Case report: Laryngeal trauma at Juba Teaching Hospital, South Sudan
Laryngeal injury is a life-threatening condition. Laryngeal trauma is very rare among children and the severity may be easily missed by the inexperienced clinician. A high index of suspicion is essential because some patients do not present with the classic symptoms and signs. Recent advances in the management of laryngeal trauma using endoscopes have significantly reduced morbidity and mortality. We present a case of a young boy who had blunt laryngeal trauma and sustained a fracture to the thyroid cartilage with an associated mucosal tear.
Key words: Laryngeal trauma, emphysema, direct laryngoscope, tracheostomy, laryngeal crepitus
Laryngeal trauma is rare compared to other head and neck injuries. It can be life threatening due to associated complications such as aspiration, vocal cord injuries and airway obstruction. Mortality from severe laryngeal trauma has been estimated at about 40% without immediate medical intervention. The injury may be blunt or penetrating, mainly from sporting equipment (e.g. ball, stick) or contact with fixed structures. In children laryngeal injuries are uncommon especially among females (male to female ratio of 77 to 33). The reasons for this difference arise from the fact that males are more likely to be involved with activities leading to injuries. [1, 3] The initial management has a direct impact on survival and outcome. [4, 5]
We report a case of blunt laryngeal trauma and describe types of laryngeal trauma, airway management and surgical approaches.
An eight-year-old boy sustained blunt laryngeal trauma while playing with a stick-rubber game (locally called Chung). He arrived in Casualty at Juba Teaching Hospital 10 hours after the incident. Initially there had been no airway obstructive symptoms. On arrival in the Casualty, he had difficulty breathing (inspiratory stridor), neck pain and confusion. His mother stated that the he had spat streaks of blood after the incident but there was no cough or change of voice.
On examination, he was restless, sweating and had swollen facies and neck with signs of surgical emphysema as indicated by palpable crepitus (Figures 1 and 2). There was bruising and a bulge (during expiration) in the region of the left thyroid cartilage, and tenderness over the left superior cornu of the thyroid cartilage. The haemoglobin level was normal (11mg/dl) and the oxygen saturation was low at 70%. Unfortunately, no imaging was done because of family financial constraints.
A diagnosis of upper airway obstruction was made and an immediate tracheostomy and subsequent direct laryngoscopy was done under general anaesthesia (flexible laryngoscopy would have been an option but we did not have the facilities). This showed a 1cm. mucosal tear and haematoma at the level of the superior cornu of the left thyroid cartilage. Cartilage was not exposed and all the other laryngeal structures were intact. The patient was given steroids (dexamethasone) by injection [IV 4mg 8hourly for 48 hours], prophylactic antibiotic (ceftriaxone injection IV 1 gm once daily for 3 days) and analgesia (mefanemic acid tabs 250mg thrice daily) for 72 hours. The emphysema subsided and tracheostomy was removed after 3 days and over a week before discharge.
Ten days after admission a direct laryngoscopic examination was repeated. The mucosal tear had healed and there were no other abnormalities. The patient was in hospital for a total of 11 days. A follow-up at three weeks after discharge revealed no complaints and the tracheostomy stoma was completely closed (Figure 3); this was confirmed at eight weeks (Figure 4).
Figure 1. Patient presented with emphysema.
Figure 2. Patient with emphysema, sweating and confusion before tracheostomy.
Figure 3a and 3b. Patient after tracheostomy removed.
Figure 4. Patient after 8 weeks.
The larynx extends from the epiglottis to the inferior border of the cricoid cartilage. Its anatomical location in the anterior aspect of the neck renders it liable to trauma. However, the elastic nature of the larynx, the presence of the cervical spine and the mandible provide a degree of protection. Other factors probably linked to a low incidence among children include a lower involvement in road traffic accidents, and less interpersonal violent confrontations which are more commonly seen in adults. [2, 3, 6]. Laryngeal injury may be caused by direct trauma (blunt as with our patient or penetrating), inhalation or ingestion of caustic substances. 
It has been estimated that laryngeal injuries, whether blunt or penetrating, range between 1-7% of trauma cases in a busy hospital facility.  The risk of laryngeal trauma from sport is high with 10% of cases arise from athletic activities. 
Patients with laryngeal trauma may present with one or more of the following symptoms and signs: neck pain and tenderness, subcutaneous emphysema, bruises and cuts. In our case the patient presented with all of these including inspiratory stridor, neck crepitus and tenderness, sweating and confusion. A high index of suspicion of the possible injuries and complications is crucial in order to minimise morbidity and mortality. 
It is very easy to misdiagnose fractures of the larynx. Internal (mucosal tears) injury may not be manifested by superficial and visible skin signs, therefore endoscopic examination is essential with the anticipation that tracheostomy may be required. 
In our case there were symptoms and signs of a mucosal tear and upper airway obstruction. A tracheostomy was selected as the intervention to secure the airway especially as we did not have adequate intensive care facilities.
Table 1. Fuhrman classification of laryngeal injury
Source: Fuhrman et al. Journal of Trauma 1990; 30(1):87-92. 
The diagnosis of laryngeal trauma can be aided by flexible endoscopy but this was not available to us. Most clinicians would prefer a direct laryngoscopy under sedation after securing airway in children. The guidelines for the pathways of management are shown in Table 2.
Table 2. Algorithm for initial airway management and investigations of patients with suggested laryngotracheal injuries
Source: Peady C. Adapted from Australasian Anaesthesia 2005; 13: Page 20 Figure 2 .
When a patient is stable from the respiratory point of view and haemodynamically other procedures for assessment may be considered including chest and neck X-rays, oesophagoscopy, bronchoscopy and angiography. 
Laryngeal trauma among children is uncommon therefore the clinician must be alert to its possibility from the history, physical examination and investigation in order to reduce morbidity and mortality.
As some cases may not present with symptoms and signs of airway obstruction immediately after the incident, observation is important. Tracheostomy or intubation may be life-saving. Endoscopic techniques have contributed immensely to improved outcomes but these require the availability of the equipment and skills to use them as well as the pre- and post-procedure care facilities
All photographs taken by Justin Rubena Lumaya with the permission of the patient.
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