Teaching Case

A 73-year-old woman with no relevant medical history tripped and fell over a wall, injuring the anterior neck. The patient started developing dyspnoea, dysphonia and haemoptysis and was brought to the emergency department. On physical examination the patient was hypoxemic and a cervical haematoma and subcutaneous emphysema were evident.

Computed tomography (CT) of the neck shows disruption of the anterior laryngeal wall, diffuse laryngeal soft tissue oedema and consequent airway narrowing. The thyroid cartilage is fractured with lateral displacement of both anterior laminae.

There is also a large amount of air in the subcutaneous tissues of the neck and anterior chest wall (subcutaneous emphysema), air dissecting the fascial planes of the neck and reaching its deep spaces, and pneumomediastinum.

Laryngeal injuries are rare and potentially life-threatening if the airway is compromised. They may occur in the setting of blunt or penetrating trauma.  Traumatic events may be also classified as external (e.g. motor vehicle accidents,  gunshots, strangulation and falls)  or internal (mostly iatrogenic) [1,2].

Patients typically present with dyspnoea, dysphonia, dysphagia, stridor and/or haemoptysis. At physical examination, local tenderness, crepitation and/or subcutaneous emphysema may be observed [3,4].

In a patient with a history of neck trauma is crucial to ensure airway patency and to stabilize neural and spinal injuries. Tracheotomy is considered the most secure method to establish a patent airway [5]. After hemodynamic stability is achieved, radiological evaluation is mandatory.  Multi-detector computed tomography (MDCT) is the imaging modality of choice for detection of internal organ damage [1,6].

Laryngeal lesions are most commonly divided in five categories using the Schaefer classification, in an ascending order of severity [7]. The most severe type of laryngeal injury is laryngotracheal separation (type 5). The patient presented here has a type 4 Schaefer lesion due to disruption of the anterior larynx.

Conservative measures including steroid therapy, anti-reflux medication, head elevation and voice rest may be enough in the treatment of mild laryngeal lesions, such as minor endolaryngeal haematomas and nondisplaced fractures. However, more severe cases require direct laryngoscopy and esophagoscopy in the operating room, surgical exploration and repair if needed [1,3].

Acute trauma of the larynx may result in long-term sequelae, such as cartilage deformation and pseudarthrosis, crico-arytenoid ankylosis, subglottic stenosis and unilateral or bilateral recurrent laryngeal nerve injury [1].

The patient presented was submitted to cervicotomy, suture of the laryngeal mucosa and reduction and internal fixation of the cartilaginous fracture with mini-plates, without complications.

Written informed patient consent for publication has been obtained.