Acute Laryngeal Fracture in a Male Collegiate Ice Hockey Athlete

Case Review

Anthony M. Rossi, MS, ATC, CSCS, NREMT, Casey L. Donovan, MS, ATC, CSCS, NREMT, and Meg A. Sharp, MS, ATC, CSCS • Adrian College

Witnessing an acute laryngeal injury is ical evaluation, and cautious management a very unique experience since laryngeal heavily determine a patient’s clinical out- fractures are the result of less than 1% of come.2,10,11 This case study aims to explain all blunt force traumas.1,2 The occurrence of the events surrounding an acute laryngeal acute laryngeal injuries is approximated to be fracture of a collegiate ice hockey patient 1 out of every 42,528 emergency room visits, as well as explore the recommendations for and only 10% of those injuries are related improved care. to athletics.3 The most common mechanism is a motor vehicle Anatomy collision, but laryngo- Key PointsPoints tracheal injury can also Since the larynx, trachea, and esophagus are Acute laryngeal injuries account for 1 out of result from strangula- particularly superficial, they are vulnerable to 42,528 emergency room visits. tion, hanging, assaults, injury in athletic events. The larynx is located and violent sports.2–6 at the midline of the neck anterior to the Only 10% of laryngeal injuries are related Due to the rarity of this fourth through sixth cervical vertebrae.7 The to athletics. type of injury, it may not larynx is composed of the hyoid bone and be included in an ath- a system of cartilages consisting of the thy- There is a lack of knowledge regarding letic trainer’s education, roid, cricoid, and arytenoid cartilages.7 The anterior laryngotracheal structure pathol- making it difficult for the thyroid cartilage is what forms the “Adam’s ogies. successful recognition apple” and provides protection to the ante- of the situation when it rior laryngeal airway. The cricoid cartilage presents itself. In addition, clinicians must makes a complete ring around the base of realize that slow and progressive obstruction the larynx.12 There are two groups of muscles of the airway can occur as a result of swelling, associated with the larynx: the intrinsic and so the first step in emergency management extrinsic laryngeal muscles.7 The intrinsic should be establishing a secure airway.2,7–10 muscles accomplish vocal cord mobility.7 Further education on acute laryngeal frac- The recurrent laryngeal branch of the vagus tures is necessary to prevent delayed care nerve primarily provides innervation of the or misdiagnosis, which can be life threat- intrinsic muscles.7 The close proximity of the ening.2,3,10 Early recognition, effective phys- recurrent laryngeal nerve to the cricoid car-

16  September 2015 international journal of Athletic Therapy & training tilage places it at risk for damage any time the larynx Case Report is compromised.7 The larynx moves as a unit under the control of two groups of extrinsic muscles: the A 23-year-old male college ice hockey player (patient) suprahyoid and infrahyoid. The three main functions was battling an opponent for the puck in the second of the laryngeal anatomy are to provide: (1) an airway; period of a game. The opponent forcefully pulled his (2) a mechanism for phonation and speech; and (3) a stick free and struck the patient in the throat with sphincter during swallowing.12 Degradation of any of the butt end of his stick (Figure 1). The patient was these functions after blunt trauma to the anterior neck wearing standard ice hockey equipment that was is indicative of a possible laryngeal injury. Trauma to well fitted, but he was not wearing any extra anterior the larynx can result in an obstructed airway, which neck protection. He immediately dropped to the ice is usually the most acute and life-threatening com- and play was stopped due to the nature of the injury. plication. Trauma can also affect the ability of the The athletic trainer and an athletic training student vocal cords to close, which ultimately could result in a performed an on-ice evaluation. They observed the decrease in the quality of voice.7 patient’s shortness of breath and a small amount of blood on the ice (hemoptysis), which he had spit out. The athletic trainer visualized a small abrasion on the Epidemiology anterior neck just inferior to the Adam’s apple. The The most common mechanism of injury for an acute athletic trainer observed and palpated the trachea to laryngeal fracture is blunt trauma to the anterior ensure it was not deviated from midline. Within 10 larynx.12 This mechanism can occur in sports when an s, the patient was able to regain a normal breath and athlete strikes an opposing athlete, hits a fixed object, speech pattern. The patient was asked to swallow or is struck with an object such as a stick, puck, bat, while the athletic trainer and athletic training student or ball.12 The presenting signs and symptoms of this observed for any deviations from midline, which did injury can be initially subtle, which makes it difficult to not occur. The patient described his pain as an intense recognize and can lead to misdiagnosis (Table 1).2,3,10,11 sore throat with a definitive hoarseness in the sound of his voice (dysphonia). He was able to skate off the ice under his own power. A cardiothoracic physician assistant providing medical coverage for the game evaluated the patient in the athletic training facility Table 1. signs and Symptoms immediately after the injury. The physician assistant’s 2,3,10,11 of Laryngeal Injury evaluation did not reveal any of the common signs Signs Symptoms and symptoms as presented in Table 1. The physi- Stridor Hoarseness cian assistant’s evaluation ruled out a crush injury to Voice changes Dyspnea Hemoptysis Dysphagia Anterior cervical edema Odynophagia Hematoma Dysphonia Laryngeal tenderness Pain with phonation Open neck wound Ecchymosis Crepitance Palpable fractures Subcutaneous emphysema Loss of thyroid cartilage prominence Loss of anterior cervical contour Figure 1 Re-creation of the mechanism of injury.

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