Diseases Of The Nose Throat And Ear

CHAPTER 39
LARYNGOTRACHEAL TRAUMA

After head injury respiratory obstruction is the second most common cause of
death at the roadside following an automobile accident. A high proportion of
these deaths is due to such injuries blocking the airway at the upper end, either
at the larynx or trachea. In a multiple injury, laryngeal fractures may well be
missed because all efforts will be directed towards establishing an airway
either by tracheostomy or intubation and dealing with the more spectacular
problems in the chest, abdomen, head or limbs. At this point the laryngeal
trauma is classified as 'acute' and remains in this eminently remedial state for
3 or 4 weeks. After this, the state of 'acute trauma', which is rewarding to
treat, passes into a state of 'chronic stenosis' which is very unrewarding to
treat. All too often this is when the problem comes to light because after 3 or 4
weeks, if the patient survives the first period, the other injuries are well
controlled and attempts are made to remove the tracheostomy tube. In these
unfortunate cases it is only when the patient is seen to be unable either to
breathe or speak without a tracheostomy tube that the larynx is examined. To
rebuild a larynx from the scarred state in order to free respiratory obstruction
is relatively easy, but to make such an organ an efficient sphincter or an
efficient 'voice box* is extremely difficult.

ACUTE LARYNGOTRACHEAL TRAUMA

The commonest cause of laryngeal or tracheal injury is a road traffic accident.
Other causes are bullet and knife wounds, damage by other sharp objects
such as sticks or falling on to a sharp edge such as a kerb, and blows to the
neck from such sports as karate and basketball where the neck is often
extended and unprotected.

The result of a car accident depends on the seat-belt situation, (a) If a full
harness is worn the occupant will be as safe as possible and will only die from
severe crushing, seat-belt injury or whiplash (Fig. 94B). (b) If the occupant has
no seat-belt on, he will be thrown about, or out of the car and the injuries
received will be a matter of chance, (c) If, as is common in North America,
lap-type seat-belts are worn, the injury sustained depends upon the length of
the front compartment of the car, and the height of the driver or passenger
(Fig. 94A). At impact, the occupant, being held at his waist, is jack-knifed
forwards and if the distance is short the face will hit the steering wheel or
dashboard and the result is likely to be a facial fracture: If the distance is
longer, the head will extend leaving a large area of neck unprotected by the
mandible and when this strikes the wheel or dashboard, the larynx is pushed
back against the cervical vertebral bodies.

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