A laryngeal fracture is an injury to one of the components of the laryngeal apparatus. These include injuries to the hyoid bone, thyroid cartilage, or cricoid cartilage. These injuries are best evaluated with a CT of the neck. Although contrast is not necessary to evaluate laryngeal injury, CECT and/or CTA is preferred for penetrating trauma. Cartilage fracture may appear as a step-off of the normally smooth contour of the cartilage. Signs of cartilage dislocation include abnormal rotation of the arytenoids cartilage and widening at the articulations. Indirect signs include submucosal edema, hematoma, and airway narrowing. Presence of extra-luminal air suggests injury to the larynx and/or esophagus.
Laryngeal fracture is more commonly caused by blunt than penetrating trauma. Assess the patient's ability to phonate, listen for the presence of stridor, and palpate for tenderness in the anterior neck. If the patient is stable, flexible laryngoscopy is performed (along with CT) to determine the extent of the injury. Patients in need of emergent airway management may be difficult or impossible to intubate via the oral route, and cricothyrotomy may be impossible depending on the level of injury. In severe cases, emergent tracheotomy may be the only way to secure the patient's airway.
Blunt trauma force sufficient to cause a laryngeal fracture often results in other injuries to the vasculature, spine, and/or esophagus. Consider CT angiography (CTA) of the neck to exclude arterial injury in patients with laryngeal fracture.
Findings of laryngeal injury may be subtle. Always review the cervical spine CT in bone and soft tissue windows when looking for these injuries as the amount of calcification within the cartilage may vary.
Figure 3.1 ▪ Thyroid Cartilage Fracture.
Axial CT image at the level of the larynx demonstrates a fracture of the normally V-shaped thyroid cartilage. Note air located anterior to the cartilage within the soft tissues.
Penetrating arterial injury is the disruption of the vessel wall by a foreign body entering the neck such as with a gunshot wound or knife injury. CTA has largely replaced conventional angiography and/or surgical neck exploration in excluding injury to the major arteries and veins of the neck. CTA findings include neck hematoma, extravasation of contrast, dissection, and pseudoaneurysm formation. A pseudoaneurysm is a saccular defect of the arterial wall where an indwelling hematoma is contained only by the adventitia of the arterial wall as opposed to a true aneurysm, where an intact arterial wall is maintained. Pseudoaneurysms are significantly more likely to rupture due to their weak architecture.
Expanding hematoma, change in phonation, and stridor after penetrating neck injury should prompt definitive airway management, and typically occur prior to the ...