Pediatric emergency medicine trisk 821

FIGURE 106.4 Loss of thyroid cartilage prominence and associated acute airway obstruction
secondary to laryngeal fracture. SG, narrowed subglottic space; TC, fracture of thyroid
cartilage.

Initial Assessment
History of a mechanism concerning for laryngeal trauma should be elicited. This
may include a “clothes line” injury or blunt force from an object across the neck.
Emergency clinicians should determine if there has been any change in the
quality of voice, hemoptysis, or significant neck pain. On physical examination,
anterior neck tenderness, crepitus, or presence of abnormal laryngeal/tracheal
cartilage contours are concerning for injury (see Fig. 106.4 ). Stable patients may
be evaluated by an otolaryngologist with an awake fiberoptic nasopharyngoscope.
Unstable patients in respiratory distress may require direct laryngoscopy,
intubation, rigid bronchoscopy, or emergent tracheostomy. An otolaryngologist or
general surgeon should be prepared to intervene with any of these procedures. For
children without distress, plain radiographs may help assess the thyroid cartilage


or trachea for injury, and to identify subcutaneous air from related injuries. CT
scans provide more details regarding the laryngeal structures in the setting of
trauma. Penetrating trauma may require MRA/MRV to evaluate the vasculature of
the neck. Surgical exploration should be considered for patients with penetrating
injuries to zone 2 of the neck, even if clinically stable. Any patients with distress
or penetrating injury should be admitted either directly to the operating room for
airway management and exploration, or after complete work up in consultation
with appropriate surgical specialists. Mildly symptomatic children with blunt
trauma but who are otherwise stable and are determined not to have clinically
significant injury by history and examination, and possibly with additional
imaging and/or surgical specialty consultation, may be observed in the ED and
discharged home if there is no worsening of symptoms over time.
Suggested Readings and Key References

Ear
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the cauliflower ear. Facial Plast Surg 2010;26:451–455.
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extraction outcomes. Ann Otol Rhinol Laryngol 2017;126(11):755–761.
Olson MD, Saw J, Visscher SL, et al. Cost comparison and safety of emergency
department conscious sedation for the removal of ear foreign bodies. Int J
Pediatr Otorhinolaryngol 2018;110:140–143.
Schuldt T, Großmann W, Weiss NM, et al. Aural and nasal foreign bodies in
children—Epidemiology and correlation with hyperkinetic disorders,
developmental disorders and congenital malformations. Int J Pediatr
Otorhinolaryngol 2019;118:165–169.
Svider PF, Vong A, Sheyn A, et al. What are we putting in our ears? A consumer
product analysis of foreign bodies. Laryngoscope 2015;125(3):709–714.
Nose and Sinuses
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epidemiological features to detect the distinction between nasal fractures and
nasal soft tissue injuries. J Craniofac Surg 2018;29(5):1334–1337.
Hwang K, Yeom SH, Hwang SH. Complications of nasal bone fractures. J
Craniofac Surg 2017;28(3):803–805.
Perkins V, Vijendren A, Egan M, et al. Optimal timing for nasal fracture
manipulation—Is a 2-week target really necessary? A single-centre


retrospective analysis of 50 patients. Clin Otolaryngol 2017;42(6):1377–1381.
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surgical considerations. Laryngoscope 2004;114:255–265.
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external splinting really warranted? J Craniofac Surg 2017;28(8):e760–e763.
Oral Cavity and Pharynx
Brietzke SE, Jones DT. Pediatric oropharyngeal trauma: what is the role of CT
scan? Int J Pediatr Otorhinolaryngol 2005;69:669–679.
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palate trauma. Pediatrics 2010;126:e1578–e1584.
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oropharyngeal trauma. Arch Otolaryngol Head Neck Surg 2006;132:446–451.
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E1524.
Larynx and Trachea
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review. Pediatr Emerg Care 2003;19(5):308–313.
Duval EL, Geraerts SD, Brackel HJ. Management of blunt tracheal trauma in
children: a case series and review of literature. Eur J Pediatr 2007;166:559–
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Gold SM, Gerber ME, Shott SR, et al. Blunt laryngotracheal trauma in children.
Arch Otolaryngol Head Neck Surg 1997;123(1):83–87.
Mace SE. Blunt laryngotracheal trauma. Ann Emerg Med 1986;15(7):836–842.
Merritt RM, Bent JP, Porubsky ES. Acute laryngeal trauma in the pediatric
patient. Ann Otol Rhinol Laryngol 1998;107:104–106.
Additional Resources
Videos


Friedman EM. Videos in clinical medicine: Removal of foreign bodies from the

ear and nose. N Engl J Med 2016;374(7):e7. Available online at
/>Holsinger FC, Kies MS, Weinstock YE, et al. Videos in clinical medicine:
examination of the larynx and pharynx. N Engl J Med 2008;358:e2. Available
online at />