Laryngeal Fracture

What is Laryngeal Fracture?

The larynx, also known as the voice box, is a strong structure in our body, shielded by the jawbone, breastbone, and neck spine. Its flexibility and movement also help keep it safe. The larynx’s cartilages, which are difficult to break, don’t harden before the age of 20, and after that, the larynx can change in different people, regardless of their age.

The larynx plays a vital role in breathing, swallowing, and speaking. Even a minor injury to it can disrupt these functions. A severe injury can lead to fractures, swelling and could consequently affect the airway, making it difficult to breathe.

What Causes Laryngeal Fracture?

For a person to sustain a laryngeal fracture, which is a break in the voice box, a significant amount of force is required. Eighty to ninety percent of these injuries often come from a serious, high-speed impact. Motor vehicle accidents or sports injuries are frequently the main culprits behind such trauma to the voice box, with penetrating neck injuries also a common cause.

Research has shown that 97% of voice box injuries occur from blunt trauma, with cases resulting from gunshots being very rare. When looking at sports injuries, they are responsible for roughly 39% of all blunt voice box traumas, followed by physical assault at around 33%. Furthermore, incidents like hangings have also been identified as a common cause of this type of injury. It is quite uncommon for this kind of trauma to happen without a physical incident or accident.

Risk Factors and Frequency for Laryngeal Fracture

Laryngeal trauma, or damage to the voice box, is quite rare. It accounts for roughly 1 in 14,000 to 1 in 30,000 emergency room visits. This type of trauma is barely represented within major trauma centers, making up less than 1% of all cases, and equating to about one patient per every 131,000 hospital admissions. It’s also considerably less common in children than adults – in adults, the incidence is around 1 per every 30,000 emergency visits. Fracture of the laryngeal cartilage, one of the consequences of such injury, varies enormously, ranging from 0 to 67% of these cases.

The death rate is about 1% for those who need to stay in the hospital for at least 13 days due to a serious injury requiring surgery. If the injury involves the cricoid cartilage, which is a complete ring in the throat, the death rate can surge to 40% due to suffocation from blockage in the airway. This blockage happens quickly because the cricoid cartilage cannot handle any swelling or accumulation of blood (hematoma).

According to existing literature, the typical age of patients with laryngeal trauma spans from 34 to 37 years, but it can vary greatly, with patients as young as 14 and as old as 84.

Signs and Symptoms of Laryngeal Fracture

In cases of major injuries, like those from car accidents, assault, or sports injury, doctors always have to be on the lookout for potential damage to the throat area or larynx. Such injuries can sometimes go unnoticed. Typical symptoms to watch out for are breathing difficulty, voice changes, trouble swallowing, pain when swallowing, and coughing up blood.

The most common symptom is a hoarse voice, followed by difficulty swallowing. There are several signs that might indicate an injury or fracture in the larynx. These include swelling, a crackling sound when the injured area is touched, trapped air beneath the skin, loss of the noticeable bump on the front of the neck (thyroid prominence), an open wound on the neck, or a fracture that can be felt through the skin.

Doctors categorize larynx injuries using the Schaefer–Fuhrman classification method, which is outlined as follows:

• Group I: minor swelling or cuts in the larynx
• Group II: obvious swelling or blood pooling without exposed cartilage
• Group III: severe swelling or cuts in the mucosa with exposed cartilage or fractured and dislocated cartilage or immobilized vocal cord
• Group IV: severe structural damage in the larynx, including disruption of the front part connecting the vocal cords, multiple unstable fractures, or serious mucosal injury
• Group V: complete separation of the laryngotracheal area.

A different classification based on the site of injury, mode, involved structure, and degree of damage is as follows:

• Supraglottic: includes injuries like blood pooling or tearing of the epiglottis, hyoid bone fractures, thyroid cartilage fractures, arytenoid dislocation or skinning, endolaryngeal swelling, or airway blockage.
• Glottic injuries: mostly associated with fractured thyroid cartilage leading to swollen vocal cords, endolaryngeal lacerations, or vocal cord tearing from the anterior part that connects them.
• Subglottic: involves the cricoid cartilage and the cervical part of the windpipe that could potentially obstruct breathing severely. Complete disruption of the cricoid tracheal airway can result in sudden death unless it’s fixed in time.

Verschueren, Bell, and others made modifications to Schaefer’s classification by including endoscopic and imaging findings and creating a management guideline.

Testing for Laryngeal Fracture

When doctors suspect there might be an issue with your larynx, the voice box in your throat, they carry out several checks. They use an instrument called a fiberoptic endoscope to look at your larynx, which is a routine procedure. Sometimes, this procedure is performed under general anesthesia. In addition, using special imaging techniques like CT scans and ultrasounds can help doctors in their diagnosis. Examining the larynx early can help doctors decide the best way to secure the airway and plan any needed surgery.

Doctors recommend having a CT scan within 24 hours of a trauma. This is important because larynx fractures are often underdiagnosed, which means they’re missed or not identified correctly. Typically, a CT scan is suggested for all patients who might have a larynx fracture. This is because a regular examination might not reveal the fracture, especially when symptoms could be as simple as swelling, a bruise, or sometimes nothing noticeable at all. So, a CT scan can guide the course of treatment and allow for early surgery if needed. Also, an ultrasound can be handy to detect fractures in the thyroid cartilage which is a part of the larynx.

Treatment Options for Laryngeal Fracture

When it comes to treating larynx injuries, the best timing for surgery is a topic of debate. Some propose that early surgery can lead to better outcomes for voice function and tube removal, while others suggest that delaying treatment can have similar results.

The first goal when treating these injuries is to ensure the patient’s airway is secure. This can be tricky, and rushed attempts can risk losing the airway. If the obstruction is severe, creating an opening in the neck to allow air to reach the lungs (a procedure called tracheostomy) may be recommended.

In terms of the management of larynx (voice box) trauma, a system called the Schaefer–Fuhrman classification can help categorize cases. Some with minor swelling, bruising and small mucosal (inner lining) cuts, can be managed non-surgically. This often requires observation, humidified air delivery, and voice rest. For more severe cases, several surgical options are available depending on the scale of the injury and its specific details such as large mucosal cuts, exposed cartilage, multiple displaced cartilage fractures, vocal cord immobility, and other serious conditions.

Doctors usually observe a patient closely for at least 24 hours after a larynx injury, because swelling can often appear several hours after the trauma. Over the past two decades, many researchers have recommended early surgery to preserve the function of the larynx, as even minor fractures can disrupt normal voice function.

Nonsurgical or “conservative” management can include observation, raising the head of the bed, steam inhalation, voice rest, and a medication called a corticosteroid administered through an IV.

If a patient needs surgery, tracheostomy is always recommended. Factors that might indicate the need for surgery include disruption of the laryngeal framework. Some sources suggest an average of around 5-6 days to perform reconstruction surgery.

Surgical exploration and correction of fractures are usually possible using various materials like mini-plates, 3-D plates, or bioresorbable plates, and a specific type of laryngeal stent. Other materials for internal fixation include thread, steel wires, and titanium plates.

Sometimes, a method involving tiny titanium plates doesn’t work, particularly in cartilage that has not yet hardened (ossified). In such cases, titanium mesh might be a good option. This can be molded into various shapes and sizes, and can adapt to various fracture types. Other treatment methods include resorbable plates. Various situations might call for a laryngeal stent, such as failure of mucosal repair, disruption of the front part of the vocal cords (anterior commissure), and highly fragmented fractures.

What else can Laryngeal Fracture be?

When someone experiences an injury to the neck or upper chest area, there are several possible injuries doctors need to consider. These can include:

• Damage to the soft tissues in the neck, such as muscles, tendons, and ligaments
• Injury to the blood vessels in the neck, which can interrupt blood flow and cause serious problems
• A pneumothorax, which is a condition where air gets into the space between the lung and the chest wall, causing the lung to collapse
• A penetrating injury to the top part of the lung. This type of injury usually happens from gunshots, stabbing, or other types of severe trauma.

What to expect with Laryngeal Fracture

Research suggests that the results of voice and airway treatments are generally positive. In 62 to 85% of cases, people reported improved voice quality, while good results for airway function were recorded in 76 to 97% of cases. The best results were seen in those who received treatment sooner rather than later.

However, age factors in as well. Older patients, particularly those over 70 years old, often don’t fare as well in terms of treatment outcomes.

Possible Complications When Diagnosed with Laryngeal Fracture

Complications of a certain procedure can happen either right after the surgery (acute complications) or over a longer duration of time (chronic complications). Acute complications could be blockage of the upper airway or lack of oxygen, nerve injury, bleeding, infection, or even death. Chronic complications, on the other hand, might include issues like vocal cord paralysis, loss of voice, repeated formation of granulation (new tissue), narrowing of the different parts of the throat, nerve issues, or chronic inhalation of food or drink into the lungs.

Here are these complications listed out:

Acute Complications:
• Upper airway obstruction or asphyxia
• Recurrent laryngeal nerve injury
• Hematoma
• Infection
• Death

Chronic Complications:

• Vocal cord paralysis
• Hoarseness
• Recurrent granulation
• Narrowing of the supraglottis, glottis, subglottis or trachea
• Recurrent laryngeal nerve dysfunction
• Chronic aspiration (inhaling food or drink into lungs)

Most patients recover their normal breathing and stable airway without suffering from throat narrowing or granulation tissue. However, some might end up with swallowing disorders.

Recovery from Laryngeal Fracture

After an operation, doctors may consider prescriptions such as steroids, antibiotics, and anti-acid reflux medications. In some cases, another endoscopic examination (a non-surgical procedure used to examine a person’s digestive tract) may be necessary before removing the breathing tube. This can help to reduce potential complications.

Preventing Laryngeal Fracture

It’s important to remember that getting medical help early can lead to better long-term results. If you experience an injury to the front of your neck and notice changes in your voice or have trouble breathing, even if these symptoms don’t last long, it’s crucial to seek medical attention as soon as possible.