Laryngeal Trauma in a 7-Year-Old Child

A 7-year-old boy presented to the emergency department with increased work of breathing and hoarseness after being struck by a bottle rocket. On examination, he had an abrasion on the anterior neck, biphasic stridor, subcostal retractions, and nasal flaring. He was tachycardic to 120 beats/minute. Flexible fiberoptic exam at the bedside showed immobility of the left vocal cord and soft tissue edema. An initial computed tomography (CT) scan of the neck showed soft tissue edema along the left neck with subcutaneous air without definitive evidence of a laryngeal fracture (Figure 1).

Figure 1.

Axial, noncontrast CT scan showing air tracking from the lumen of the larynx to the anterior midline. CT indicates computed tomography.

A direct laryngoscopy and bronchoscopy (DLB) and esophagoscopy were performed under general anesthesia, which showed bilateral vocal fold hematomas. The child underwent telescopic endotracheal intubation and was transferred to the pediatric intensive care unit for observation with a plan to repeat the DLB in 72 hours. He was started on steroids and a proton pump inhibitor.

A high-resolution CT scan of the neck showed pneumomediastinum and a possible longitudinal anterior thyroid cartilage fracture. He was taken back to the operating room for repeat DLB and repair of the laryngeal injury. The injury was approached via a midline incision. A longitudinal fracture of the thyroid cartilage was identified (Figure 2), which was reduced and repaired using 4-0 polydioxanone sutures. The laryngeal framework was then palpated telescopically. There was no restriction of mobility of the arytenoids. Skin was closed over a drain. The patient was extubated on postoperative day 5 and discharged on day 13. Pediatric voice handicap index showed steady improvement during assessments every 4 to 6 weeks, although the left vocal cord immobility has persisted.

Figure 2.

Intraoperative photograph demonstrating the fracture through the thyroid cartilage.

Blunt laryngeal trauma is a rare but serious cause of airway and voice injury. Common presenting symptoms include dyspnea, dysphagia, pain, and dysphonia. ¹ A high clinical suspicion is needed to avoid sequelae such as subglottic or tracheal stenosis. In a stable child, initial workup includes flexible laryngoscopy, CT imaging, and DLB under general anesthesia.

Children with mild mucosal injuries alone can be managed conservatively with humidified air, a proton pump inhibitor, and steroids. They should be observed for at least 24 hours. Initial management of the child with an unstable airway is controversial. Some advocate for tracheostomy rather than endotracheal intubation. ² Tracheostomy may prevent additional trauma. However, good outcomes can also be achieved with endotracheal intubation under direct visualization. ³

Data are limited on the timing of surgical repair in children, although early repair has been traditionally favored. ⁴ Others recommend delaying surgery for reduction in edema and for surgical planning. ³ Up to 60% of children with vocal cord paralysis will regain movement without intervention. Therefore, in a child with a unilateral vocal fold paralysis, observation for 1 to 3 years prior to intervention is prudent. ⁵

This report describes a child with blunt laryngeal trauma that was managed with endotracheal intubation followed by initial conservative management and subsequent surgical repair. The management algorithm as demonstrated in this article shows that deferred operative management, that facilitates better visualization due to reduction of mucosal edema, can obtain good vocal and swallowing outcomes.