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Blunt Trauma to the Larynx and Trachea: Considerations for the Professional Voice User

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Blunt Trauma to the Larynx and Trachea: Considerations for the Professional Voice User Care of the Professional Voice ASSOCIATE EDITOR: Robert T. Sataloff, MD, DMA Blunt Trauma to the Larynx and Trachea: Considerations for the Professional Voice User Yolanda D. Heman-Ackah, MD and Robert T. Sataloff, MD, DMA cation rates as high as fifteen to nized and treated promptly. Singing INTRODUCTION twenty-five percent.2-4 Because of the teachers are often the first profes- Blunt injury to the larynx (the voice potential for untreated laryngeal and sionals in a position to recognize the box) and trachea (the windpipe) is tracheal injuries to cause permanent potential importance of such an appar- the most common cause of laryngo- voice, swallowing, and breathing dis- ently "minor" event. tracheal injury in the United States abilities, early evaluation and treat- today, accounting for sixty percent of ment by an otolaryngologist or LARYNGOTRACHEAL ANATOMY all injuries to the laryngotracheal laryngologist (an otolaryngologist complex.1,2 These injuries result who specializes in the treatment of The larynx is relatively protected from motor vehicle collisions, laryngeal and voice disorders) is from trauma by the overhang of the accidents involving all-terrain imperative. It is essential for singing mandible (the jaw) above, the bony vehicles, bicycle accidents, stage teachers to be familiar with these prominence of the clavicles (the col- injuries, contact sports, strangulation, problems and their proper larbone) and sternal manubrium (the and hanging-type injuries. The management. Symptoms and signs breast bone) below, and by the mass complications associated with such of voice-threatening, and even life- of the neck muscles on the sides. The injuries range from airway threatening, injuries maybe subtle framework (structure) of the larynx obstruction and difficulty breathing and dismissed even by some consists primarily of four cartilages, to voice compromise and permanent physicians as insignificant. Even an the thyroid, the cricoid, and the paired hoarseness, with compli- injury caused by something as arytenoid cartilages. The thyroid innocent as an arm or elbow striking cartilage is shaped like a shield and Journal of Singing, September/October 2002 the neck of a fellow actor, dancer, or forms the protective casing for the Volume 59, No. 1, pp. 41-47 singer during a theatrical perform- vocal folds. The prominence of the Copyright 2002 National Association of Teachers of Singing ance can be disastrous unless recog- thyroid SEPTEMBER/OCTOBER 2002 41 Yolanda D. Heman-Ackah, MD and. Robert T. Sataloff, MD, DMA cartilage in the necks of men is often in a vehicle without protective air also become displaced from their joint referred to as the "Adam's apple." The bags. Upon collision, the front seat space, resulting in cricoarytenoid dis- arytenoid cartilages sit on top of the passenger or driver is propelled for- location. If one segment of the thy- cricoid cartilage in the back of the ward with the neck in extension, elim- roid cartilage fails to return to its larynx and serve as points of inating the jaw as a protective shield. normal position, an overlapping attachment for the vocal folds. In the As the front of the neck hits the dash- fracture may occur, resulting in front of the larynx, the vocal folds board or steering wheel, the cartilages malposition of the vocal fold. All of attach to the inner aspect of the of the larynx are crushed against the these injuries will result in thyroid cartilage, and thus span the spine of the neck.'," Lower impact, hoarseness that may not resolve distance between the arytenoid and direct blows to the larynx can occur unless the injured tissues and thyroid cartilages. The cricoid during athletic competition (such as cartilages are repaired; and even cartilage sits below the vocal folds playing basketball, hockey, or foot- then, some permanent voice deficit and is shaped like a signet ring. The ball); during dances, stage fights or is common. ring-like structure of the cricoid other performance activities; while After the thyroid cartilage frac- serves as a stent to help hold open falling forward onto a blunt object tures, the force then impacts the the airway below the vocal folds. The such as the handle bars of a bicycle; cricoid ring, which was previously trachea connects to the bottom with strangulation; or with hanging shielded by the thyroid cartilage. In portion of the cricoid cartilage and of the neck from a suspended rope or a patient with a marked laryngeal serves as the conduit for air to pass wire. Such forces also compress the prominence, multiple fractures of the through the larynx to the lungs. The larynx and trachea against the spine, thyroid cartilage may occur prior to muscles of the vocal folds and the resulting in injury. the distribution of force onto the other muscles of voice production The thyroid and cricoid cartilages cricoid cartilage.' The cricoid has a attach to the thyroid, cricoid, and interact dynamically to protect the relatively thin front arch that blends arytenoid cartilages. If a normal airway from blunt injury' Forces to on the sides into a thicker, more sturdy voice is to be produced, each of the front part of the larynx often are cartilage. The thicker regions on the these cartilages and muscles must encountered first by the thyroid car- sides of the cricoid cartilage provide function properly and lie in its tilage, which bends against the cer- most of the support for this portion correct anatomical location. vical (neck) spine on impact. The of the airway. Lower level impacts, Displaced fractures of the cartilages, thyroid cartilage eventually reaches such as elbow injuries to the neck, tears in the vocal fold and/or a point of maximal flexibility, and a may result in cricothyroid joint laryngeal muscles, or dislocations of fracture occurs often at or near the injuries or in midline fractures of the the arytenoids from their normal midline of the cartilage. cricoid. The airway is maintained by positions on the cricoid cartilage Vocal fold injuries result from ver- the thicker cartilage on the sides of (cricoarytenoid dislocation) often tical fractures of the thyroid cartilage. the cricoid cartilage. With higher result in hoarse or breathy voices and, As the thyroid cartilage snaps back impact forces, secondary fractures occasionally, airway obstruction and from its compression against the cer- can occur on the sides of the cricoid breathing difficulties. Dislocation of a vical spine, the thyroarytenoid mus- cartilage, resulting in airway collapse cricothyroid joint (the joint that cle and ligament (which together and possible injury to the recurrent connects the cricoid and thyroid car- comprise the vocal fold) may tear, laryngeal nerve (the nerve that sup- tilage) may result in loss of the ability resulting in a separation at any point plies motor function to the vocal folds) to change pitch.' along its length. This may be evident due to impingement of the nerve by as lacerations or hemorrhage (bleed- segments of fractured cartilage. ADULT LARYNGOTRACHEAL ing) of one or both vocal folds. The If the force is severe and/or low in INJURIES FROM BLUNT TRAUMA mucosa (the lining tissue) on the ary- the neck, complete separation of the tenoids may be denuded or avulsed. larynx and trachea may occur.' This Laryngotracheal injuries are rela- Because of the traction on the ary- situation is potentially life-threaten- tively rare in adults, except when there tenoids from the spring-like motion ing and requires emergent medical is a direct blow to the neck. In motor of the thyroid cartilage as it snaps back care. Separation usually occurs below vehicle collisions, the typical victim from the spine, the arytenoids may the cricoid cartilage, resulting in dis- of laryngotracheal trauma is an un- placement of the trachea into the chest belted, front seat passenger or driver 42 JOURNAL OF SINGING Care of the Professional Voice and collapse of neck tissues into the of the airway. In addition, there may specialty trained in the diagnosis and airway, with consequent airway be an associated injury, and possibly treatment of laryngeal injuries. The obstruction and difficulty breath- transection, of both recurrent laryn- professional voice user with symp- ing.8-11 The neck muscles may serve geal nerves that are also compressed toms after laryngeal trauma should as a temporary opening for air until against the cervical spine during the be particularly vigilant about seeking edema (swelling) and hematoma for- injury.11,14 This paralyzes both vocal care from these specialists, as an mation (bleeding into the tissues) folds so they cannot open to breathe; injury that may not be recognized by result in obstruction of this tempo- the resultant immobility of the vocal other physicians can cause significant rary airway. folds can also be devastating to the long-term voice disability. voice. Evaluation and Treatment PEDIATRIC LARYNGOTRACHEAL of the Blunt Trauma Patient INJURIES FROM BLUNT TRAUMA ASSESSMENT OF BLUNT without Airway Distress INJURIES Fractures of the thyroid and cricoid In the patient without immediate cartilage from blunt trauma are un- Initial evaluation and assessment of signs of upper airway compromise, common in children. The greater elas- the blunt trauma patient is similar evaluation proceeds with a complete ticity of a child's cartilages makes them for adults and children. It is impor- evaluation, including examination of more resilient to external stresses. The tant for the physician to understand the neck, assessment of voice quality, child's larynx also sits higher in the the mechanism of injury. A high index and flexible fiberoptic evaluation of neck than in the adult, and the jaw of suspicion for blunt neck injury the larynx and upper airway. Fiber- serves more effectively as a protec- should be maintained in motor vehi- optic laryngoscopy is a procedure that tive shield in the child than it does in cle collisions, even without obvious involves the placement of a thin, the adult.12 Children are more likely to external signs.
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