Emergency War Surgery NATO Handbook: Part IV: Regional Wounds and Injuries: Chapter XXVII: Wounds and Injuries of the Neck

Wounds of the Larynx and Trachea

United States Department of Defense
Peer Review Status: Internally Peer Reviewed

Serious wounds of the larynx and trachea may present in the following ways:

1. Asphyxia. Asphyxia results from serious laryngotracheal obstruction. The obstruction may be caused by destruction of the larynx, the fragments of which form obstructing flaps; by hemorrhage, which blocks the airway with blood or clots; or by traumatic laryngotracheal edema. Restlessness observed in these patients, if secondary to cerebral hypoxia, heralds impending asphyxia.
2. Dyspnea. Dyspnea may result from lesser damage to the larynx or trachea. The cause of asphyxial injuries is usually immediately apparent, whereas injuries causing dyspnea can often be found only by careful examination. The most common symptoms and signs of airway injury, in addition to dyspnea, are dysphonia, laryngeal cough, hemoptysis, dysphagia, and excess mobility of the larynx. Roentgenologic examination of the laryngeal and tracheal cartilages, which are always ossified to some degree in adults, and preoperative laryngoscopy are of diagnostic assistance.
3. Subcutaneous emphysema of the face and neck. Retropharyngeal swelling, although infrequently detected on physical examination, is readily demonstrable on biplanar soft-tissue X-ray films by narrowing or distortion of the air column.

All injuries of the trachea and larynx are serious. Diagnosis is confirmed by laryngoscopy or bronchoscopy, which should be performed at the slightest suspicion of injury. These examinations are often done at the time of airway control, following which an endotracheal tube may be inserted. The early use of this procedure often precludes the performance of a hasty tracheostomy. On the other hand, emergency tracheostomy may be necessary when the injury crushes or distorts the larynx or hypopharynx such that intubation cannot be accomplished. In such cases, urgent decompression of the deep subfascial space may also be necessary to relieve pressure on the airway. In the presence of a functioning tracheostomy, laryngeal injuries can go undiagnosed, with subsequent serious loss of function, much of which may have been prevented by early diagnosis and appropriate treatment.

Careful and conservative debridement of laryngotracheal injuries is emphasized. Following debridement, the fragmented larynx or trachea should be reapproximated and an intraluminal stent utilized to maintain the anatomical architecture. Late tracheal and laryngeal stenosis from injudicious and excessive removal of tissue, particularly cartilage and mucosa, must be prevented. Care must be taken to identify associated wounds of adjacent structures, such as esophagus, pharynx, and major vessels.

Airway control via either endotracheal intubation or tracheostomy requires constant aftercare to avoid sudden obstruction with resultant asphyxia. Proper tube size is important. Too small a tube can result in gradual respiratory insufficiency, leading to hypoxia and cardiac arrest. Overinflation of "hard" endotracheal tube balloons must be prevented to avoid damage to tracheal tissue.

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