Airway and blunt force neck trauma

RED FLAGS

  • Neck trauma with noisy breathing

  • Neck trauma associated with laryngeal voice change: hoarse, croaky, husky or no voice

  • Expanding swellings in the neck that could be indicative of haematoma

  • Any history or signs of head and neck burns: singed eyebrows, mucosal burns, soot in nostrils, swollen lips

WHY IS THIS IMPORTANT?

Patients may present with isolated blunt force trauma to the neck or with these injuries in the context of complex trauma and other distracting injuries. Airway and blunt force trauma may compromise the airway very quickly. Being aware of the red flags is critical in avoiding delay in treatment.

Airway and blunt force neck trauma can be divided into three categories:

  • Blunt force airway trauma (fracture, transection, cord palsy etc of the airway itself)

  • Inhalational burn injury

  • Expanding space occupying lesion threatening the airway (usually haematoma)

Common mechanisms of injury include cycling (eg neck forwards against handlebars), inhalation of smoke, and interpersonal or domestic violence (eg attempted strangulation).

WHO TO ADMIT

  • Patients with a significant mechanism of blunt force injury to the neck should be monitored

  • Any patient with red flag symptoms

  • Any patient with a history of an inhalation injury

WHEN TO INVOLVE THE ENT REGISTRAR

  • Immediately: Any presentation of blunt force neck trauma with associated red flags (see above)

  • Immediately: Patients a history of inhalational burn injury (and alert an experienced anaesthetist/ITU)

  • Soon: Significant injuries from blunt force neck trauma

ASSESSMENT AND RECOGNITION

Due to the potential of airway compromise, patients should be monitored in an appropriate environment with an appropriate team (often a trauma team). Remember, call for help early if there are signs of an impending airway obstruction or significant bleeding!

Assessment and appropriate resuscitative measures should be performed in accordance to the Advanced Trauma Life Support ® (ATLS) guidance.

An AMPLE history is often useful (allergies, medications, past medical history, last meal, events)

Patients may initially be asymptomatic; however, they should still be assessed thoroughly and monitored due to the potential for delayed oedema/haematoma

Blunt trauma to the neck can damage the cervical spine, structures of the airway, as well as the digestive tract and vasculature of the neck.

Note any symptoms such as:

  • Dysphagia

  • Surgical emphysema

  • Continuously blood stained saliva

  • Hoarseness or loss of voice (similar to having been shouting all day)

  • Difficulty in breathing

  • Noisy breathing

  • Haemoptysis

  • Deviated trachea or larynx

In burns, ensure you note any red flags such as singed eyebrows, facial burns or soot near the mouth and nose.

MANAGEMENT 

Manage the patient using the Advanced Trauma Life Support ® (ATLS) guidance. Resuscitative efforts should continue in parallel with airway assessment:

  • High flow oxygen, ideally with some humidification or intermittent saline nebulisers (avoid drying of the airway)

  • Keep the patient nil by mouth until review by a senior ENT surgeon

  • Intubation with airway plan and burns management.

  • FBC, U&Es, coagulation profile and group & save/crossmatch

  • Arterial blood gas if appropriate

  • If the patient is unstable and in a significant amount of respiratory distress, assessment of the airway will go hand-in-hand with attempts to secure a definitive airway. Call for help early and ensure you have formulated a joint anaesthetics and ENT airway plan. If the patient is stable, then airway assessment should still proceed with appropriate back up as below.

  • Flexible nasendoscopy – looking for signs of airway damage, bleeding or haematoma. The function of the larynx should be examined as significant laryngeal fractures may disrupt this. If stable enough, a CT scan of the neck may aid surgical planning and delineate the anatomy in the neck. If there is a suspicion of bleeding, this should be done as a CT angiogram in both arterial and venous phase.

  • Other CT imaging or plain radiography to assess the extent of the injury/other injuries, as appropriate

If a patient has no red flag symptoms and examination does not find any significant injury, it may be appropriate to admit them for 24 hours of airway monitoring.

Medical management of blunt force airway or neck trauma involves:

  • IV steroid

  • Humidification

  • Antibiotics (if haematoma or surgical emphysema)

  • Anti-reflux medication

  • Voice rest

  • Speech and language input if ongoing issues with swallow

  • Interval water-soluble contrast swallow test

FURTHER MANAGEMENT

Surgical management will depend on how stable the patient is, and the extent of injury. Airway trauma can be classified using the Schaefer classification system.

Schaefer Classification

  • Group 1: Minor endolaryngeal hematomas or lacerations without detectable fractures

    • Usually managed conservatively with close airway monitoring.

  • Group 2: More severe oedema, hematoma, minor mucosal disruption without exposed cartilage, or nondisplaced fractures

    • Often managed conservatively, however will need panendoscopy as the injuries may be more severe than the signs seen on flexible nasendoscopy.

  • Group 3: Massive oedema, large mucosal lacerations, exposed cartilage, displaced fractures, or vocal cord immobility.

    • Likely to require a tracheostomy to secure a definitive airway prior to surgical correction of injuries.

  • Group 4: Same as group 3, but more severe, with disruption of anterior larynx, unstable fractures, two or more fractures lines, or severe mucosal injuries.

    • Will require tracheostomy as a definitive airway as well as surgical fixation and stenting.

  • Group 5: Complete laryngotracheal separation.

    • High mortality as the altered anatomy may make tracheostomy difficult.

Further management will depend on the extent and severity of trauma, as well as local expertise. Patients may need to be transferred to a tertiary/trauma centre if they require surgical management.

Patients managed conservatively should receive ongoing medical therapy and airway monitoring on the ward. Inform the ENT Registrar of any deterioration during admission.

Patient with significant injuries requiring fixation often have ongoing issues with speech and swallow, therefore liaison with speech and language therapy may be necessary.

Link to ExR Virtual Reality: Paediatric blunt neck trauma

Page last reviewed: 04 May 2024