Journal of Pediatric Surgery (2009) 44, 1292–1294

www.elsevier.com/locate/jpedsurg

Pediatric Surgical Image

Blunt posterior tracheal laceration and esophageal injury in

a child
Kaushik Mukherjee a , James M. Isbell a , Edmund Yang MD, PhD b,⁎
a
Monroe Carell Jr, Children's Hospital at Vanderbilt, Nashville, Tenn 37232, USA
b
Department of Pediatric Surgery, Cardinal Glennon Children's Medical Center at Saint Louis University, St. Louis, MO

Received 9 December 2008; revised 15 January 2009; accepted 15 January 2009

Key words: Abstract Blunt force trauma to the neck can result in the unusual injury pattern of laceration of the
Tracheal injury;
posterior tracheal wall in combination with esophageal injury. We present the report of a 10-year-old
Esophageal injury;
child who had blunt cervical trauma because of a bicycle accident and subsequently presented with
Blunt cervical trauma;
profound subcutaneous emphysema. This case was addressed with operative management with a good
Subcutaneous emphysema
result. The essential management principles for this rare constellation of injuries include a high index of
suspicion, early control of the airway, endoscopic and radiographic diagnosis, and use of a buttressing
strap muscle flap in the event of operative management to prevent delayed complications, including leak
and tracheoesophageal fistula.
© 2009 Elsevier Inc. All rights reserved.

1. Case RAE endotracheal tube (Nellcor Inc, Boulder, Colo) and

transferred to our hospital via air ambulance. Although the
The patient is a 10-year-old otherwise healthy female who patient was hemodynamically stable with excellent oxygen
fell while riding her bicycle, striking her neck on the saturations upon examination in the emergency department,
handlebars. She was stable from a respiratory and hemody- there was a rapid worsening of subcutaneous emphysema
namic standpoint after the accident and was able to ambulate indicating a continuing air leak.
and speak at an outside facility. Significant crepitus was The patient was taken emergently to the operating room.
noted on physical examination. Plain chest radiography Flexible fiber-optic bronchoscopy revealed an extensive
revealed pneumomediastinum and subcutaneous emphy- longitudinal tear in the posterior tracheal wall after the
sema. Computed tomography of the neck revealed findings endotracheal tube cuff was deflated; at this time, the existing
concerning for a posterior tracheal laceration (Figs. 1 and 2). endotracheal tube was advanced past the tear, and the cuff
The patient was intubated at the outside facility with an Oral was reinflated. The neck was explored through a collar
incision, and after circumferential mobilization of the
trachea, a 4-cm longitudinal injury in the membranous
portion of the trachea was identified. The right, but not the
⁎ Corresponding author. Associate Professor of Surgery, Cardinal
left, recurrent laryngeal nerve was identified. At this time, the
Glennon Children’s Medical Center at Saint Louis University, 1465 South
Grand Boulevard, St. Louis, MO 63104. Tel.: +1 314 577-5629; fax: +1 314 existing Oral RAE endotracheal tube was replaced with a
268-6454. standard 5.5 oral endotracheal tube that was advanced past
E-mail address: [email protected] (E. Yang). the injury. The tracheal injury was repaired with interrupted

0022-3468/$ – see front matter © 2009 Elsevier Inc. All rights reserved.
doi:10.1016/j.jpedsurg.2009.01.012
Blunt posterior tracheal laceration and esophageal injury 1293

previously, can make it extremely difficult to gain access to

the airway [2].
The presentation of these injuries ranges widely from
nearly asymptomatic lesions that can be safely managed with
observation to complete tracheal transection presenting with
cyanosis, hypoxemia, acidosis, and profound respiratory
distress [2]. This particular case fits the pattern of a classic
“handlebar injury” [3] with direct force applied to the anterior
trachea that results in deformation of the cartilaginous rings
and laceration of the posterior wall of the trachea.
Previous authors have strongly recommended tracheost-
omy to gain access to the airway in blunt tracheal injury [1].
Immediate tracheostomy is certainly appropriate for manage-
ment of tracheal transaction and near transection because it
may be impossible to intubate these children via the oral
Fig. 1 Axial computed tomographic image of the neck. A large route even in experienced hands using advanced techniques.
amount of subcutaneous emphysema is noted, as well as a posterior However, orotracheal intubation with surgical availability in
midline tracheal laceration. the event that tracheostomy is required is likely appropriate
for lesions of lesser severity [4].
3-0 PDS sutures. Upon mobilization of the esophagus an area From an imaging standpoint, plain radiography of the
of mucosa was identified bulging through a 3-cm linear tear chest is mandatory. In the modern setting, it possible to
of the external muscular layer. The muscular layer was obtain high-resolution computed tomographic images that
reapproximated with interrupted 3-0 PDS sutures. An 8F can assist in the precise localization of the injury [4]. It is
pediatric feeding tube was advanced past the repair. A right worth noting, however, that it is essential to rule out
sternothyroid muscle flap was mobilized from the sternum concomitant esophageal injury with a water-soluble contrast
and rotated superiorly between the trachea and esophagus. It study [5]; if operative exploration is performed for a tracheal
was sewn to the outer muscular layer of the esophagus near injury, it is also beneficial to mobilize the esophagus. This
the site of the repair. A Penrose drain was placed in the was an essential maneuver in this case because the tracheal
operative site, and the incision was closed. injury, but not the esophageal injury, was diagnosed before
The patient did well postoperatively, was extubated operative intervention via computed tomography.
successfully on the first postoperative day, and nasogastric Depending on the severity of symptoms and level of
tube feeds were begun. An esophagram performed on hemodynamic and respiratory stability of the patient,
postoperative day 2 with water-soluble contrast indicated treatment strategies ranging from observation with serial
no leak, and a videofluoroscopic swallowing study indicated flexible fiber-optic bronchoscopy to operative exploration
tolerance of soft solids but not liquids. The patient was and attempted repair are appropriate [5]. Usually, injuries
started on a soft diet and was able to be discharged to home measuring less than one third of the tracheal circumference
without her drain or any need for tube feedings on or longitudinal injuries with good coaptation of the 2 edges
postoperative day 4. The videofluoroscopic swallowing
study was repeated on postoperative day 8 and was normal;
the patient was advanced to a regular diet including thin
liquids, and her phonation was normal.

2. Comment

Estimates of the incidence of blunt tracheal injury in

combination with blunt esophageal injury are not available in
the literature. It is suggested in one study that blunt tracheal
injury has an incidence between 0.34% and 1.5% of all
trauma patients [1]. It is believed that children may be
relatively well protected from the phenomenon of blunt
cervical injury because of their relatively short neck and
proportionally large head and thorax; however, once this
injury occurs, the small size of the larynx in relationship to Fig. 2 Sagittal computed tomographic image of the neck. A
the epiglottis and arytenoids, as well as the factors mentioned posterior tracheal disruption is visualized.
1294 K. Mukherjee et al.

can be managed conservatively [6]. If the lesion will not be preferred to avoid obfuscation of later images by residual
directly repaired, control of the airway via endotracheal tube barium. Surgical repair is accomplished via cervical incision
or tracheostomy is necessary [5]. In the described case, there or right posterolateral thoracotomy, with or without the use
was an extensive longitudinal tear in the membranous of a buttressing muscle flap.
portion of the trachea, and there was a significant persistent The combination of posterior tracheal wall laceration and
air leak despite endotracheal intubation. These findings esophageal injury secondary to blunt cervical trauma
mandated immediate exploration and repair. presents multiple challenges in management. The essential
Blunt esophageal injury in combination with blunt principles include a high index of suspicion for the injury
laceration of the posterior tracheal wall is exceedingly rare pattern, followed by rapid securing of the airway via
[7]. As mentioned previously, it is necessary to have a high endotracheal tube or tracheostomy. Endoscopic and radio-
index of suspicion for these injuries and to rule them out with graphic methods are used to verify the precise location of the
imaging or operative exploration, as they can be missed by lesions, and they are addressed via conservative management
standard imaging techniques. Furthermore, a missed cervical or aggressive surgery as appropriate. The illustrated case
esophageal injury can cause severe morbidity, including indicates that early diagnosis and aggressive treatment can
tracheal and esophageal stenosis and tracheoesophageal result in excellent outcome.
fistula [7]. Of course, a missed thoracic esophageal injury
can be catastrophic because of the high mortality of
mediastinitis [8]. Although it is possible to manage
esophageal perforation, particularly in the neck, with
References
aggressive antibiotic therapy and drain placement rather
[1] Reece GP, Shatney CH. Blunt injuries of the cervical trachea: review of
than primary repair, this approach is not sufficient for severe
51 patients. South Med J 1988;81:1542-8.
esophageal injuries such as transection [7]. The surgical [2] Duval EL, Geraerts SK, Brackel HJ. Management of blunt tracheal
options for concomitant blunt tracheal and esophageal injury trauma in children: a case series and review of the literature. Eur J
include primary repair, palliation with tracheostomy and/or Pediatr 2007;166:559-63.
gastrostomy, staged reconstructive procedures, and 1-stage [3] Mezhir JJ, Glynn L, Liu DC, et al. Handlebar injuries in children: should
we raise the bar of suspicion? Am Surg 2007;73:807-10.
reconstruction. In this case, the latter was feasible because of
[4] Marathe US, Tran LP. Pediatric neck trauma causing massive
early diagnosis and the absence of significant contamination. subcutaneous emphysema. J Trauma 2006;61:440-3.
In all cases of operative management of esophageal [5] Claes I, Van Schil P, Corthouts B, et al. Posterior tracheal wall laceration
perforation, the placement of drains is strongly recom- after blunt neck trauma in children: a case report and review of the
mended if not mandatory. Furthermore, the use of a flap literature. Resuscitation 2004;63:97-102.
[6] Becmeur F, Donato L, Horta-Geraud P, et. al. Rupture of the airways
mobilized from the ipsilateral strap muscles can serve as a
after blunt chest trauma in two children. Eur J Pediatr Surg 10(2):133-
well-vascularized barrier between the tracheal and esopha- 135.
geal suture lines, minimizing the risk of delayed tracheoe- [7] Sokolov VV, Bagirov MM. Reconstructive surgery for combined
sophageal fistula [7]. Fistula formation after blunt trauma, tracheo-esophageal injuries and their sequelae. Eur J Cardiothorac Surg
although also exceedingly rare, can present with dysphagia, 2001;20:1025-9.
[8] Martinez L, Rivas S, Hernandez F, et al. Aggressive conservative
pleural effusion, or pneumonia. The “swallow-cough com-
treatment of esophageal perforations in children. J Pediatr Surg 2003;
plex,” also known as Ono's sign, is pathognomonic for 38:685-9.
traumatic tracheoesophageal fistula [9]. Barium esophagram [9] John V, Mathai J, Chacko J, et al. Tracheoesophageal fistula in a child
is diagnostic, although water-soluble contrast media are after blunt chest trauma. J Pediatr Surg 2006;41:E27-9.