocation of the laryngeal cartilages, avulsion of the vocal cords, edema, hematomas and other injuries can be visualized via this endoscopic technique. Indirect laryngoscopy is generally not employed, due to the sympathetic response of gagging and choking seen during the procedure.

Radiography of the chest and cervical spine must be performed to exclude any associated cervical or airway injuries.

The procedure of choice, in order to visualize the laryngeal anatomy, is a computerized tomography (CT) scan [6] [7]. Laryngeal injuries have been classified based on CT scan and endoscopic findings. These imaging techniques can help to guide the management of laryngeal fractures and may prevent the need for excessive or unwanted surgery. Three-dimensional CT scanning has a higher sensitivity in terms of revealing minor fractures and is becoming more popular nowadays.

Magnetic resonance imaging (MRI) is not an optimal choice to assess laryngeal injuries [8]. Other common studies that may be performed include bronchoscopy, esophagoscopy, cervical arteriography and certain histological tests.

For severe laryngeal fractures, reparative procedures and stenting constitute the standard treatment. However, in selected and especially critical cases, a primary partial or reconstructive laryngectomy is justifiable. [ncbi.nlm.nih.gov]

We are also able to assess the mortality associated with the location and side of injury, examine the time from injury until diagnosis and treatment, and evaluate treatment outcome. [scienceopen.com]

Schaefer SD: The treatment of acute external laryngeal injuries. ‘State of the art’. Arch Otolaryngol Head Neck Surg 1991;117:35–39. Olson NR: Surgical treatment of acute blunt laryngeal injuries. Ann Otol Rhinol Laryngol 1978;87:716–721. [karger.com]

A historical comparison of treatment methods. Arch Otolaryngol 1983 ; 109 : 106 –11 10 Butler, AP, Wood, BP, O'Rourke, AK, Porubsky, ES. Acute external laryngeal trauma: experience with 112 patients. [cambridge.org]

Treatment and prognosis The key goals of management are: maintaining airway: preserve life restoring function to larynx: voice quality Blunt trauma has a worse prognosis than penetrating trauma with increased length of stay and short-term mortality (40% [radiopaedia.org]

Literature has reported relatively good outcomes and has used functional parameters to assess prognosis. [ncbi.nlm.nih.gov]

The overall outcome and prognosis of a patient with a laryngeal fracture depends on several factors, such as extent of injury, timing of repair, and the ability of the otolaryngologist to properly evaluate and treat the patient who has been traumatized [emedicine.medscape.com]

[…] serial examination. [3] Cervical spine injury requires continuous immobilization of the entire patient with a semi-rigid cervical collar, head immobilization, backboard, tape, and straps before and during transfer to a definitive-care facility. [4] Prognosis [cdemcurriculum.com]

Objectives: Describe the etiology of laryngeal trauma/fracture. Summarize clinical presentation and clinical grading of laryngeal trauma/fracture. [ncbi.nlm.nih.gov]

Etiology The larynx may be injured in a number of ways 1,2,6: external blunt: motor vehicle accidents, "clothesline" accidents, strangulation, falls, sporting injuries external penetrating: stabbing, shooting internal blunt: iatrogenic during endotracheal [radiopaedia.org]

In addition to appropriate management, we discuss the biomechanics of sneezing and the forces generated during sternutation to better understand the etiology of such events. [journals.sagepub.com]

Its etiology is still unknown. A congenital anomaly of the laryngeal cartilage is proposed, associated with an alteration in the mineralization and ossification, producing sites of focal weakness that predisposes them to develop fractures [4]. [hindawi.com]

The most common associated injuries with laryngeal fractures are intracranial injuries (13%), open neck injuries (9%), cervical spine fractures (8%), and esophageal injuries (3%). 1 Etiology Laryngeal fractures can be categorized as either penetrating [oralmaxillo-facialsurgery.blogspot.com]

Surgical treatment was used in 10.9% of cases in a 2012 meta-analysis.[1] Epidemiology[edit] Hyoid bones fractures represent 0.002% of all fractures; they are rare because the hyoid bone is well-protected by its location in the neck behind the mandible [en.wikipedia.org]

This activity outlines the etiology and epidemiology of laryngeal fracture, it also highlights the clinical presentation of laryngeal fracture, severity grading, and management. [ncbi.nlm.nih.gov]

Epidemiology of lacrosse injuries in high school-aged girls and boys: a 3-year prospective study. Am J Sports Med. 2005;33(9):1305-1314.PubMedGoogle ScholarCrossref [jamanetwork.com]

Airway trauma: A review on epidemiology, mechanisms of injury, diagnosis and treatment. J Cardiothorac Surg. 2014;9: 117-8090-9-117. Schaefer SD. The acute management of external laryngeal trauma. A 27-year experience. [appliedradiology.com]

Epidemiology Frequency A laryngeal fracture is a rare condition, occurring in approximately 1 per 137,000 inpatient visits, [10] 1 patient per 14,000-42,000 emergency department visits, [11] and less than 1% of all blunt traumas. [12] Using the Nationwide [emedicine.medscape.com]

Pathophysiology The mechanism of injury reflects the causative agent. Inherent in any injury resulting in a laryngeal fracture is the possibility of skeletal disruption, specifically, cricothyroid and cricoarytenoid dislocations. [oralmaxillo-facialsurgery.blogspot.com]

[…] cricoid cartilage is a complete ring that cannot accommodate any degree of swelling or hematoma.[18] In literature, the average age of patients with laryngeal trauma is reportedly approximately 34 to 37 old, but the range is wide from 14 to 84.[10][11] Pathophysiology [ncbi.nlm.nih.gov]

A small percentage of causes include direct blows sustained during assaults, sport injuries, hanging, manual strangulation, and iatrogenic causes. [19, 20, 21, 22] Pathophysiology The mechanism of injury reflects the causative agent. [emedicine.medscape.com]

Stent placement helps to maintain the proper alignment of the commissure and prevent anterior glottic webs. [annalscts.com]

[…] be placed such that it extends from false vocal cords to first tracheal ring  Stent secured by monofilament sutures through the laryngeal ventricle and cricothyroid membrane and tied to skin buttons.  Removed in a period of 10 to 14 days to prevent [slideshare.net]

This prevents the chyme to get from the oral cavity or pharynx into the lower airways. 4 Clinical presentation The pathological changes in the area of the larynx are the domain of ENT medicine. [flexikon.doccheck.com]

These can be prevented or treated in the following ways: Granulation tissue Covering all exposed cartilage to prevent Avoiding stents when possible Careful excision Laryngeal stenosis Excision with mucosal coverage Stenting selected cases Laryngotracheoplasty [emedicine.medscape.com]

1. Gussack GS, Jurkovich GJ, Luterman A. Laryngotracheal trauma: a protocol approach to a rare injury. Laryngoscope. 1986;96:660–665.
2. Jalisi S, Zoccoli M. Management of laryngeal fractures--a 10-year experience. J Voice. 2011;25:473–479.
3. Schaefer SD. The acute management of external laryngeal trauma. A 27-year experience. Arch Otolaryngol Head Neck Surg. 1992;118:598–604.
4. Hwang SY, Yeak SC. Management dilemmas in laryngeal trauma. J Laryngol Otol. 2004;118:325–328.
5. Kim JP, Cho SJ, Son HY, Park JJ, Woo SH. Analysis of clinical feature and management of laryngeal fracture: recent 22 case review. Yonsei Med J. 2012 Sep. 53(5):992-8.
6. Rajs J, Thiblin I. Histologic appearance of fractured thyroid cartilage and surrounding tissues. Forensic Sci Int. 2000 Dec 11. 114(3):155-66.
7. Schaefer SD, Brown OE. Selective application of CT in the management of laryngeal trauma. Laryngoscope. 1983 Nov. 93(11 Pt 1):1473-5.
8. Shockley WW. Laryngeal trauma. Shockley WW, Pillsbury HC, eds. The Neck: Diagnosis and Surgery. St. Louis, Mo: Mosby; 1994. 189-208.