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Operative Techniques in Otolaryngology xxx (xxxx) xxx

Laryngeal Trauma: External Approaches ✩

David Myssiorek, MD, FACS a, Ahmed M.S. Soliman, MD b

From the a Department of Otolaryngology Head and Neck Surgery, Bronxcare Health Center, Bronx,
NY, 10457
b
Voice, Airway, & Swallowing Center, Department of Otolaryngology Head and Neck Surgery, Lewis
Katz School of Medicine at Temple University, Philadelphia, PA, 19140

KEYWORDS When endolaryngeal approaches are inadequate and when there is significant injury to the larynx,
Larynx; transcervical approaches are necessary. This is most often necessary for Schaefer-Fuhrman Class II-
Trauma; IV. Assessment and treatment always begin with evaluation and management of the airway followed
Surgical approach; by operative endoscopy to determine the extent of injury and guide surgical repair. Treatment includes
Plating; open reduction and fixation of cartilaginous fractures but when there is significant endolaryngeal
Management injury, a laryngofissure with or without stenting is often necessary. Postoperative care continues until
decannulation. Secondary procedures may be required.
© 2020 Published by Elsevier Inc.

Introduction sternocleidomastoid muscles afford protection as well.

The spine provides posterior protection. Consequently,
The preceding article covered the symptomatology, di- most laryngeal injuries occur during decelerations in
agnosis, and treatment of endolaryngeal trauma. This ar- motor vehicle accidents with the head extended and the
ticle will focus on the use of external approaches for neck contacting the steering wheel or other dashboard
the treatment of open laryngeal fractures. The Schaefer- structures resulting in compression of the larynx against
Fuhrman classification of laryngeal trauma (Table 1) is the spine. The widespread installation of airbags in auto-
useful in determining which treatment will be pursued.1 , 2 mobiles has decreased the incidence of laryngeal trauma.
Effectively, approaches to laryngeal injuries above the Unfortunately, the simultaneous widespread availability of
Schaefer-Fuhrman classification II will be included here. high caliber weapons and the increase in urban violence
has increased the incidence of penetrating injuries to the
neck and laryngopharynx.
Laryngeal ossification, which occurs after calcification,
Anatomy & Pathophysiology commences around age 25 in the male thyroid cartilage.3
The larynx is protected from trauma by a visor like It takes place somewhat later in the cricoid cartilage, and
mechanism. The mandible, when the neck is flexed, covers later still in the female larynx. In fact, the female thyroid
the larynx as it approaches the sternum. Laterally, the cartilage remains cartilaginous anteriorly throughout most
of life. The older larynx is much more likely to fracture,
usually in more than 1 location due to lack of elastic-
✩ The authors have nothing to disclose. ity. The cricoid cartilage, being the only complete ring in
Address reprint requests and correspondence: David Myssiorek, MD,
the airway, is more prone to fracture as there is no mem-
FACS, Bronxcare Health Center, 1650 Selwyn Avenue, 11th floor, Bronx,
NY 10457 branous section to absorb compressive forces. In contrast,
E-mail address: [email protected] the pediatric larynx being primarily cartilaginous tends to
http://doi.org/10.1016/j.otot.2020.10.009
1043-1810/© 2020 Published by Elsevier Inc.

Please cite this article as: David Myssiorek and Ahmed M.S. Soliman, Laryngeal Trauma: External Approaches, Operative Techniques in Otolaryngology
- Head and Neck Surgery, https:// doi.org/ 10.1016/ j.otot.2020.10.009
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Table 1 Schaefer-Fuhrman classification of laryngeal trauma

Group Findings
1 Minor lacerations or hematomas, no fractures
2 Edema, hematoma, minor mucosal disruption without
exposed cartilage. Nondisplaced fracture, varying
degrees of airway compromise
3 Massive edema, large mucosal lacerations, exposed
cartilage Displaced fracture. Vocal fold immobility
4 Same as group 3 with severe mucosal disruption,
anterior commissure disruption Unstable fracture,
two or more fractures
5 Complete laryngotracheal separation

compress rather than fracture. Knowledge of ossification Figure 1 Positioning for awake tracheotomy; note that back is
patterns is important in predicting fracture sites and help- elevated 15 degrees and neck extended using small shoulder roll.
ing guide surgical repair.
using advanced trauma life support (ATLS) guidelines in-
cluding primary and secondary surveys. Imaging may be
performed at this time if not done previously.
Airway Management
Assessing and securing the airway is of primary impor-
tance in patients with laryngeal trauma. Although, patients Endoscopy
with injuries classified as Schaefer-Fuhrman classification
II and above often require tracheotomy, whenever possible, Once the airway is established, endoscopy is performed
the patient should have an awake flexible fiberoptic exam- to assess the location and extent of injuries, as well
ination of the larynx first, as symptom severity does not as guide repair.5 Direct laryngoscopy may be accom-
necessarily correlate with the extent of injury.4 This allows plished with a Dedo or similar laryngoscope. Use of a
evaluation of the severity of injury, vocal fold motion, and rod telescope will dramatically improve visualization and
airway patency. If the airway is deemed adequate and the allow identification of mucosal tears, exposed cartilage,
patient is breathing comfortably, he/she may undergo imag- and avulsed structures. These scopes may also be passed
ing, however this should be done rapidly, as edema may through the vocal folds to examine the subglottis and prox-
progress quickly resulting in airway compromise. Imaging imal trachea. Rigid esophagoscopy may be challenging if
is covered elsewhere in this issue. there is restricted mouth opening or limited neck exten-
Endotracheal intubation is generally not recommended sion. A pediatric flexible esophagoscope is very helpful in
for Schaefer-Fuhrman classification II and above injuries these instances but insufflation should be limited to pre-
as this may further disrupt the already injured larynx. Tra- vent worsening subcutaneous emphysema in case there is
cheotomy using local anesthesia and minimal sedation is a pharyngeal/esophageal tear. A flexible bronchoscope may
often the best option. Communication between the surgeon be passed through the tracheotomy tube to assess the distal
and anesthesia provider is critical during the procedure, trachea.
in particular regarding reduction of oxygen delivery while
electrocautery is in use to decrease fire risk. Positioning
of the patient must be done with care in many cases as Neck Exploration
the possibility of concomitant cervical spine injury must
be considered. Placing the patient in the supine position Once the need for surgical repair of the larynx has been
may further may also be further compromise their airway. determined, the surgeon should consider a broad apron flap
Elevating the head 30-45 degrees limits dependent airway incorporating the tracheotomy skin incision. Alternatively,
collapse and improves comfort. A small shoulder roll facil- a separate incision may be used, preferably in a natural
itates access to the neck during tracheotomy, particularly skin crease overlying the inferior larynx to allow access to
in larger patients or those with short necks. (Figure 1) the entire laryngeal framework. Subplatysmal flaps should
A skin incision is made low in the neck caudal to the be elevated superiorly to the level of the hyoid bone and
cricoid cartilage. The strap muscles are divided in the mid- inferiorly to the cricoid cartilage taking care to avoid com-
line and retracted laterally. The thyroid isthmus is similarly municating with the tracheotomy incision whenever pos-
divided in the midline. Entry into the trachea should be sible. In cases of penetrating trauma where the patient
several rings below the cricoid to avoid extending the tra- presents with a large skin laceration, this may be used
cheotomy into the fracture site(s). Once the airway is se- or extended to allow access to the larynx without the need
cured, the patient must be examined for associated injuries for multiple incisions (Figure 2).

Please cite this article as: David Myssiorek and Ahmed M.S. Soliman, Laryngeal Trauma: External Approaches, Operative Techniques in Otolaryngology
- Head and Neck Surgery, https:// doi.org/ 10.1016/ j.otot.2020.10.009
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Figure 3 Right sided laryngeal linear cartilage fracture repaired

with PDS suture through cartilage and perichondrium.
Figure 2 Patient with large vertical incision from emergency
tracheotomy in the field which was extended superiorly to allow
access to the larynx for repair of the fractures.

nent monofilament suture with high tensile strength which

The strap muscles are divided in the midline while pre- may be used to approximate the perichondrium and carti-
serving their superior/inferior attachments as they may be lage but can result in granuloma formation if exposed en-
used for flap coverage during the repair. Careful exposure doluminally. Polydioxanone (PDS) is a synthetic monofil-
of the entire larynx is necessary as some fractures may not ament suture which has similar tensile strength but with
be immediately apparent. Comminuted fractures should be an absorption time of 6-8 months and very little reactiv-
gently debrided keeping the fragments in a sterile saline ity has essentially supplanted the use of wires and other
soaked gauze. Bleeding should be controlled with precise suture materials for the repair of laryngeal fractures. It re-
use of a bipolar cautery to limit thermal injury to the peri- tains 70% of its tensile strength for 2 weeks and 50%
chondrium which provides the vascular supply to the un- for 4 weeks8 . There is minimal tissue reaction even with
derlying cartilage. endoluminal exposure and it is best used with a tapered
needle to decrease the likelihood of tearing cartilage and
perichondrium. Predrilling with an 18G needle or 1 mm
Repair of Fractures drill may be necessary in ossified segments (Figure 3).
Internal fixation of laryngeal fractures with adaptation
Isolated, displaced cartilaginous fractures without sig- plates was first described in 19909 . The main advan-
nificant endolaryngeal disruption on endoscopy may be tages of this technique include surgeon familiarity with
repaired at this time. Several methods of laryngeal frame- the instruments, decreased risk of endolaryngeal exposure,
work fixation have been described including nonabsorbable and shorter operative time.10-12 Plating may also promote
monofilament suture, stainless steel wire, and titanium cartilaginous union.13 Although initially titanium plates
miniplates.6 Simply reducing thyroid cartilage fractures were used, more recently absorbable miniplates have been
without fixation does not ensure preservation of the in- shown to be safe and effective.14 , 15 There is less arti-
ternal structure of the larynx and may result in loss of fact during postoperative imaging and less plate migration.
anterior/posterior diameter. In cases of comminuted fractures where there is loss of
For decades, stainless steel wire was the material of structural support, they may obviate the need for stenting
choice for repair of laryngeal fractures. Using a 1 mm thereby allowing earlier use of the larynx.16
drill or an 18-gauge needle, fragments or sections of car- Plating of laryngeal fractures is technically different
tilage are pierced, and 30-gauge wire passed through the from the mandible or other bony structures since the lar-
needle or directly through the hole made and retrieved with ynx may be partially or completely nonossified (Figure 4).
a clamp. The wire is then passed through a second needle Once the miniplate has been conformed to the larynx, per-
or hole on the other side of the fracture/displaced segment. pendicular to the fracture line, a 20-gauge needle may
Using this technique can be tedious and time-consuming. be used to create a narrow hole to guide screw place-
Additionally, wires may pierce the endolarynx when used ment in the laryngeal cartilage.9 Alternatively, 1.5 mm to
on angled fractures or pull through the cartilage while re- 2 mm thick and 4-6 mm long screws are suggested with-
ducing large gaps. Wires may also deform or break from out pretapping the holes.6 , 7 Tightening is stopped once re-
shearing forces during speaking swallowing or coughing, sistance is met to avoid stripping. In ossified segments,
resulting in a loss of reduction.7 predrilling may be required, although the drill bit used
Suture fixation is technically easier than the use of wires should be smaller than the anticipated screw size. The
and was initially used to stabilize minimally displaced frac- decision to use 2 plates versus a 3-dimensional conforming
tures where perichondrium exists. 4-0 Prolene is a perma- mesh plate is often dictated by the location and extent of

Please cite this article as: David Myssiorek and Ahmed M.S. Soliman, Laryngeal Trauma: External Approaches, Operative Techniques in Otolaryngology
- Head and Neck Surgery, https:// doi.org/ 10.1016/ j.otot.2020.10.009
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Figure 4 Vertical fracture of thyroid cartilage (from Decker

Med). Figure 6 Cricoid fracture with missing anterior segment of car-
tilage.

rowest part of the airway. Plating, wiring or suturing may

all be used, and stenting is usually recommended for 4-6
weeks.17 In cases where there is significant loss of carti-
lage or the cricoid is irreparable, debridement of the ante-
rior cartilage followed by reconstruction with a bone graft
is recommended.

Laryngofissure
In cases with significant endolaryngeal injury requiring
repair, a laryngofissure is indicated. On occasion, the frac-
ture line is in a favorable location and may be used or
extended to allow access to the endolarynx. Otherwise, a
midline laryngofissure is performed by first making a ver-
tical incision through the perichondrium 1cm to either side
of the midline. This will avoid overlap of the cartilaginous
and perichondrial suture lines during closure, thus decreas-
ing the likelihood of wound breakdown and fistula forma-
Figure 5 Plating of larynx with two screws on each side of the
fracture (from Decker Med). tion. The perichondrium is elevated with a Freer elevator
only enough to allow visualization of the midline. The car-
tilage is then divided in the midline with an oscillating saw
the fracture. At least 2 screws on each side of the fracture or a #15 scalpel blade if less ossified. Regardless of the
line(s) is necessary (Figure 5). instrument, care must be taken to not incise the endolaryn-
Cricoid fractures can occur in isolation or with asso- geal mucosa prematurely. With the 2 halves of the thyroid
ciated thyroid cartilage fractures (Figure 6). Because the cartilage retracted laterally using a single skin hook, a #12
cricoid is a solid ring, it usually fractures at 2 sites. If (sickle-shaped) scalpel blade or angled scissors is then in-
nondisplaced, it may not require intervention. However, troduced through the cricothyroid membrane and precise
when displaced, any significant compromise of the lumen division of the subglottic mucosa, anterior commissure and
must be addressed since the cricoid represents the nar- false vocal folds in the midline is accomplished (Figure 7).

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Figure 9 Anterior commissure reconstituted prior to stenting

and plating of fracture (from Decker Med).

ing tube should be placed and secured to the naris at this

time to ensure that it has not inadvertently entered the
Figure 7 Laryngofissure through fracture dividing anterior airway, if not already placed during direct laryngoscopy.
commissure sharply (from Decker Med).
Broyle’s ligament (anterior commissure tendon) should be
sutured to the outer perichondrium of the thyroid cartilage
on each side separately with 4-0 Vicryl or 4-0 PDS suture
(Figure 9).

Stenting
Stenting is considered in cases of significant mucosal
disruption where the patient is at risk for scar formation
and stenosis. The decision is sometimes subjective based
upon clinical judgment at the time of the laryngofissure,
but the surgeon should err on the side of using them as
there is little disadvantage. If placed, they should be re-
moved in about 2 weeks via direct laryngoscopy.
There are a variety of options for stenting including pre-
Figure 8 Laryngofissure performed to allow access to endolar-
ynx for repair of mucosal lacerations. fabricated silastic laryngeal molds which are available in
several sizes, endotracheal tubes which may be shortened,
and silastic “T-tubes” airway stents which may be simi-
A small self-retaining retractor or 2 sutures are then used larly adjusted to size. A “finger cot” soft stent may also
to keep the lateral thyroid cartilages separated (Figure 8). be fashioned from a sterile glove finger which is filled
Necrotic tissue should be conservatively debrided. Mu- with Vaseline gauze or a portion of a surgical sponge and
cosal lacerations are re-approximated using 5-0 or 6-0 tied at the open end with a suture that can also be used
Vicryl suture using multiple interrupted stitches. Avulsion for retrieval. Regardless of the type of stent used, they
injuries to the vocal process can be reapproximated with must be secured by passing a large non absorbable suture
5-0 or 6-0 Vicryl suture, burying the knots. Botulinum (0-Nylon or Prolene) on a long straight needle through the
toxin injection into the thyroarytenoid muscle on the side thyroid cartilage from one side to the next passing through
of the avulsion may be considered to diminish muscular the stent, in between (Figure 10) (figure 11). This must
distraction forces on the repaired arytenoid.18 Dislocated be done under direct visualization before closure of the
arytenoids may be repositioned and secured to the cricoid laryngofissure. The suture is then tied down onto a sterile
with a 4-0 PDS suture although posterior access is often silastic button placed on the external neck skin on each
limited despite adequate laryngofissure. Local mucosal ad- side after skin closure.
vancement flaps may be used to cover areas of exposed Closure of the laryngofissure is accomplished with mul-
cartilage to decrease the likelihood of granuloma forma- tiple 3-0 nonabsorbable monofilament sutures on tapered
tion. Buccal mucosa may also be harvested and used as needles for the cartilage being careful not to tear through it;
a free graft if necessary. In many cases, manual reduc- predrilling with an 18 gauge needle or 1mm drill bit may
tion of the fracture externally will minimize the amount be necessary in ossified cartilage or to facilitate passing the
of exposed cartilage endolaryngeally. A nasogastric feed- suture. The perichondrium is then separately repaired in a

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Figure 10 Nylon suture passed through and through the neck, Figure 12 Laryngofissure closed in two layers first through the
larynx, and stent to secure it in place prior to closure of the cartilage and a second layer through the perichondrium using
laryngofissure. multiple interrupted PDS stitches.

sion. The trachea will need to be reapproximated using a

technique similar to that employed after tracheal resection.
A muscle flap should be placed between the trachea and
esophagus to decrease the likelihood of tracheoesophageal
fistula formation which is a potential devastating compli-
cation of this injury.17

Postoperative Care
The drains are removed once their output is minimal
and there is no evidence of subcutaneous collections. In
the early postoperative period, swallowing function will
be impaired in most patients undergoing transcervical re-
pair of laryngeal fractures. Nasogastric feeding should be
maintained until a modified barium swallow shows a func-
tional safe swallow. This is usually not done before stent
removal.
Most patients undergoing open repair of laryngeal frac-
tures are eventually decannulated. Assuming no stent has
been placed, the tracheotomy is first downsized on postop-
Figure 11 Suspension of laryngeal stent in the endolarynx erative day 5-7 to an uncuffed tube; a 1-way speaking valve
(from Decker Med). may be placed at this time. Capping of the tracheotomy is
initiated a few days later and decannulation is completed
once the patient tolerates capping without symptoms for a
similar fashion (Figure 12). The strap muscles are approx- minimum of 48 hours. This may be done after discharge
imated as are the platysma and skin. The authors of this in the outpatient setting.
article prefer passive drainage with a Penrose or similar
drain placed deep to the strap muscles. The purpose is to
allow egress of free air and fluid without negative pressure Outcomes
which may potentially track air across suture lines.
Following decannulation and stent removal, voice ther-
apy may be initiated. Patient expectations regarding voice
Complete Transection should be tempered as approximately one fifth of patients
sustaining laryngeal trauma will have long-term vocal dys-
Complete transection of the tracheoesophageal unit is function commensurate with the extent of the injury.19 This
beyond the scope of this issue. However, it is worth men- is usually due to vocal fold scarring, web formation, vocal
tioning that a 2-layer closure of the esophagus is necessary fold immobility, and laryngeal stenosis. Most published re-
following placement of a nasogastric tube under direct vi- ports use a very gross perceptual characterizations of voice

Please cite this article as: David Myssiorek and Ahmed M.S. Soliman, Laryngeal Trauma: External Approaches, Operative Techniques in Otolaryngology
- Head and Neck Surgery, https:// doi.org/ 10.1016/ j.otot.2020.10.009
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David Myssiorek and Ahmed M.S. Soliman 7

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Please cite this article as: David Myssiorek and Ahmed M.S. Soliman, Laryngeal Trauma: External Approaches, Operative Techniques in Otolaryngology
- Head and Neck Surgery, https:// doi.org/ 10.1016/ j.otot.2020.10.009