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The diagnosis of tracheobronchial injury may be difficult in the pediatric
population. The mechanism of injury (e.g., fall, crush, direct blow) provides an
important clue. Symptoms such as chest pain and dyspnea are common but
nonspecific. Clinical signs include cyanosis, hemoptysis, tachypnea, and
subcutaneous emphysema (cervical, mediastinal, or both). Pneumomediastinum
and cervical subcutaneous emphysema are seen commonly in airway rupture. If a
pneumothorax is present with these findings, a bronchial rupture should be
suspected. A continued air leak after insertion of a thoracostomy tube should alert
the physician to the possibility of a tracheobronchial disruption. Because of
anatomic differences, ruptures of the bronchi occur on the right side more
frequently than the left. In the absence of a pneumothorax, tracheal or esophageal
rupture should be suspected if a pneumomediastinum or cervical emphysema is
present. However, in most patients with asymptomatic pneumomediastinum, no
source is identified on evaluation.
The treatment includes initial airway stabilization and bronchoscopic
evaluation of the airway. Numerous case reports describe partial tracheal tears
becoming complete after endotracheal intubation. Therefore, if the airway is
stable and a tear is known or strongly suspected, oral tracheal intubation should
be performed in the operating room under bronchoscopic guidance. This prevents
further trauma to the airway, and if a complication arises, emergency surgical
access to the airway is readily available. If the airway is unstable and emergent
endotracheal intubation needs to be performed, backup surgical approaches
should be prepared. Emergent recruitment of a trauma or thoracic surgeon to
assist if tracheal disruption worsens can be lifesaving. An advantage of early
bronchoscopy is exact identification and location of the lesion. The best surgical
results are achieved when operative exploration is performed early ( Table 115.1
). In the stable patient, CT scan of the chest can also help confirm the diagnosis
and identify other injuries.

ESOPHAGEAL INJURIES
Esophageal injury is rare in children, and presents a diagnostic challenge when it

does occur. Timely and accurate diagnosis of an esophageal injury is paramount.
The complications of delayed diagnosis include mediastinal sepsis and death. The
most common cause for esophageal perforation in the pediatric population is
iatrogenic, followed by penetrating trauma (gunshot and stab wounds).
Esophageal perforation can occur in blunt trauma if there is a significant amount
of chest or pharyngeal compression. The cervical and thoracic regions are more