Airway Trauma

Ruben Peralta, MD William E. Hurford, MD

Descriptions of penetrating neck injuries were first reported in the Edwin Smith papyrus approximately 5000 years ago.1 According to de Fourmestranx, successful management of a penetrating vascular injury in the neck was first documented in 1952. Ambroise Pare reportedly saved a man who had been injured in a duel and presented with a lacerated common carotid artery and internal jugular vein. The patient survived but had aphasia and a hemiplegia.2,3 In 1803, Fleming was successful in ligating the common carotid artery in a sailor who had attempted suicide by cutting his neck.2,4 In 1811, Abernathy, treating a patient who had been gored by a bull, ligated the lacerated left common and internal carotid arteries. The patient subsequently developed acute hemiplegia and did not survive.2,4 Hugh Munro of Scotland documented the treatment of penetrating wounds of the trachea as early as 1792. He believed that longitudinal tracheal lacerations could be held together by straps. He reported that the most common tracheal injuries were transverse between two cartilages and that these wounds could be sutured over a stent, with the patients neck remaining in a flexed position while the wound was allowed to heal.5 In 1873, Seuvre6 reported the first case of traumatic bronchial rupture in a patient with a right main bronchus avulsion. Sanger7 performed the first suture repair of a bronchial laceration in 1945. The first successful primary repair of a bronchial rupture caused by blunt trauma was reported in 1947 by Kinsella and Johnsrud.8 With the development of improved diagnostic facilities, reduced time from injury to definitive therapy, and advanced therapeutic modalities, the mortality rate of patients with neck and airway injuries has steadily declined. The current mortality rate due to penetrating neck injuries is approximately 2% to 6%, whereas mortality rates were reported to be around 15% in the Vietnam war.914 Mortality rates from blunt and penetrating airway injuries remain much higher.
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Incidence
Blunt injury to the lower airway is uncommon. This is primarily due to anatomical protection by the mandible and sternum anteriorly, the spinal column posteriorly, and the mobility and the elasticity of the upper airway itself. The larynx or cervical trachea is injured in <1% of patients admitted to the hospital for blunt trauma.15 Angood and colleagues16 reported that only 16 patients with laryngeal injury and 4 patients with cervical tracheal injury were treated at the Montreal General Hospital over a 10-year period. Of 46 patients with blunt upper airway injuries reported by Cicala and associates,17 11 (24%) died, and 4 (36%) of these deaths were primarily due to airway injury. Kelly and coworkers18 reported that 21% of patients with blunt airway injuries died in the first 2 hours after admission to a hospital. The incidence of such injuries has increased over the past 3 decades.19,20 Penetrating airway injuries in the neck are also relatively uncommon. Capan and colleagues21 reviewed 17 reports published between 1965 1989 describing acute cervical airway injuries. Approximately 300 patients were identified, accounting for an average of <3 cases per year per reporting center. Penetrating injuries of the neck involved the larynx in up to 5%15% of patients, with the patients who had carotid artery or digestive tract injuries being at least twice as likely to have airway injuries.22,23 About one-third of airway injuries involved the larynx and two-thirds involved the cervical trachea.17 The sites of nonpenetrating upper airway injuries vary among patients. Cicala and associates17 reviewing a series of blunt injuries to the upper airway, reported seven (35%) larynx injuries above the cricoid, three (15%) involving the cricoid cartilage, nine (45%) involving the cervical trachea, and one (5%) involving other sites. Trone and colleagues24 reported the thyroid cartilage to be the most commonly fractured site in blunt and penetrating laryngeal injuries (47%), followed by arytenoid cartilage (24%) and cricoid cartilage (22%). The prevailing site of tracheal transection is the junction of the cricoid with the trachea because the connective tissues in this area are relatively weak.

Mechanism of Injury
The pattern of injuries is closely related to the mechanism of injury. The majority of laryngotracheal injuries are caused by blunt trauma. Other etiologies include inhalation of noxious or hot gas fumes; aspiration of foreign bodies; iatrogenic injuries such as those occurring during diagnostic procedures, endotracheal intubation, percutaneous tracheostomy or tracheostomy; and penetrating trauma.

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Inhalation Injury

The inhalation of extremely hot steam, gas, or other noxious fumes will tend to primarily injure the larynx and cervical trachea, and, seldomly, will damage the lower airway. The resulting necrosis and scar formation narrows and deforms the affected area. Early intubation or tracheostomy is essential in most cases, due to the rapid development of laryngeal edema. Intubation and tracheostomy can produce additional injury to the previously damaged trachea.
Intubation Injury

Injuries resulting from endotracheal intubation have been the most common indication for tracheal resection and reconstruction (Fig. 1). In a study at Massachusetts General Hospital by Grillo,25 208 patients received operations to repair injuries resulting from tracheal intubation; 185 had tracheostomy injuries and 23 had injuries from endotracheal

Figure 1. (A) Axial computed tomography (CT) scan at the level of the thoracic inlet of a patient with a laryngotracheal laceration following attempted cricothyrotomy shows that extensive subcutaneous emphysema is present. An endotracheal tube is present within the tracheal lumen. (B) CT scan at the midtracheal level of the same patient shows that subcutaneous and mediastinal emphysema is present. Bilateral dependent consolidations of the lungs and acute respiratory failure occurred secondary to aspiration of gastric contents.

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intubation, with 22 of the 23 being cuff injuries. Cuff injuries also accounted for approximately half of the injuries in the patients who had tracheostomies. The percentage of laryngeal injuries due to intubation is unclear, but a prospective study by Kambic and Radsel26 reported it to be approximately 0.1%. The most frequent intubation injury is chronic cicatrix with stenosis (Fig. 2). Other injuries in the study by Grillo25 included nine patients with

Figure 2. An anteroposterior tomogram of the larynx and trachea demonstrates narrowing of the subglottic trachea (at arrow) consistent with a cicatrization and stenosis following endotracheal intubation.

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tracheoesophageal fistula, eight with tracheal erosion by the tracheostomy tube, and one with a trachea-innominate artery fistula. Bronchial rupture following endotracheal intubation has been reported by Patel and associates.27 High pressures within endotracheal tube cuffs, which were common prior to the introduction of low-pressure, high-volume cuffs, are thought to be the etiology of most injuries following endotracheal intubation (see chapter by Dunn and Goulet). In a study by Thomas,28 consisting of 46 patients treated between 1961 to 1972, it was observed that 22% of surviving patients who had cuffed tracheal tubes subsequently developed tracheal stenosis. Since the development of high-volume, low-pressure cuffs, the incidence of tracheal stenosis from this type of injury appears to have decreased, but injuries continue to occur and continue to be the most common indication for tracheal resection and reconstruction.29 Injuries may occur even after a brief period of intubation.30 Endotracheal cuff injuries may be more common in children31 and when the trachea has been injured by inhalation injury.32
Blunt Injuries

Most blunt injuries to the upper airway and chest are the result of direct blows, severe flexion/extension injuries, or crushing injuries to the chest.33 Frequently, the blunt injury is the result of a motor vehicle crash (MVC) in which the victim is pinned between the car seat and the steering wheel or is ejected from the vehicle and pinned beneath the wreckage (Fig. 3).34 In a study by Sklar and coworkers35 involving 35 cases, 40% were the result of a MVC (of which 64% were ejected from and crushed by the vehicle when it rolled over them), 26% were due to the slippage of cars from jacks, and 20% were secondary to industrial accidents. Direct blows are most likely to injure the cartilages of the larynx,36 while flexion/extension injuries are most commonly associated with tra-

Figure 3. Photograph shows a chest contusion and discoloration in an unrestrained driver following a motor vehicle crash. The injury resulted in bronchial disruption at the level of the carina.

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cheal tears or laryngotracheal separation.37 When the trachea is damaged from a crushing injury, it may be the result of the trachea becoming compressed between the manubrium and the vertebral column. Blunt injuries to the chest may produce vertical tears in the membranous portion of the trachea or bronchi, usually within 2.5 cm of the carina (Figs. 4, 5).17,38,39
Penetrating Injuries

Although penetrating injuries can involve any portion of the airway, the trachea is the structure most commonly injured by stab wounds. The larynx is injured in approximately one-third of upper airway injuries, with the cervical trachea accounting for the remaining two-thirds.17 Death in patients with penetrating airway trauma is usually due to an associated vascular injury and is rarely due to the airway injury itself.18

Figure 4. (A) Chest radiograph demonstrates a tracheal laceration sustained following a dirt bike injury with extensive pneumomediastinum and subcutaneous emphysema within the neck. (B) Axial computed tomography scan through the superior mediastinum reveals extensive mediastinal emphysema and subcutaneous emphysema. There is a laceration of the membranous wall of the trachea.

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Figure 5. Chest radiograph reveals a complete avulsion of the right mainstem bronchus, resulting in pneumothorax and complete collapse of the right lung.

Associated Upper Airway Pathology

Edema fluid can rapidly accumulate in the supraglottic and the subglottic submucosa. The resulting subglottic endolaryngeal swelling tends to be circumferential, increasing the possibility of airway obstruction. Vertical spread of accumulated edema is limited by the conus elasticus.40 Air dissecting within the submucosal space can further reduce the luminal diameter of the larynx and trachea. Air within the soft tissues (subcutaneous emphysema) may produce epiglottic emphysema and narrowing of the supraglottic airway.39,41 Most submucosal edema and hematoma formation occurs within several hours after trauma.42 Consequently, it is unlikely that endolaryngeal swelling will produce airway obstruction more than 6 hours after the trauma. Straining, coughing, and speaking, however, can increase the amount of subcutaneous air and can produce intramural bleeding, which can worsen airway obstruction. Multiple factors, including the magnitude and direction of force, the position of the cervical spine at impact, the age of the patient, and the consistency of the laryngotracheal cartilages and soft tissue, determine the type of airway injury (such as laryngotracheal contusion, edema, hematoma, laceration avulsion, and/or fracture and dislocation of the thyroid, cricoid, or tracheal cartilages) that may occur.21 Older patients with calcified cartilages presumably are more likely to be vulnerable to a laryngeal fracture, although it may occur at any age. This theory regarding vulnerability due to age has never been formally proved, however, probably because patients that sustain this type of injury tend to be younger

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adults.43 A combination of soft tissue, supraglottic, glottic, and infraglottic injuries in a single patient is common.
Associated Injuries

Injuries sufficient to result in severe laryngotracheal damage can also easily damage the cervical spine, esophagus, and vascular structures. At least 10%24 and as many as 50%16 of patients with blunt airway trauma have concurrent cervical spine injuries. A cervical spine injury should be considered present in such injuries until proven otherwise.44 When performing endotracheal intubation, bronchoscopy, or esophagoscopy or when undertaking measures to ease pressure on a tracheal anastomosis, flexion or extension of the neck must be avoided until cervical spine injuries are excluded. An existing cervical spine injury or neurological symptoms will determine the timing and surgical management of associated airway injuries. Patients with blunt laryngotracheal trauma also commonly present with closed head injury. Airway obstruction from the injury can be mistakenly thought to be a result of upper airway obstruction resulting from coma. Maxillofacial injuries are also common and, again, airway obstruction may be blamed on the facial injuries. An emergency cricothyroidotomy performed under such conditions may convert a partial airway obstruction to a complete airway obstruction. Patients with penetrating trauma are likely to have concurrent vascular, esophageal, and thoracic injuries. Esophageal injury occurs in 25% of patients with penetrating airway injuries but may be missed until late in the patients hospital course.18 Traumatic asphyxia is a syndrome that results from a crush injury, usually of short duration, to the chest. The condition is rare, with only 10 cases identified in a 12.5-year period at the Shock Trauma Center of the University of Maryland.35,45 Associated injuries are expected and include injuries to the chest wall, lung, and liver. Management is focused on protection of the airway, ventilatory and vascular support, and treatment of the associated injuries. The majority of patients with isolated traumatic asphyxia survive; morbidity and mortality are related primarily to associated injuries and cerebral anoxia.

Diagnosis
Physical Findings

Airway injuries produce a spectrum of signs and symptomatology. Presentation varies according to the mechanism of injury from no visible sign of trauma, to visible sign of tissue destruction such as contusion and

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subcutaneous emphysema, to extensive lacerations that expose vascular and airway structures. In 1965, Harris and Ainsworth46 reported using an evaluation system to classify the location, type, and severity of laryngotracheal injuries. This system was subsequently refined by Potter and coworkers.47 While a high index of clinical suspicion and a thorough history and physical examination are imperative, reports suggest that at least 25% of patients with laryngotracheal trauma requiring surgery have no physical evidence of such injury and may not display symptoms until 24 to 48 hours after trauma.48,49 In the series of upper airway injuries reported by Cicala and associates,17 10 of 46 (22%) patients were not diagnosed from presenting signs and symptoms. Of these 10 patients, 5 were diagnosed by computed tomography (CT), 1 by laryngoscopy, 1 by bronchoscopy, 1 during the induction of the anesthesia, and 1 at autopsy. Patients may present with only subtle signs of airway injury. In diagnosing laryngotracheal injury, one should take into consideration the type of accident and be alert for signs or a combination of signs of local contusion, subcutaneous emphysema, changes in the voice such as hoarseness or inspiratory stridor, respiratory distress, and hemoptysis. Subcutaneous or mediastinal emphysema are sometimes the only factors present in an injury to the distal trachea, and the airway otherwise appears surprisingly normal. It is imperative that the surgeon, if time and circumstances allow, carefully and fully evaluates, each patient for signs of these injuries. Injuries to the distal trachea and carina may present with additional findings, including subcutaneous emphysema and pneumothorax with a minimal to a large air leak in which the lung fails to reexpand completely after placement of a chest tube. Laryngoscopy, flexible and rigid bronchoscopy, and esophagoscopy can be performed to definitely delineate the anatomy of the airway and associated injuries. Failure to recognize injuries acutely may lead to progressive airway obstruction as cicatrization occurs and stenosis develops. Delayed diagnosis of laryngotracheal injuries is not unusual, especially when emergency intubation is performed. In one series, delayed diagnosis was reported in 37% (7 of 19) of patients who remained undiagnosed until they presented with airway stenosis 8 days to 3 years after the initial trauma.50 The outcome due to delayed diagnosis of associated injuries (i.e., esophageal perforation) can be devastating due to the development of lifethreatening complications such as mediastinitis.
Radiological Assessment

A radiograph of the neck can reveal tracheal injuries.51 Angood and colleagues16 reported that radiography alone was sufficient for diagnosing 12 (60%) out of 20 patients with cervical airway trauma. The use of ra-

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diographs of the esophagus or cervical spine and additional use of tomograms of the trachea and larynx can be very useful in discovering subtle, previously undetected injuries. While radiological studies can be very helpful, definitive airway management should not be delayed excessively by their use, since an apparently stable airway can rapidly progress to an acute airway obstruction. Additional radiological examinations that may be indicated in selected patients include contrast-enhanced esophageal studies, computed tomography, and magnetic resonance imaging. Highresolution helical CT scanning can permit three-dimensional reconstruction of the airway (Fig. 6). Patients who are unable to lie supine because of airway symptoms or dyspnea, however, may not be able to tolerate

Figure 6. Helical computed tomography (CT) scans with reconstructed images can accurately define airway pathology. These images demonstrate a soft tissue mass consistent with a mucoepidermoid carcinoma of the trachea. The anatomy of lesions associated with airway trauma can be similarly defined. (A) Helical CT scan reconstructed in through the trachea demonstrates a rounded soft tissue mass in the distal trachea 3 cm above the carina and arising from the right lateral wall of the trachea. (B) Sagittal reconstruction demonstrates the soft tissue mass arising from the anterior wall of the distal trachea. (C) Virtual bronchoscopic image reconstructed from a helical CT demonstrates the soft tissue mass arising from the right anterolateral wall of the trachea.

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prolonged radiological examinations. Use of intravenous sedatives during imaging in these patients may lead to disastrous airway compromise and is not advised.

Airway Management
Many patients with upper airway injuries may be successfully managed using traditional techniques to establish an airway.17,52 In a retrospective review of upper airway injuries reported by Cicala and associates,17 threefourths (35/46) of the patients had no apparent airway management problems and were either observed without requiring endotracheal intubation (4 patients), intubated through an obvious airway defect (6 patients), or endotracheally intubated using traditional techniques (25 patients). The remaining patients required emergent tracheostomy, most commonly following blunt trauma. Airway management in patients with neck trauma is based upon a high index of clinical suspicion for cricoid or cervical tracheal injuries. Attempts at endotracheal intubation in patients with unsuspected cricoid injuries can be disastrous.17 Cricoid pressure or the attempted passage of an endotracheal tube may dislocate a fractured cricoid cartilage and/or entirely disrupt a partial tracheal transection, producing complete airway obstruction (Fig. 7). The equipment and personnel required to perform an immediate

Figure 7. Intraoperative view of a tracheal transection shows the proximal and distal ends of the trachea, which remain attached only by the posterior membranous wall and the soft tissues surrounding the trachea. An endotracheal tube is present within the lumen of the trachea.

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tracheostomy must be present prior to manipulation of an injured airway. Positive pressure ventilation can exacerbate air leaks and rapidly worsen symptoms from pneumothorax, pneumomediastinum, and air dissecting around airway structures. Whenever possible, the patient should be permitted to breathe spontaneously. Rapid induction of anesthesia and neuromuscular blockade can rapidly produce loss of the airway and the inability to provide positive pressure ventilation. Attempts at direct laryngoscopy or intubation over a flexible bronchoscope may be futile because of bleeding within the airway or distortion of anatomical structures. The danger also exists that flexible bronchoscopy may occlude the airway or precipitate airway obstruction in patients with critical airway stenosis.37 Under ideal circumstances, preoxygenation followed by awake flexible bronchoscopy may permit evaluation of airway injuries and safe endotracheal intubation. Prior induction of general anesthesia, using a potent inhalation anesthetic such as sevoflurane, while maintaining spontaneous ventilation, may be appropriate in some patients. This approach can permit rigid laryngoscopy and rigid bronchoscopy while maintaining spontaneous ventilation. These techniques may be preferable when bleeding or debris obscure the airway, making fiberoptic examination impossible. If endotracheal intubation appears unwise and the patient is unstable or the airway is lost, immediate tracheostomy is the only appropriate choice. When the trachea itself is injured, it is preferable to conserve normal trachea by placing the tracheostomy through the damaged area. This will facilitate subsequent surgical repair of the trachea.37

Anesthetic Considerations
Anesthesia and airway management for tracheal surgery has been discussed in detail in a recent issue of International Anesthesiology Clinics.53 Induction of general anesthesia using a potent volatile agent and spontaneous ventilation is generally considered to be the safest technique to induce anesthesia in patients with possible airway injuries.54,55 The use of intravenous agents such as propofol, however, may be necessary if the patient is confused or uncooperative. Once anesthetized, the airway may be secured by passing a rigid bronchoscope or an endotracheal tube into the distal airway and past the point of injury. An endobronchial intubation sometimes is necessary to accomplish this. Once an endotracheal tube has been placed across or distal to the site of injury, controlled positive pressure ventilation can begin (Fig. 8). The use of neuromuscular-blocking agents should generally be avoided until the airway is secured. Positive pressure ventilation by mask may become impossible under such conditions, and may worsen subcutaneous emphysema. Immediate tracheostomy is then the only option. Cricothyrotomy may be useless if the cricoid cartilage or distal trachea is injured. The use of cardiopulmonary bypass to

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Figure 8. Intraoperative view illustrates a complete tracheal transection secondary to a wire clothesline injury of the neck. The airway is secured by temporary intubation distal to the site of injury.

provide emergency support after complete tracheal disruption has been described.56

Outcome
Morbidity

Patients who have suffered severe laryngotracheal injuries usually suffer some permanent airway or voice impairment and may have increased difficulties protecting the airway from aspiration of pharyngeal contents. These complications generally are due to scar contracture or excess granulation tissue formation.37,57,58 Patients sustaining blunt neck trauma tend to have more late complications, such as difficulties with phonation or scarring, than those with penetrating trauma.55,59 Schaefer60 reported that more severe laryngeal injuries are correlated with an increased likelihood and severity of long-term sequelae. Late complications are more common when definitive treatment does not occur for more than 24 hours after injury.37,44,57,58,61,62 Additional studies58,63,64 have reported that the quality of the voice and airway is highly, if not directly, related to

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expedient repair of the injury. Reece and Shatney63 reported that delays in repair increased the possibility of late airway stenosis, and Dedo and Rowe65 concluded that a delay in diagnosis of 24 to 48 hours resulted in the development of strictures for all affected patients.
Mortality

Mortality rates of patients with airway injuries are reported to be between 15% to 30%18,19 and are usually the result of irreversible shock, massive aspiration of blood, related cervicothoracic vascular injuries, and injured organs. Emergency management with failed intubation attempts also may produce airway obstruction and even death.66 Cicala and associates17 reported mortality rates of 24% (11 of 46) for upper airway injuries. Causes of death were exsanguination in 5 (45%) patients, airway problems in 4 (36%), brain injury in 1 patient (9%), and sepsis in 1 patient (9%). The mortality rate for gunshot wounds producing airway injury was 35%, for blunt trauma was 25%, and for stab wounds to the upper airway was 22%.17

Summary
Traumatic airway injuries fortunately are rare. While sometimes injuries are obvious and initial management straightforward, frequently the diagnosis is difficult. Prompt diagnosis of airway injuries requires a high index of clinical suspicion, complemented by judicious use of endoscopy and radiological imaging. Initial management can be complicated by associated head, neck, and thoracic injuries. Importantly, a patients airway can be lost because of injudicious use of sedation or failure to be properly cautious during attempts at airway management and endotracheal intubation. Mortality rates and the incidence of late complications remain high and have been related to delays in diagnosis and definitive treatment.

References
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