194 THE LARYNX, BRONCHI AND OESOPHAGUS If there is total airway obstruction the patient will die at the roadside, but if he gets as far as hospital then the dyspnoea may not be as marked as expected. Detached vocal cords could well increase the size of the airway initially only to decrease it again when reactive swelling occurs some hours after the injury. So it is that a patient with a fractured larynx, and say a ruptured spleen, could be admitted with shock and no respiratory obstruction. The anaesthetist could lift the detached epiglottis with his laryngoscope, intubate the patient, the spleen Fig. 97. Loss of normal neck outline after fracture of the larynx. could be removed and on extubation the patient may well develop respiratory obstruction since by now the larynx is reactively oedematous. Pain is a relatively minor feature; it may occur on swallowing and be transmitted to the ear. Mirror examination may show oedematous, haemorrhagic arytenoids, mucosal tears and disorganized vocal cords. Direct laryngoscopy should be done in all suspected cases. Plain films will show swelling within the larynx, and subcutaneous em- physema, but laryngographs do not have much importance in the acute stage because of the relative complexity of the examination and also because of the fact that the patient is seldom in a condition to cooperate with the investigation. TREATMENT. When the injury is slight there is no need for any treatment apart from observation in case laryngeal oedema develops. If the patient's condition deteriorates he should be put to bed and treated with humidification, oxygen and steroids, and if oedema progresses a tracheostomy should be done. In the more severe cases there are two principles of treatment: (a) the establishment of an airway with a tracheostomy, and (b) open exploration, repair and reduction, and fixation of the fracture. After the tracheostomy has been done, further exploration is carried out through a horizontal collar incision. It is usually possible to enter the larynx through the fracture and all torn soft tissue, such as detached cords, are stitched back into position. There should be minimal dSbridement.