Blunt pediatric laryngotracheal trauma: Case reports and review of the literature

Blunt Pediatric Laryngotracheal Trauma: Case Reports and Review of the Literature HOWARD KADISH, MD,*t JEFF SCHUNK, MD,*t GEORGE A. WOODWARD, MD*t Blunt laryngotracheel trauma can be a life-threatening event. Two cases of isolated blunt latyngotracheal trauma in pediatric patients are presented. One case involves a 12.year-old male who suffered isolated tracheal trauma from a fall. He developed respiratory distress and required a tracheostomy. lntraoperatlvely he was noted to have a thyroid cartilage fracture. The other case involves a lGyear-old female who was kicked in the neck by a horse. After unsuccessful lntubatlon attempts that completed a tracheal transaction, she required an emergency cricothyrotomy and a subsequent tr8Ch8Ootomy. The diagnosis, dlff8Mtial diagnosis, associated injuries, and trsatment options for blunt IarynQeal trauma are revlewed. (Am J Emerg Med 1994;12:207-211. Copyright 0 1994 by W.B. Saunders Company) Isolated blunt iaryngotracheal trauma is rare in adults and even more unusual in children.’ When it does occur, it frequently results in significant morbidity and mortality.2S3 The management of blunt trauma to the larynx may be difficult and anxiety provoking because the physician must be concerned with adequacy of the airway, stability of the cervical spine, potential for major hemorrhage, and other associated traumatic injuries. Two cases of isolated blunt laryngotracheal trauma are presented. Both patients initially were treated by emergency personnel at a referring hospital with care transferred to a pediatric emergency physician after transport. An Otolaryngologist and Pediatric intensivist became involved with these patients on arrival to the operating room or intensive care unit. The etiology, anatomy, related injuries, diagnosis, and treatment of blunt laryngotracheal trauma are discussed. CASE REPORT NO. 1 A IZyear-old male was referred from an emergency department (ED) to Primary Children’s Medical Center (PCMC), a tertiary pediatric referral hospital, after falling 6 ft from a ladder to a chain link fence. The patient struck the fence with his neck. There was no loss of consciousness. At the referring ED, the patient had normal vital signs and was not in respiratory distress, but exhibited a muffled, hoarse voice and an anterior neck laceration. On presentation to PCMC, 2 hours after the injury, the patient remained awake and alert, but complained of pain with swallowing. The patient’s vital signs were temperature, 37.4”C; pulse, 80 beats/min; blood pressure,

From the *Department of Pediatrics, University of Utah College of Medicine, and the tEmergency Department, Primary Children’s Medical Center, Salt Lake City, UT. Manuscript received April 2, 1993; revision accepted September 5, 1993. Address reprint requests to Dr Kadish, Emergency Department, Primary Children’s Medical Center, 100 N Medical Dr, Salt Lake City, UT 84113. Key Words: Laryngotracheal trauma, pediatrics, thyroid cartilage. Copyright 0 1994 by W.B. Saunders Company 0735-6757/94/1202-0018$5.00/O

100/70 mm Hg; and respiratory rate, 30 breathsimin. His voice remained hoarse and muffled. His neck examination demonstrated crepitus. thyroid cartilage tenderness, and a 4-cm anterior, horizontal laceration at the hyoid level that did not penetrate the platysma. The remainder of the physical examination was normal. A neck x-ray documented an intact cervical spine, but demonstrated subcutaneous emphysema (Figure I). The patient subsequently underwent computerized tomographic (CT) scan of the neck that suggested a fracture of the left thyroid cartilage anteriorly and an intact hyoid bone. A mass displaced the larynx and airway to the left. This was thought to be consistent with hematoma or edema of the right aryepiglottic fold. No abnormalities of the subglottic region could be seen. Under direct vision (nasopharyngoscope) the glottic area was erythematous and swollen. The false cord was edematous and vocal cord motion showed decreased abduction. The patient was admitted to the pediatric intensive care unit without respiratory distress. Within 6 hours of the accident, the patient began to show signs of respiratory distress and an increased oxygen requirement. He was electively intubated with a 5.0 cuffed endotracheal tube. The endotracheal tube was passed through the glottic opening at the inferior left aspect secondary to edema. After intubation, the patient was stable on minimal ventilatory settings. A repeat CT scan of the neck on hospital day 5 showed the left thyroid cartilage to be displaced posteriorly with a vertical fracture in the mid portion (Figure 2). The patient remained intubated until hospital day 7 because of significant airway edema. On hospital day 7 his thyroid cartilage was surgically repaired and a tracheostomy placed. Intraoperatively, the thyroid cartilage was observed to be fractured in the midline with edema of the false vocal cords and aryepiglottic folds noted. The epiglottis was normal. There was no significant subglottic narrowing or tracheal abnormality to the level of the tracheostomy site. Postoperatively, the patient did well without any complications. Sixteen days after the injury, he was decannulated and subsequently discharged from the hospital. At a 2-week followup appointment with otolaryngology, the patient was doing well without any complications. CASE REPORT NO. 2 A 1Cyear-old female was in her usual good state of health until she was kicked in the neck by a horse while swimming. She was awake and alert when pulled from the lake by a friend. On arrival at the closest hospital (45 minutes later), she remained awake, but was noted to be hypothermic, with an axillary temperature of 93.7”F and hypotensive with a blood pressure of 84152 mm Hg. The remainder of her vital signs showed a heart rate of 56 beatslmin and respiratory rate of 12 breathslmin. No pulsus paradoxicus was appreciated. Her physical examination was remarkable for cool, pale skin, an abrasion over the midline of her neck that extended to the left side, a raspy voice, and subcutaneous air noted in the neck that extended slightly below the clavicles. She demonstrated paradoxical neck motion with inspiration, and her breath sounds were equal but diminished. Her heart sounds were also felt to be distant. She remained awake when stimulated, but would doze when not actively engaged. An arterial blood gas on arrival at the initial hospital was pH, 7.39; PACO’, 39 mm Hg; PAO*, 96 mm Hg; O2 saturation, %%; and base deficit, 6 with 5 L of oxygen being delivered through a face mask. 207

208

FIGURE 1. A soft-tissue subcutaneous emphysema.

AMERICAN JOURNAL OF EMERGENCY MEDICINE n Volume 12, Number 2 n March 1994

lateral neck radiograph demonstrating

Cervical spine radiographs showed subcutaneous air in the neck, but no evidence of cervical spine fracture. Insertion of an artificial airway was recommended, by the PCMC control physician before the 90-minute fixed-wing flight. The patient was awake for the first nasotracheal attempt at intubation, which was unsuccessful. This was attempted approximately 2 hours after

the injury by a Certified Registered Nurse Anesthetist (CRNA) in the operating room. The tube was removed and the patient ventilated spontaneously and easily with 100% oxygen by mask. A second awake attempt 3 minutes later was also unsuccessful. Nine minutes later the child was given 200 mg of sodium pentothal and an oral intubation was attempted. This was unsuccessful and a transected trachea was suggested after the tube passed through the vocal cords and abutted against the skin of the neck. Two minutes later, the anesthesiologist inserted a 7.0 endotracheal tube through a cricoid incision. At this point, the patient’s oxygen saturation was 15% and remained low despite ventilation with 100% oxygen for the next 2 minutes until the saturation increased to 85%. Blood pressure was 129180 mm Hg and pulse rate of 108 beatsimin. The breath sounds were described as appropriate, but coarse. A chest radiograph, performed 12 minutes later, demonstrated a small left pneumothorax. A left chest tube was successfully placed. Twelve minutes after the x-ray, the patient was spontaneously moving and responding appropriately to painful stimuli, but not following commands. A blood gas was obtained with pH, 7.30; PACO’. 44 mm Hg; PAO’. 49 mm Hg: and base deficit, of 5, but was felt to represent a venous sample because the pulse oximeter was 100% at that time and the patient was awake and alert. The transport was accomplished with cervical spine immobilization and the cricoid tube secured in place with sutures and tape. On arrival at PCMC, the patient was admitted to the operating room, where a large. complete tracheal laceration was repaired, an endotracheal tube inserted as a stent, a formal tracheostomy placed below the insertion site of the emergency airway, and a right-sided chest tube placed secondary to an operative pneumothorax. Her hospital course was unremarkable and her neurological examination remained normal. She was discharged 14 days after the incident. She returned 2 months later for removal of granulation tissue at the repair and tracheostomy site. One month later, she was decannulated without difficulty.

ETIOLOGY Laryngotracheal trauma in children is rare. A review by Jurkovich et al of more than 30,000 trauma cases at their level 1 trauma center included only 12 cases of cervical laryngotracheal trauma.4 Only 1 of 12 was a pediatric patient. In another review, laryngotracheal injuries were diagnosed in less than 1% of all blunt trauma patients.j At our ED, during a 4-year period, isolated blunt laryngeal trauma occurred in only 2 of 15,000 trauma cases reviewed. The biodynamics of laryngotracheal injury in children after blunt trauma to the neck are similar to those in adu1ts.6 A common mechanism in adults occurs during motor vehicle accidents when the steering wheel strikes the larynx or trachea of a restrained driver.6 Other mechanisms include direct blows during sports (football, karate), strangulation, and “clothesline” injuries to drivers of motorcycles, snowmobiles, or all-terrain vehicles.7 In children, handlebar injuries from bicycles have been reported. ANATOMY

FIGURE 2. Patient no. 1 CT of the neck. Arrow demonstrates the left thyroid cartilage displaced posteriorly with a vertical fracture in the mid portion.

In the adult, the larynx is located at the level of the fourth, fifth, and sixth cervical vertebrae. There are nine cartilages all interconnected by ligaments and membranes (Figure 3). The epiglottis is attached to the upper thyroid cartilage by the thyroepiglottic ligament. The thyroid cartilage (Adam’s apple) is the largest and most easily palpable. The thyroid cartilage is connected to the hyoid bone by the thyrohyoid ligament. The cricoid cartilage is connected to the thyroid cartilage by the cricothyroid ligament. The cricoid cartilage is rigid because it is the only circumferential ring of cartilage

KADISH ET AL W BLUNT

PEDIATRIC

LARYNGOTRACHEAL

Ep’GLo\ /'OlD

yo&\

BONE

SUPERIOR HORN THYROID CARTIL

FAT BODY OF LIGAMENT

THYROID

INF HORN OF

CARTILAGE -

CRICOTHYROID

k~iC0lD CARTILAGE

LIG

CRICOTRACHEAL 1 LIGAMENT

~\TRACHEAL CARTILAGES

FIGURE 3. A schematic diagram depicting the numerous ments, membranes, and cartilage of the adult larynx.

209

TRAUMA

liga-

in the larynx. These three unpaired cartilages form the foundation of the larynx. The three paired cartilages (arytenoid, cuneiform, and corniculate) are important in phonation. The intrinsic and extrinsic laryngeal muscles and ligaments function to provide vocal cord movement for voice and airway function. If these structures are damaged the voice can become mumed and the airway obstructed. These laryngeal structures are protected by the mandible, sternum, and spine. The large mandible usually protects the larynx, with the head. neck, and face absorbing the major force of impact.6 In incidents in which the neck is extended, the larynx is exposed to possible blunt injury. The neck may hit the steering wheel or dashboard compressing the larynx against the cervical spine.* Children are less susceptible to blunt laryngeal trauma than adults because of the flexibility and mobility of the cartilage and larynx.’ The intrathoracic trachea and bronchi are more commonly injured by penetrating rather than blunt trauma because of their more protected position.” Certain anatomic distinctions should be made between adults and children. The larynx of the child differs from that of an adult in terms of its size, shape, consistency, and position. In the infant and young child, the larynx is not only smaller in actual size, but has smaller relative dimensions compared with the adult larynx. In children, the arytenoids are larger, the epiglottis has an omega shape, and the larynx has a funnel shape that is narrowest in the subglottis. These anatomic differences along with the ring-like cricoid cartilage result in a narrowed laryngeal inlet.” In adults, the narrowest point of the trachea is located at the level of C7, whereas in children it is at the cricoid cartilage (C3). Adolescents and adults can tolerate up to 50% narrowing of the airway without obvious respiratory distress. Infants and children will experience significant respiratory embarrass-

ment with this degree of restriction. The laryngeal framework of the child is soft and pliable making cartilaginous fractures uncommon. Laryngotracheal disruption occurs more commonly in children as a result of the immaturity of the intercartilaginous connecting membranes and ligaments.12 The position, unlike the size, shape, and consistency of the pediatric larynx. is a protective factor. The larynx is situated higher in the neck of a child than it is in the adolescent or adult. The infant’s head and jaw are proportionately larger in relation to the neck and trunk providing greater protection for the neck. LARYNGEAL TRAUMA Laryngeal injury can range from soft tissue edema and ecchymosis to mucosal lacerations, vocal cord avulsion, and fractures of the thyroid or cricoid cartilage. Arytenoid joint subluxation, recurrent laryngeal nerve laceration or contusion, or complete laryngotracheal disruption are also observed.13 Edema, hematoma, and subcutaneous emphysema are commonly observed in laryngeal trauma; most will resolve spontaneously. Occasionally, progressive swelling of the tissues may result in airway obstruction. Laryngeal injuries can be divided anatomically into supraglottic, tracheal, and infraglottic. Supraglottic injuries include fracture of the thyroid cartilage, avulsion of the attachments of the epiglottis from the thyroid cartilage and fracture of the epiglottis. Mucous membrane laceration and cord paralysis may also be observed.‘0.‘4 Tracheal avulsion poses a significant risk because the distal portion may retract into the upper mediastinum making acute airway management difftcult. As demonstrated in case report no. 2, a partial tear may become complete with airway manipulation. Infraglottic injuries involve fracture of thyroid and cricoid cartilage, avulsion of lower trachea, and recurrent laryngeal nerve injury.‘o,‘4 Associated Injuries Associated injuries are observed with laryngeal trauma and can include cervical fractures and dislocations. In the series by Fitz-Hugh et al, 50% of patients with tracheal transection had an associated cervical fracture.15 Kirsh demonstrated that 50% of tracheobronchial disruptions had associated severe injuries with a mortality rate of 30%.16 Several recent articles have reported a greater than 50% rate of associated injuries in patients with tracheobronchial disruption and have concluded that tracheobronchial disruption from blunt trauma rarely occurs as an isolated injury.‘7.‘8 Other associated injuries include chest trauma, facial fractures and lacerations, closed head injury, esophageal laceration, and recurrent laryngeal nerve injury.‘0~‘7~‘8~s~‘9Detection of these associated injuries requires a high index of suspicion. Pediatric Experience There are few case reports of children sustaining blunt laryngotracheal trauma. In our review of the literature, the mechanism of injury included motor vehicle accidents, falls, striking bicycle handlebars, child abuse, suicide attempt (hanging), and a tumbling accident. In a review by Baumgartner et al of tracheal and bronchial disruptions from blunt

210

AMERICAN

JOURNAL OF EMERGENCY

chest trauma, three of four pediatric patients demonstrated subcutaneous air on examination, x-ray, or both. All were successfully endotracheally intubated.” Humar et al*’ and Lusk” both reported cases of isolated pediatric blunt cervical trauma. Both patients demonstrated subcutaneous air on x-ray or examination, but neither had respiratory distress. Direct visualization of their airways demonstrated tracheal tears. Kielmovitch et al described two pediatric patients with blunt cervical trauma. Both patients exhibited subcutaneous air and thyroid cartilage tenderness. One patient underwent computerized tomographic (CT) scan before direct visualization. Both were found to have tears in their trachea.** In summary, most pediatric patients demonstrated subcutaneous air on examination and radiographically. Most patients were tender over the larynx or trachea. Dyspnea, hoarseness, or dysphagia were uncommon findings. In the two case reports presented, both patients demonstrated subcutaneous air, neck tenderness, and superficial neck lacerations. Table 1 summarizes the series and case reports. All investigators concluded that laryngeal, tracheal, and bronchial endoscopy is crucial for diagnosing airway injury.‘8~20~2’ Adult Experience Symptoms in patients with blunt laryngeal trauma may be subtle or attributed to other injuries. A change in the patients voice (dysphonia) or total loss of voice (aphonia) may be the only finding. In Fuhrman’s series of 10 patients, hoarseness was the most frequent symptom.5 Other common symptoms include difficulty swallowing (dysphagia) or pain with swallowing (odynophagia). Shortness of breath, pain caused by neck motion or speaking, hemoptysis, and stridor may be present initially or develop later. Signs of laryngotracheal injury commonly include tenderness, subcutaneous emphysema, deformities, contusions of the neck, and tracheal deviation.* Subcutaneous emphysema, as in the two pediatric cases presented, may be seen on radiographs. Airway Management Initial management should ensure an adequate airway. Previous literature advocated cricothyroidotomy or tracheostomy to treat a potentially unstable airway.“.” Recently,

TABLE 1.

Pediatric

Author

Series

(Year)

and

Case

No. of Pediatric Patients

Reports

for Blunt

Symptom(s)

O’Keeffe and Maw*s (1992) Humar and Pitters” (1991)

1 1

Dysphagia Neck pain

Baumgartner

4

Chest pain Neck pain

et aI’s (1990)

Kielmovitch and Friedman2* (1988) Macez3 (1986)

2

Neck pain

1

Lusk”

1

Chest pain Neck pain Neck pain

2

Not reported

(1986)

Softerman*’

(1981)

Laryngotracheal

MEDICINE

n Volume 12, Number 2 W March 1994

however, there have been differing opinions concerning the management of the airway. Gussack et all9 advocate intubation over tracheostomy. In their review of nine blunt laryngotracheal trauma patients, three were intubated, three underwent emergent tracheostomy, and three were given supplemental oxygen only. They feel the advantage of endotracheal intubation is that it is faster than tracheostomy and iatrogenic tracheal injury may result from an emergency tracheostomy. Gussack’s protocol reserves tracheostomy for patients sustaining blunt injury with significant laryngotracheal disruption or if intubation cannot be performed rapidly and successfully. Protocol by Schaefer calls for immediate tracheostomy for any unstable airway. 29 Fuhrman et al also recommend tracheostomy as the only method of airway control in blunt laryngotracheal trauma.5 Their concern is that attempted placement of an endotracheal tube across an already injured airway may cause a small mucosal laceration to progress to a complicated airway problem, as demonstrated in case report no. 2. In cases of laryngotracheal separation, the transected ends of the trachea may separate by as much as 8 (3rn.j Successful passage of an endotracheal tube across this distance would be difficult and may delay or preclude airway control. Trauma to the airway may also produce a blind path and the inability to successfully pass an endotracheal tube. Radiographic

Evaluation

Any patient with suspected laryngotracheal injury should undergo chest, cervical spine, and soft tissue lateral neck roentgenograms. Gussak advocates neck CT scan in all blunt laryngotracheal trauma that does not require emergency surgery.” In his review, CT scan was used in five of nine blunt trauma injuries. Surgical exploration was avoided in two cases. Schaefer recommends operative laryngoscopy and bronchoscopy as the patient is already in the operating room for a tracheostomy.29 In the pediatric patient, a CT scan of the thyroid cartilage may be difficult to interpret because of delayed ossification of the thyroid cartilage. Surgical

Intervention

The goal of treatment in the pediatric and adult population should be the restoration of a normal airway and voice. Phy-

Trauma

Signs

CT

Direct Visualization

Injury

Stridor Respiratory distress Ecchymosis Subcutaneous air Subcutaneous air Respiratory distress

No No

Yes Yes

Hemorrhagic edema cords Posterior tracheal tear

No

Yes

Subcutaneous air Ecchymosis Respiratory distress Subcutaneous air Subcutaneous air Ecchymosis Stridor Subcutaneous air Hoarseness

1 patient

Yes

Bronchial transection (2) Bronchial laceration (1) Tracheal transection (1) Posterior tracheal tear (2)

Yes

Yes

Ecchymosis

Yes

Posterior

tracheal

Tracheal

transection

No No

Tracheostomy performed

aryepiglottic tear

folds

KADISH ET AL n BLUNT PEDIATRIC

LARYNGOTRACHEAL

TRAUMA

sicians with prior experience in blunt laryngotracheal trauma should be consulted early and involved in all aspects of patient care. Patients requiring immediate open exploration include those with hematemesis, hemoptysis, exposed cartilage, cord paralysis, displaced fractures and significant mucosal injury.’ Best results are achieved when operative exploration is performed early in blunt laryngotracheal trauma.5.28 SUMMARY Two cases of isolated blunt laryngotracheal trauma in children are presented. This type of trauma is rare in the pediatric population and unusual as an isolated injury. Reported mechanisms of injury include motor vehicle accidents, clothesline injuries. strangulation, or bicycle handlebar accidents. Typical associated injuries include facial fractures, cervical spine fractures, and chest trauma. Any patient with significant laryngeal trauma should be evaluated for multisystem trauma. Clues to laryngeal injury include pain on swallowing or speaking, aphonia, and inability to tolerate the supine position and hoarseness. Signs of laryngotracheal injury include subcutaneous emphysema, hematoma, neck asymmetry, tenderness, loss of palpable landmarks, and respiratory distress. Specific airway management remains controversial. In the adult population, some investigators recommend endotracheal intubation unless there is laryngotracheal disruption, while other investigators advocate tracheostomy for any unstable or potentially unstable airway. Even though there is limited experience in the pediatric literature, most investigators recommend careful oral intubation reserving tracheostomy only if the airway cannot be visualized because of blood or edema. Radiographic evaluation should always include chest, cervical spine, and soft tissue of the lateral neck. Neck CT scan is indicated unless the patient requires an emergency operation in which panendoscopy will be performed. CT scan remains the best radiographic modality for visualizing the airway and any laryngeal structure in an emergency, but has its limitations in young patients. If an airway injury is suspected, laryngeal, tracheal, bronchial, and pharyngoesophageal endoscopy is mandatory. Good outcome is dependent on early recognition of respiratory compromise before progression to respiratory failure and early intervention by personnel experienced in blunt laryngotracheal trauma. REFERENCES 1. Eichelberger M, Mangubat E, Sacco W: Outcome analysis of blunt injury in children. J Trauma 1988;28:1109-1117 2. Zorludemir U, Ergoren Y, Yucesan S: Mortality due to trauma in childhood. J Trauma 1988;28:869-671 3. Kilman J, Charnock E: Thoracic trauma in infancy and childhood. J Trauma 1969;9:863-873

211

4. Jurkovich G, Luterman A: Laryngotracheal trauma: A protocol approach to a rare injury. Laryngoscope 1986;96:660-665 5. Fuhrman G, Stieg F, Buerk C: Blunt laryngeal trauma: Classification and management protocol. J Trauma 1990;30:8792 6. Nahum A, Siegal A: Biodynamics of injury to the larynx in automobile collisions. Ann Otolaryngol 1967;76:781-790 7. Alonso W, Caruso V, Roncase E: Minibikes: A new factor in laryngotracheal trauma. Ann Otolaryngol 1973;82:800-804 8. Butler R, Moser F: The padded dash syndrome: Blunt trauma to the larynx and trachea. Laryngoscope 1968;78:11721176 9. Fearon B: Acute airway obstruction. In Ferguson C, Kendig (eds): Otolaryngology, ed 2. Philadelphia, PA, Saunders, 1972, pp 1183-1213 10. Gallia L: Laryngotracheal trauma. In Blaisdell W, Trunkey D (eds): Cervicothoracic Trauma. New York, NY, Thieme, 1986, pp 117-128 11. Alonso W: Injuries of the lower respiratory tract. In Bluestone C, Stool S (eds): Pediatric Otolaryngology. Philadelphia, PA, Saunders, 1990, pp 1178-l 193 12. Alonso W, Pratt L: Complications of laryngotracheal disruption Laryngoscope 1974;84:1276-1290 13. Larson D, Cohn A: Management of acute laryngeal injury: A critical review. J Trauma 1976;16:858-862 14. Birney J, Kulig K: Laryngeal emergencies. In Kravis T, Warner C (eds): Emergency Medicine: A Comprehensive Review. Rockville, MD, Aspen Publishers, 1987, pp 1265-1269 15. Fitz-Huoh G. Wallenborn W. McGovern F: lniuries of the larynx and cehicai trauma. Ann dtolaryngol 1971;80:419-442 16. Kirsh M, Orringer M, Behrendt D:. Management of tracheobronchial disruption secondary to nonpenetrating trauma. Ann Thorac Surg 1976;22:93-101 17. Jones W, Mavroudis C, Richardson J: Management of tracheobronchial disruption resulting from blunt trauma. Surgery 1984;95:319-322 18. Baumgartner F, Sheppard B, Virgilio C: Tracheal and main bronchial disruptions after blunt chest trauma: Presentation and management. Ann Thorac Surg 1990;50:569-574 19. Gussack G, Jurkovich G: Treatment dilemmas in laryngotracheal trauma. J Trauma 1988;28:1439-1444 20. Humar A, Pitters C: Emergency department management of blunt cervical tracheal trauma in children. Pediatr Emerg Care 1991;7(5):291-293 21. Lusk R: The evaluation of minor cervical blunt trauma in the pediatric patient. Clin Pediatrics 1986;25:445-447 22. Kielmovitch I, Friedman W: Lacerations of the cervical trachea in children. Int J Pediatr Otorhinolaryngol 1988;15:73-78 23. Mace S: Blunt laryngotracheal trauma. Ann Emerg Med 1986;15(7):836-841 24. Hancock B, Wiseman N: Tracheobronchial injuries in children. J Pediatr Surg 1991;26(11):1316-1319 25. Orobello P, Myer C, Cotton R, et al: Blunt laryngeal trauma in children. Laryngoscope 1987;97:1043-1048 26. O’Keeffe L, Maw A: The dangers of minor blunt laryngeal trauma. J Laryngol Otolaryngol 1991;106:372-373 27. Sofferman R: Management of laryngotracheal trauma. Am Surg 1981;141:412-417 28. Fitz-Hugh G, Powell J: Management of laryngotracheal injuries. VA Med Month 1970;97:490-493 29. Schaefer S: Primary management of laryngeal trauma. Ann Otorhinolaryngol 1982;91:399-402