**2.2 Neck and laryngeal trauma**


**55**

*Airway Trauma: Assessment and Management DOI: http://dx.doi.org/10.5772/intechopen.96894*

• Laryngeal trauma: The clinical presentation may not reflect the severity of the injury; some patients may present with delayed airway obstruction after blunt trauma to the neck. Others are associated with fracture base of the skull,

Patients with neck trauma including the trachea can be presented with one or combination of the following symptoms and signs: subcutaneous emphysema, crepitus, external bleeding, ecchymosis, hematoma, dyspnea, hypopnea, stridor, wheezing, cough, dysphonia, hoarseness, pain with phonation, dysphagia, drool-

Despite the incidence of airway traumatic injury being low, it is associated to

According to a retrospective review of 12,187 civilian patients treated at a regional trauma Canadian centre, mortality was 36% in blunt airway trauma and

The definitive airway assessment and instantaneous management may be performed as soon as indicated, whether outside the hospital in case of profuse bleeding with airway compromise or inside the hospital, as it may cause early death in trauma. Securing the airway should be done with cervical spine stabilization to avoid spinal cord injury and based on the advanced trauma life support (ATLS) concept for managing patients who have sustained life-threatening

The airway should be reevaluated frequently at least for several hours. The symptoms and signs of airway obstruction described before should be carefully examined, for example, inspiratory stridor suggests impending loss of airway. Ability to speak and answer simple questions indicates a patent airway, enough respiratory effort to

A thorough history and physical examination should be made for every patient before the initiation of anaesthetic care and airway management. However, this should not delay the immediate securing of the airway in case of its compromise; as indicated in the Advanced Trauma Life Support Manual, there are three underlying

2.The lack of a definitive diagnosis should never impede the application of an

3.A detailed history is not essential to begin the evaluation of a patient with

Gruen et al. found 16% of inpatients' deaths among 2594 trauma patients due to

This is followed by the standard preoperative airway assessment, which attempts to identify risk factors for difficult bag mask ventilation combined with difficult

The next step is to evaluate the traumatized airway and the adjoining structures using direct or video laryngoscopy, fiberoptic bronchoscopy (FOB) or ultrasonic

C-spine injury, pharyngeal, oesophageal and vascular injury [9].

ing, haemoptysis, tracheal deviation and nerve injury [4].

injuries, or to the airway obstruction and severe hypoxemia [1, 2].

generate voice and enough blood pressure to perfuse the brain [11].

failure to establish and/or secure the airway and oxygenation [13].

imaging, with or without sedation and topical anaesthesia.

**3. Airway assessment and management**

16% in penetrating airway trauma [1].

1.Treat the greatest threat to life first.

indicated treatment.

acute injuries [12].

direct laryngoscopy [14].

injuries [3, 10].

concepts:

*Airway Trauma: Assessment and Management DOI: http://dx.doi.org/10.5772/intechopen.96894*

*Special Considerations in Human Airway Management*

airway obstruction.

airway obstruction.

**and De Angelis studies**

be the cause of mouth lock.

rhea and cranial nerves palsy.

**2.2 Neck and laryngeal trauma**

**2.1 Maxillofacial trauma**

compromise.

4.Haemorrhage from open wounds or severe nasal bleeding may contribute to

5.Trauma-induced soft tissue oedema and swelling can cause delayed airway

**2. Airway trauma and findings, modified from Jain et al.** 

injuries may be associated with cervical spine injury.

6.Trauma to the larynx and the trachea can cause displacement of the epiglottis, arytenoid cartilages and vocal cords, thereby increasing the risk of cervical

• Dento-alveolar: Exfoliated and/or fractured teeth, soft tissue lacerations, swelling and oropharyngeal bleeding [4, 5]. Gastric distension from swallowing of the blood can cause regurgitation and aspiration while securing the airway.

• Bilateral or comminuted parasymphyseal mandibular fractures: It can lead to posterior tongue displacement in supine position and airway obstruction. Movement to sitting position can relieve the obstruction, however those

• Temporo-mandibular fractures: A condylar fracture and displacement can prevent mouth opening. The mouth may be locked open or closed. Trismus which is secondary to the spasm of the masseter muscle due to irritation may

• Mid-face fractures: Unilateral or bilateral Le Fort fractures (I-II&III) may cause airway compromise via maxillary prolapse, oedema or hemorrhage. Le Fort fractures II&III may be associated with fracture base of the skull with CSF leakage from the nose, epistaxis and oedema. Ng and colleagues reported establishing an emergency airway in 22 (34%) of 64 patients presenting with Le Fort fractures; the severity of the Le Fort fracture also correlated with an increased need for intubation [6].

• Zygomatic and orbital fractures: It can cause retro-bulbar hemorrhage and vision loss, traumatic mydriasis and increased intraocular pressure.

• Fracture base of the skull (temporal, occipital, sphenoid and ethmoid bones): It can cause peri-orbital ecchymosis (Raccoon eyes), Battle's sign, CSF rhinor-

• Penetrating trauma to the neck can cause arterial injury in 12–13% of the cases, and venous injury in 18–20% of the patients as reported by Britt et al. [7].

• Blunt trauma can cause airway obstruction by tissue disruption, oedema and hematoma. It can be associated with cervical spine (C-spine) injury. C-spine injury at or above C4 and C5 can cause airway obstruction by laryngeal oedema

and apnea by diaphragmatic paralysis and neurogenic shock [8].

**54**

• Laryngeal trauma: The clinical presentation may not reflect the severity of the injury; some patients may present with delayed airway obstruction after blunt trauma to the neck. Others are associated with fracture base of the skull, C-spine injury, pharyngeal, oesophageal and vascular injury [9].

Patients with neck trauma including the trachea can be presented with one or combination of the following symptoms and signs: subcutaneous emphysema, crepitus, external bleeding, ecchymosis, hematoma, dyspnea, hypopnea, stridor, wheezing, cough, dysphonia, hoarseness, pain with phonation, dysphagia, drooling, haemoptysis, tracheal deviation and nerve injury [4].

### **3. Airway assessment and management**

Despite the incidence of airway traumatic injury being low, it is associated to injuries, or to the airway obstruction and severe hypoxemia [1, 2].

According to a retrospective review of 12,187 civilian patients treated at a regional trauma Canadian centre, mortality was 36% in blunt airway trauma and 16% in penetrating airway trauma [1].

The definitive airway assessment and instantaneous management may be performed as soon as indicated, whether outside the hospital in case of profuse bleeding with airway compromise or inside the hospital, as it may cause early death in trauma. Securing the airway should be done with cervical spine stabilization to avoid spinal cord injury and based on the advanced trauma life support (ATLS) concept for managing patients who have sustained life-threatening injuries [3, 10].

The airway should be reevaluated frequently at least for several hours. The symptoms and signs of airway obstruction described before should be carefully examined, for example, inspiratory stridor suggests impending loss of airway. Ability to speak and answer simple questions indicates a patent airway, enough respiratory effort to generate voice and enough blood pressure to perfuse the brain [11].

A thorough history and physical examination should be made for every patient before the initiation of anaesthetic care and airway management. However, this should not delay the immediate securing of the airway in case of its compromise; as indicated in the Advanced Trauma Life Support Manual, there are three underlying concepts:


Gruen et al. found 16% of inpatients' deaths among 2594 trauma patients due to failure to establish and/or secure the airway and oxygenation [13].

This is followed by the standard preoperative airway assessment, which attempts to identify risk factors for difficult bag mask ventilation combined with difficult direct laryngoscopy [14].

The next step is to evaluate the traumatized airway and the adjoining structures using direct or video laryngoscopy, fiberoptic bronchoscopy (FOB) or ultrasonic imaging, with or without sedation and topical anaesthesia.

#### **Figure 1.**

*3-D CT reconstruction showing loose teeth and bone that can cause airway obstruction.*

If airway is maintained and there is no need for intubation, then computerized Tomography (CT) and Magnetic Resonance Imaging (MRI) can be performed. Imaging provides comprehensive information about airway and surrounding.

Virtual endoscopy and 3-D reconstruction of upper airway could be done, and all the injuries are identified, and the risk of airway compression is evaluated (**Figure 1**).

Once the airway risk assessment is done, the choice of airway management and possible interventions should be planned before the induction of anaesthesia.
