What is Laryngeal Injury?

Damage to the larynx and trachea, which are parts of the throat, can be serious even though they don’t happen often. These injuries can be caused by either a sharp object or a strong impact and can happen in different areas of the throat. It’s very important to quickly and accurately identify any throat injury. How and how badly the throat is injured can differ when it’s caused by a sharp object as opposed to an impact.

Anyone who comes in with a history of injuring the front part of their neck needs a thorough health check to find out if they have a throat injury. It’s also crucial to make sure that they can breathe safely. If there’s any doubt about this, measures must be taken immediately to ensure their airway is unblocked before any other examinations are carried out.

What Causes Laryngeal Injury?

Car accidents are the main reason laryngeal injuries or damage to the voice box, occur. However, the use of seat belts, airbags and other car safety features have largely helped in reducing these injuries. Other reasons for such injuries can include acts of violence, physical assault, attempted choking, or accidents involving clotheslines. Medical procedures like bronchoscopy, a procedure to look into the airways, emergency breathing tube insertion, or an incision made in the throat to relieve an obstruction to breathing, can sometimes cause laryngeal injuries as well.

Usually, our voice box is shielded from direct impact thanks to our chest bone and lower-jaw bone. Injury to the voice box can happen when the neck is stretched back too far due to an accident, like from a car accident that gives you a whiplash-type injury, or from “clothesline accidents” where your exposed neck hits something narrow and solid like a tree branch or fence wire, common in motorbike riding and snowmobiling. It can also happen when the voice box is specifically targeted in an attack, like a hitting right to the neck or in a strangulation.

Injuries to the neck come with a specific set of procedures for doctors to follow, and the voice box can certainly be at risk. It’s usually easy to figure out whether a patient was injured with a blunt force or with a puncturing force, but doctors are always on the lookout and prepared to address it right away in the case of a neck injury.

Risk Factors and Frequency for Laryngeal Injury

Damages to the larynx, or the voice box, make up less than 1% of all trauma-related injuries. Even though they are infrequent, these injuries can be extremely serious. After brain injuries, they are the second leading cause of death in patients with trauma to the head and neck. For quick reference, doctors use the Schaefer classification system. It grades larynx injuries according to severity, which helps doctors choose the best course of action.

The Schaefer Classification is explained below:

Minor internal bleeding or laceration in the larynx with no broken bones.
Severe swelling, internal bleeding, minor skin cut without visible cartilage, or a fracture where the bone is not misaligned.
Huge swelling, large skin cuts, misaligned fractures or frozen vocal cords that expose cartilage.
Major damage to the front of the larynx, unstable fractures, more than one fracture line, and extensive skin injuries.
Complete separation of the larynx and the windpipe.

In actual medical practice, patients are usually divided into two groups based on whether their breathing is stable or not. This separation is crucial since it immediately influences follow-up examinations and treatments. Unstable patients need to have a safe breathing passage created, often through an urgent procedure called tracheostomy or cricothyrotomy, before any further examinations. Stable patients may undergo further assessments such as a fiberoptic examination and/or imaging.

Signs and Symptoms of Laryngeal Injury

If someone has had a neck injury, it’s crucial to check for possible damage to the larynx, which is part of the throat. Anyone who has experienced a frontal neck injury should be examined closely for signs of laryngeal damage, regardless of whether the injury was caused by a blunt force or a sharp object. The timing of the injury and any accompanying injuries are also important to consider. Car accident victims, for instance, might not be able to communicate effectively due to their injuries, so it’s important to bear in mind that they could also have a laryngeal injury.

Some symptoms that might indicate a laryngeal injury include:

A record of a frontal neck injury
Changes in voice or hoarseness
Pain in the frontal neck area
Difficulty breathing
Trouble swallowing
Subcutaneous emphysema, which refers to air bubbles under the skin

An examination for laryngeal injuries should begin with an overall assessment of the patient’s breathing. Keep in mind the basic tenets of trauma treatment. Wheezing could be present while breathing in, breathing out, or both, and might come with changes in voice. All patients with neck injuries should be examined for possible injuries to the cervical spine, which is the part of the spine located in the neck. The neck check should involve detecting tenderness over the thyroid cartilage and windpipe, a diminished prominence of the thyroid cartilage, presence of subcutaneous emphysema, bruises over the front of the neck, and voice changes. Injuries caused by sharp objects should be clear at this point, but minor external signs could conceal serious internal injuries to the larynx. Consequently, a thorough examination is necessary in all cases.

Patients with a stable airway should undergo a flexible laryngoscopy to check the larynx and pharynx, the cavity behind the mouth and nose. If an injury is detected, treatment should begin. But if a patient doesn’t have any symptoms or has only mild symptoms and their flexible laryngeal examination is normal, close observation is essential. If the examination isn’t clear, but the patient’s airway is stable, especially if they have a concerning injury history and mechanism, a computed tomography (CT) scan is warranted to clearly show images of the larynx and trachea. When a CT scan is unsafe or the clinical suspicion is high, the patient should be taken to the operating room for a controlled endoscopic and bronchoscopic investigation, with the possibility of a neck exploration and a tracheostomy.

Testing for Laryngeal Injury

If your doctor suspects you have an issue with your airway, they may choose to do a flexible laryngoscopy. This is an examination that uses a flexible tube to view the inside of your larynx and upper part of your digestive tract. It can pick up signs of swelling, cuts, bruises, or other abnormalities that could lead to complications.

If your vocal cords aren’t moving as they should, this could be a sign of a hidden injury to your larynx or windpipe, and your doctor will want to investigate further. If there’s any concern about a hidden injury—even if your larynx looks normal on the laryngoscopy—your doctor may want to do more tests. However, if you are not experiencing symptoms, you might not need to be put on a breathing machine before these tests.

Imaging tests such as computed tomography (CT) or X-rays can be incredibly helpful, but they are typically only used if they’re safe and will affect how your doctor treats your condition. For instance, you likely won’t need a CT scan if your larynx appears normal during the laryngoscopy and you don’t have any symptoms. However, if your doctor has reason to believe you have a hidden injury, a CT scan could help visualize the structures in your neck and highlight any fractures that might need stabilizing.

Sometimes, if your larynx is fractured, your esophagus might be injured too. If your doctor suspects this, an esophagram may be done in the future. An esophagram is an X-ray of the esophagus.

Lastly, if your doctor suspects a neck injury and you have trauma in other parts of your body, a chest X-ray might be part of your routine checkup. If you have subcutaneous emphysema—which is air trapped under your skin—it could signify a chest injury.

Treatment Options for Laryngeal Injury

The first step in treating injuries to the voice box or “larynx” is to check and secure the patient’s airway, which is the passageway from the mouth or nose to the lungs that allows us to breathe. If a person can talk normally, their airway is at least open, but that doesn’t necessarily mean it’s stable.

Certain signs and symptoms could mean that immediate medical intervention is required, these include: difficulty breathing, swelling and bleeding in the neck, air trapped under the skin of the neck, an abnormal breathing sound referred to as “stridor”, voice changes or hoarseness, coughing up blood, abnormal vibrations or sounds in the neck, and twisted neck anatomy. If the voice box is clearly fractured or if the patient is struggling to breathe, an emergency surgical procedure (either a tracheostomy or cricothyrotomy) may need to be performed to establish an airway.

Based on a review of multiple studies and clinical expertise, a plan has been suggested for dealing with laryngeal injuries. If the patient’s airway is in danger of becoming blocked, experts may perform a tracheostomy, intubation, or cricothyrotomy. Patients are then examined with a laryngoscope and an esophagoscope, tools used to visually inspect the voice box and upper stomach, respectively. The treatments provided depend on the outcome of these investigations and might range from simple observation to surgical procedures to fix the voice box fractures and/or treat any tears on the lining of the voice box.

If the patient’s airway is stable, a flexible, fiberoptic laryngoscope, along with a CT scan of the neck, can be used to examine the voice box. The outcomes of these tests dictate the best course of treatment. For straightforward injuries, close monitoring might be all that’s needed. This could involve inhaled steroids, as well as IV steroids, to manage inflammation. Continual monitoring of the airway and the oxygen level in the blood is recommended for the first 24 hours or so. In cases where there’s no significant permanent damage, this could be the extent of the necessary treatment.

More severe cases will often require surgery, alongside a thorough examination under anesthesia, which includes an examination of the larynx and the upper part of the stomach. Surgical repair of any voice box injuries can be performed by an endoscopic surgery for smaller tears, but significant injuries might need an open-neck surgery to fix fractures of the larynx and repair other injuries. After the surgery, patients are monitored closely in the intensive care unit. Many may need a tracheostomy tube until the voice box is fully healed. During this stage, the patients are fed through either a feeding tube or a gastrostomy tube (inserted directly into the stomach through the abdominal wall) because of a high risk of food or fluid entering the lungs (aspiration). This comprehensive treatment approach is designed to help patients recover safely and effectively from laryngeal injuries.

There are several types of injuries and symptoms that can result from trauma:

Vascular injury – This type of injury may cause bleeding or blood clots, low blood pressure, and symptoms of a stroke. It can also appear as severe bruising on the neck.
Pharyngoesophageal injury – This injury can cause symptoms like blood in saliva, vomiting blood, difficulty or pain when swallowing, and coughing up blood. It may also result in subcutaneous emphysema, which is when air gets into tissues under the skin.
Pneumothorax – This condition, also known as a collapsed lung, can cause respiratory distress.

What to expect with Laryngeal Injury

Injuries to the larynx (voice box) and trachea (windpipe) can be quite serious and may even be life-threatening. It’s crucial to quickly establish a clear pathway for air to reach the lungs. Failure to timely identify and treat a significant injury to the larynx can lead to a blocked airway and potentially death.

Patients with minor injuries, such as scratches or small cuts on the larynx or trachea, are typically managed in a cautious manner. This might involve careful monitoring, repeated visual inspections of the area (using a scope), and the use of steroids (medications to reduce inflammation.)

For those with fractures in the larynx, getting early airway management can enhance their recovery. Patients who are diagnosed and treated quickly tend to have better voice and airway function in the aftermath.

Possible Complications When Diagnosed with Laryngeal Injury

Complications from any injury within the larynx can range from minor to very severe. As the larynx heals, it might develop some granulation tissue, which is a type of scar tissue. Sometimes, this scar tissue can become very severe, leading to scarring or rarely, a blocking mass. The formation of scars, also known as cicatrix formation, is a significant complication. The best way to avoid this is to repair the mucosa (the lining of the larynx) quickly and avoid exposing the cartilage or muscles within the larynx. In rare cases, if the scarring is severe or persistent, it may result in a long-term dependence on a tracheostomy, which is a medical procedure that creates an opening in the neck to allow air to enter the lungs.

There’s also a risk of complications with the wound healing, such as the formation of fistulae; these are abnormal passageways between the trachea and the larynx or skin, although they’re quite rare. Not noticing an injury to the esophagus is another serious potential complication.

Vocal cord paralysis, or a decrease in strength, may occur after the injury. While it is usually temporary and might take up to a year to heal, there’s a possibility it could be permanent and require further medical procedures. Similarly, damage could be inflicted on the recurrent laryngeal nerve or superior laryngeal nerve during the repair, causing voice changes or swallowing difficulties, which might need further medical attention.

Common Complications:

Development of granulation tissue or severe scarring
Formation of an obstructive mass
Persistent or severe scarring leading to long-term tracheostomy dependence
Formation of fistulae between the trachea and the larynx or skin
Undetected injury to the esophagus
Vocal cord paralysis or decrease in strength
Injury to the recurrent laryngeal nerve or superior laryngeal nerve

Recovery from Laryngeal Injury

When someone has experienced a trauma or injury to their larynx – also known as the voice box, it is necessary for them to stay in the hospital for monitoring. Minor injuries, like small tissue damages, non-displaced fractures, or blood-filled swelling (known as hematomas), can often be cared for with methods such as keeping the head elevated, using humidified air, pain relief medication, steroids, resting the voice, and maintaining a clear diet.

The main aim of the treatment for these patients is to help them get back their normal swallowing function and voice. In case of more serious injuries, extended therapy for speech and swallowing may be needed. There may also be a higher chance of needing a long-term tracheostomy or gastronomy tube for breathing and feeding support respectively.

Preventing Laryngeal Injury

People who have experienced neck injuries, like those from car accidents, gunshots, attempted hangings, knife injuries or assaults, should go to the emergency room for check-up. This is crucial because injuries to the larynx (your voice box) or trachea (windpipe) can be severe and can even cause death. Even if the person seems to be fine now, there can be serious complications that show up later.

Patients with difficulty in breathing may usually need a procedure called a tracheostomy. This involves making a hole in the windpipe to allow the passage of air. However, doctors usually avoid another procedure called intubation (inserting a tube down your throat to assist with breathing), until they get a better view of the upper airway (the part of the body that air passes through before it reaches the lungs). If a good view of the upper airway is not possible, a tracheostomy may be performed.

Patients who are stable and haven’t experienced severe trauma might still need imaging tests (like x-rays or scans), monitoring by hospital staff, or might be admitted to the hospital for further assessment and care.

Frequently asked questions

Laryngeal injury refers to damage to the larynx, which is part of the throat. It can be caused by a sharp object or a strong impact and can occur in different areas of the throat. It is important to quickly and accurately identify any throat injury, including laryngeal injury.

Laryngeal injuries make up less than 1% of all trauma-related injuries.

Some signs and symptoms of laryngeal injury include: - A record of a frontal neck injury - Changes in voice or hoarseness - Pain in the frontal neck area - Difficulty breathing - Trouble swallowing - Subcutaneous emphysema, which refers to air bubbles under the skin These symptoms should be closely monitored and assessed in individuals who have experienced a neck injury, regardless of whether it was caused by a blunt force or a sharp object. It is important to consider the timing of the injury and any accompanying injuries, as well as the possibility of laryngeal injury in car accident victims who may have difficulty communicating due to their injuries. An examination for laryngeal injuries should begin with an overall assessment of the patient's breathing, and all patients with neck injuries should be examined for possible injuries to the cervical spine. Thorough examination is necessary in all cases, as minor external signs could conceal serious internal injuries to the larynx. If an injury is detected, treatment should begin, but if a patient doesn't have any symptoms or has only mild symptoms and their examination is normal, close observation is essential. In cases where the examination isn't clear but the patient's airway is stable, a computed tomography (CT) scan may be warranted to clearly show images of the larynx and trachea. In situations where a CT scan is unsafe or the clinical suspicion is high, a controlled endoscopic and bronchoscopic investigation, with the possibility of a neck exploration and a tracheostomy, may be necessary.

Laryngeal injuries can occur from car accidents, acts of violence, physical assault, attempted choking, accidents involving clotheslines, medical procedures like bronchoscopy or emergency breathing tube insertion, and incisions made in the throat to relieve an obstruction to breathing.

The doctor needs to rule out the following conditions when diagnosing Laryngeal Injury: 1. Vascular injury - This may cause bleeding or blood clots, low blood pressure, symptoms of a stroke, and severe bruising on the neck. 2. Pharyngoesophageal injury - This may cause symptoms like blood in saliva, vomiting blood, difficulty or pain when swallowing, coughing up blood, and subcutaneous emphysema. 3. Pneumothorax - This condition, also known as a collapsed lung, can cause respiratory distress.

The types of tests that may be needed for a laryngeal injury include: - Flexible laryngoscopy: This examination uses a flexible tube to view the inside of the larynx and upper part of the digestive tract to detect any abnormalities. - Imaging tests such as computed tomography (CT) or X-rays: These tests may be used to visualize the structures in the neck and identify any fractures that may require stabilization. - Esophagram: If there is suspicion of an injured esophagus, an X-ray of the esophagus may be performed. - Chest X-ray: If there is concern about a neck injury and trauma in other parts of the body, a chest X-ray may be included in the routine checkup.

Laryngeal injuries are treated based on the severity and stability of the patient's airway. If the airway is in danger of becoming blocked, emergency surgical procedures such as tracheostomy or cricothyrotomy may be performed to establish an airway. If the airway is stable, a flexible, fiberoptic laryngoscope and a CT scan of the neck can be used to examine the voice box. The treatment plan depends on the outcome of these investigations and may range from simple observation to surgical procedures to fix voice box fractures and treat any tears on the lining of the voice box. In more severe cases, surgery may be required, along with a thorough examination under anesthesia. After surgery, patients are closely monitored in the intensive care unit and may need a tracheostomy tube until the voice box is fully healed.

The side effects when treating Laryngeal Injury can include: - Development of granulation tissue or severe scarring - Formation of an obstructive mass - Persistent or severe scarring leading to long-term tracheostomy dependence - Formation of fistulae between the trachea and the larynx or skin - Undetected injury to the esophagus - Vocal cord paralysis or decrease in strength - Injury to the recurrent laryngeal nerve or superior laryngeal nerve

The prognosis for laryngeal injury depends on the severity of the injury and how quickly it is identified and treated. Patients with minor injuries, such as scratches or small cuts, can typically be managed with careful monitoring and medication to reduce inflammation. For those with fractures or more severe injuries, early airway management can enhance recovery and improve voice and airway function in the long term.

An otolaryngologist or ENT (Ear, Nose, and Throat) doctor.