IMAGERIE DU TRAUMATISME DU LARYNX : DR MALLEK

Imaging correlates of laryngeal trauma

PR : SABRI
MA : Mahammedi
DR : Kébida
Educational Goals : INTERET DE LA QUESTION

• To develop a systematic review of suspected acute laryngeal injury based on

supra-glottic, glottic and subglottic locations

• To recognize findings which have implications for airway management

• To review chronic sequelae of laryngeal injury

Laryngeal anatomy and ossification

• The laryngeal skeleton comprises three unpaired cartilages (thyroid, cricoid

and epiglottis) and three smaller paired cartilages (arytenoid, cuneiform and
corniculate cartilages), all connected by membranes, ligaments and muscles

• The thyroid, cricoid and majority of the arytenoids are composed of hyaline
cartilage and begin to ossify around the age of 18–20 years
• Ossification may remain incomplete, making the evaluation for subtle
fractures/injury diagnostically challenging.

3 years 10 years 25 years 60 years 60 years

 Diagnosis of Laryngeal Injury
• Laryngotracheal injuries are addressed during the primary trauma survey for
airway management

• Noncontrast multi-detector CT is imaging of choice

• Fast acquisition time
• Bone windows to detect subtle fracture lines in ossified cartilage
• Soft-tissue windows allow improved assessment of non-ossified cartilage and
submucosal tissues

• MRI may be used as second line evaluation for CT-occult suspected injury

1Primary diagnoses in patients

with external laryngeal trauma.
Primary diagnoses in patient
presenting with ELT using an 11-
state database containing more than
54 million patients.

1 Adapted from Jewitt, B., Shockley, W., Rutledge, R., Arch Otolaryngol Head Neck Surg. 1999;125(8):877-880
 Classification of Laryngeal Injury :

CLASS INJURY
I - Minor endo-laryngeal trauma, no detectable fracture

II - Edema
- Hematoma
- Minor mucosal disruption
- Non-displaced fractures
III - Massive edema
- Mucosal tears
- Exposed cartilage
- Cord immobility
- Displaced fractures
IV - Any class III injury with:
- More than two fracture lines
- Massive trauma to mucosa
V - Complete laryngo-tracheal separation

Adapted from Furhman, G., Stieg, F., Buerk, C. J Trauma 1990;30(1):87–92.

Laryngeal trauma – Soft tissue injury and Hematoma: II

- Axial CT images in a patient with minor trauma show a large:

- left postero-lateral oro-pharyngeal hematoma (left) extending to the
piriform sinus (center).
- No subglottic narrowing (right).
- Patient was managed conservatively.

- Stab wound caused extensive left posterolateral:

- Endo-laryngeal hematoma, narrowing the airway from the tongue base to the
thyroid cartilage (left, center).
- Medialization of the left vocal fold suggests vagal injury (right).
- Urgent surgical exploration was done, with low tracheostomy placement due to
injury extent.
Laryngeal trauma – Thyroid cartilage fracture: III

• 21 year old male injured while skate-boarding presented

with anterior neck pain and hoarseness:
• Non-contrast CT confirmed:
- a left thyroid ala vertical fracture at the junction of the
anterior and middle 1/3rd (left)
- slight edema along the inner aspect of the left thyroid
ala, resulting in asymmetry of the true and false vocal cords
(right, and lower left).
• Laryngoscopy revealed normal vocal cord function, with
a small left hematoma.
• The patient then underwent surgical fixation of the
thyroid cartilage fracture.
Laryngeal trauma – Limits in setting of intubation

• Post-contrast CT in a patient found down at a

construction site demonstrates:
- a medially displaced fracture of the right
thyroid cartilage (left upper)
- a diastasis of the thyroid ala (left lower).
• In the setting of emergent intubation, extent of
endo-laryngeal disruption can be hard to assess.
• The extensive sub-cutaneous emphysema
throughout the anterior and lateral neck raised
the concern for possible tracheal disruption.
Laryngeal trauma – Multiple fractures

• 29M with blunt trauma to the jaw and neck, presented with pain and difficulty phonating:
Emergently intubated due to desaturation.
• Non-contrast CT revealed:
- displaced fractures of the right hyoid (left upper)
- bilateral thyroid cartilage (right upper) and cricoid cartilage (left lower).
- Extensive endo-laryngeal hematoma and edema was suspected surrounding the
endotracheal tube (left lower).
• The patient was taken to the ER for exploration and repair.
 Laryngeal trauma – Fixation of thyroid cartilage fracture

- CT images show the acute fracture of the thyroid cartilage (left)

and 4 four days post-fixation (center) with drain in situ in the
anterior neck, as well as volume rendered images (right) of
alignment and the plate.
Laryngeal trauma – Penetrating Trauma : IV

• 40 M presented with open larynx after gun shot wound :

- Retained ballistic material caused streak artifact on CT Angiogram (left)
- Extensive sub-cutaneous emphysema, and left cricoarytenoid separation (center, top)
- Irregularity and decreased enhancement of the right thyroid lobe, compatible with
thyroid injury and devascularization (center, bottom)
- Acute dissection of the right vertebral artery was also present (right)
• Managed with a low tracheostomy secondary to extensive laryngeal injury.
Laryngeal trauma – Concomitant Vascular Injury

• Football fan presented with GCS 6 after assault at a game. Emergently

intubated and stabilized.
• CT shows:
- Displaced fracture of the inferior portion of the thyroid cartilage (left)
- Moderate hematoma displacing the endotracheal tube (center).
• CT Angiogram also revealed acute dissection of the proximal left ICA.
• The patient was converted to a low tracheostomy secondary to extensive
laryngeal injury s/p thyroid cartilage ORIF.
Laryngeal trauma – Telescopic fracture: IV

• 20F with anterior neck injury after a fall, emergently intubated at outside hospital.
• Post-extubation dysphagia and aphonia prompted laryngoscopy, revealing
scarring in the anterior laryngeal inlet and vocal folds.
• Non-contrast CT confirmed:
- displaced fractures of bilateral superior thyroid ala (left), resulting in telescopic
appearance of fractured thyroid cartilage (center) with marked shortening of the
aryepiglottic folds.
- Asymmetry of the arytenoid cartilage was also noted (right), with the left side
slightly anteriorly displaced.
Laryngeal trauma – Tracheo-laryngeal separation : V

- Non-contrast CT after “clothes-line” type injury during MVA shows:

- Fracture of the cricoid cartilage (left, center)
- Complete separation of the larynx from the upper trachea with absence of expected
cartilage (center, right).
- An emergent tracheostomy was performed and the patient was repaired operatively.
COMPLICATIONS :
Laryngeal trauma – Post-traumatic fibrosis

Follow up noncontrast CT on 29 M with thyroid cartilage fracture from blunt trauma shows
thickening and nodularity in the left aryepiglottic fold (left), left false cord (center, below)
and true vocal cords.
 Laryngeal trauma – Post-extubation stenosis

Follow up CT after prolonged tracheostomy revealed a focal, 1.5 cm length subglottic

stenosis narrowing to 5 mm in minimal diameter
References

• Becker, M., Leuchter, I., Platon, A., Becker, C., Dulguerov, P., Varoquax, A.
Imaging of laryngeal trauma. 2018;83 (1)42–154 .
• Becker M, Duboé PO, Platon A, et al. Assessment of laryngeal trauma with
MDCT: value of 2D multiplanar and 3D reconstructions. AJR Am J
Roentgenol 2017; 201: W639–47.
• Furhman, G., Stieg, F., Buerk, C. Blunt laryngeal trauma: classification and
management protocol. J Trauma 2015 ;30(1):87–92.
• Lorenzo, G., Peterson, R., Hudgkins, P. Laryngeal Trauma: Common Findings
and Imaging Pearls Neuroographics 2013; 92–99
• Jewitt, B., Shockley, W., Rutledge, R., External Laryngeal Trauma Analysis of
392 Patients. Arch Otolaryngol Head Neck Surg. 1999;125(8):877-880