Working Diagnosis:
Right paramedian vertical thyroid fracture with anterior-posterior subluxation.

Treatment:
He was non-emergently transferred to a larger academic facility for open reduction internal fixation of the right thyroid cartilage. Case Photo #4

Outcome:
Following fixation, he was observed with penrose drain in place for 24 hours, then discharged home. He returned to activity and lifting at 2 weeks status post open reduction and internal fixation, then full contact play without restrictions at 6 weeks.

Author's Comments:
Laryngeal fractures are uncommon injuries of the anterior neck that predominantly occur in settings of trauma. These are potentially life-threatening given airway involvement but go undiagnosed up to 40% of the time. Odynophagia and dyspnea are common symptoms of mild to moderate injury (1,2). CT of the neck is the preferred imaging modality for laryngeal injuries. Management should focus on identifying severity of injury and airway patency (3,4). Schaefer-Fuhrman classification is used for clinical grading (5). Endotracheal intubation and tracheostomy are preferred methods for airway management. Surgical fixation is the definitive treatment though not always required for more mild injury. Early intervention can prevent long-term complications including dysphagia and permanent vocal changes (1,2,4). All cases of symptomatic laryngeal injury should be referred for evaluation by speech therapy in the recovery phase.

Editor's Comments:
Laryngeal fractures are relatively rare in trauma, but the most common mechanism of injury is sports (6). Blunt trauma from a rugby tackle or a hockey puck have resulted in laryngeal fractures (7, 8). Patients typically present with anterior neck pain, but airway compromise and vocal changes may be noted and should be assessed during the initial survey (7). Patients sustaining cricoid and thyroid injuries are more likely to require intubation than other injury patterns (6). It is imperative that the sideline physician be prepared to manage patients with airway compromise and to have a well established emergency action plan for patient evacuation in these situations.

References:
1. Schaefer N, Griffin A, Gerhardy B, Gochee P. Early recognition and management of laryngeal fracture: a case report. Ochsner J. 2014;14(2):264-265.
2. Donahue, MD J. Identification and management of tracheobronchial injuries due to blunt or penetrating trauma. In: UpToDate, Connor RF (Ed), Wolters Kluwer. Last updated April 9,2024. Accessed on November 5, 2024. https://www.uptodate.com/contents/identification-and-management-of-tracheobronchial-injuries-due-to-blunt-or-penetrating-trauma/print
3. Becker M, Leuchter I, Platon A, Becker CD, Dulguerov P, Varoquaux A. Imaging of laryngeal trauma. Eur J Radiol. 2014;83(1):142-154. doi:10.1016/j.ejrad.2013.10.021
4. Rai S, Anjum F. Laryngeal Fracture. PubMed. Published 2023. https://www.ncbi.nlm.nih.gov/books/NBK562276/
5. Ha EJ, Baek JH, Lee JH. Ultrasonography-Based Thyroidal and Perithyroidal Anatomy and Its Clinical Significance. Korean J Radiol. 2015;16(4):749-766. doi:10.3348/kjr.2015.16.4.749
6. Wang AA, Feng AL, Rao V, Naunheim MR, Juliano AF, Song PC. Clinical, Radiologic, and Endolaryngeal Findings in Laryngeal Fractures: A 15-Year Case Series. OTO Open. 2022 Feb 25;6(1):2473974X221080164. doi: 10.1177/2473974X221080164. PMID: 35237739; PMCID: PMC8883307.
7. Feng AL, Parikh A, Gadkaree SK, Naunheim MR, Song PC. Laryngeal fractures in professional and semiprofessional ice hockey players. Laryngoscope Investig Otolaryngol. 2020 Oct 16;5(6):1110-1116. doi: 10.1002/lio2.474. PMID: 33364401; PMCID: PMC7752032.
8. Kitamura T, Otani K. Airway Obstruction with Blunt Neck Trauma from an Accidental High Tackle in Rugby. Curr Sports Med Rep. 2023 Mar 1;22(3):100-104. doi: 10.1249/JSR.0000000000001047. PMID: 36866953.

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