Dysphagia After Strangulation

A sixty-four year old Caucasian male presented with a three-month history of dysphagia and cough since being physically assaulted by strangulation. He had tenderness on palpation of the left jugulodiastric area. Nasopharyngolaryngoscopy (NPL) revealed a submucous structure that displaced the left piriform sinus anteromedially and contacted the aryepiglottic fold. A CT scan of the neck and a barium swallow both failed to demonstrate the abnormality, and the patient had persistent symptoms at his follow up visit.

Figure 1.

This is a preoperative view of the anteromedially displaced piriform sinus mucosa resulting from a fractured left thyroid cornu (black arrow).

Figure 2.

This is an intraoperative view of the left thyroid ala. A single hook is placed laterally and medially to the fractured cornu.

Figure 3.

This image was obtained following cornu resection. Note the normalization of piriform sinus contour.

A direct laryngoscopy was performed. The structure was firm on palpation and appeared to be consistent with a fractured and displaced superior cornu of the thyroid cartilage.

The fracture site was approached through a transcervical incision. The cornu was skeletonized, retracted laterally and resected at its base. A post procedural direct laryngoscopy was performed to confirm normalization of piriform sinus contour. The patient was seen in follow up one week later and had resolution of his symptoms. Exam by NPL verified resolution of the previous piriform sinus abnormality.

Laryngeal fractures are relatively rare however otolaryngologists must be familiar in diagnosing and appropriately treating them. Only two thirds of fractures are symptomatic and can present with dyspnea, dysphonia, dysphagia or odynophagia. History of neck or multisystem trauma and physical exam findings of stridor, hemoptysis, subcutaneous emphysema, point tenderness and visible deformity should raise suspicion of laryngeal injury. ¹ The cornua are the most commonly fractured sub sites within the thyroid cartilage. These fractures typically result from anterior forces compressing the posteriorly positioned cornua against the cervical spine. ² Patients with isolated cornu fractures can be asymptomatic in the acute setting and go on to develop chronic symptoms of odynophagia and globus sensation months after the inciting injury. ^3,4 Knopke and colleagues hypothesized that healing of misaligned fractures leads to this phenomenon of late-occurring symptoms called “pseudoarthrosis”. ⁵

Initial evaluation and management can significantly impact the long-term outcomes of laryngeal fractures. Undiagnosed or untreated fractures can result in delayed complications. The evaluating practitioner must maintain a low threshold for visualization by laryngoscopy even in asymptomatic patients with a history of neck trauma. Patients with a stable airway can benefit from a thin-cut laryngeal CT for diagnosis and surgical planning. Thyroid cornua fractures are typically treated by resection through an external neck incision. Mortensen et al recently described a transoral endoscopic approach for resection of thyroid cornua in the setting of superior cornu syndrome. ⁶ This approach was shown to be safe, technically feasible, and may prove to be a less invasive method of treating problematic cornu fractures in the future.