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22) (D. [270] E. CHAPTER 8 Head and Neck Trauma 473 cornus of thyroid cartilage may lacerate pharyngeal mucosa Cricotracheal Separation: trachea tends to retract substernally and the larynx tends to migrate superiorly, high mortality, risk of clothesline injuries, may have bilateral recurrent laryngeal nerve paralysis Pharyngoesophageal Tears Recurrent Laryngeal Nerve Injury Management Establish Airway and Stabilize Cervical Spine (ABCs) must establish airway while protecting the cervical spine in blunt trauma premature endotracheal intubation is avoided to pre- vent an airway crisis (fiberoptic intubation may be attempted) a surgical airway is a safe method to establish an airway without obscuring diagnostic viewing and potentiating an airway crisis (should be completed under local anesthesia) Diagnosis Physical Exam: soft tissue edema or hematoma, laryngeal tenderness and crepitus, subcutaneous emphysema, laryngeal tenderness Fiberoptic Nasopharyngoscope: first-line diagnostic test, allows visuali- zation of the endolarynx with minimal risk to airway, evaluate vocal fold mobility (fixation, arytenoid dislocation or avulsion), endolaryn- geal lacerations, airway patency, laryngeal edema and hematomas CT of Neck: diagnostic test of choice to evaluate laryngeal fractures (hyoid bone, thyroid and cricoid cartilage); however, not indicated if injury is severe enough that exploration would occur regardless of CT result (CTs have replaced contrast laryngograms which may compro- mise a marginal airway) Roentgenograms of the Neck: largely been replaced with CT Esophagram: best to begin with a water soluble contrast to avoid barium-sulfate-induced mediastinitis Direct Laryngoscopy and Esophagoscopy: may be considered after air- way has been established to evaluate the endolarynx (allows palpation of arytenoids) Medical Management Indications for Medical Management Only: smaller soft tissue injuries (hematomas, lacerations), single nondisplaced fracture (controversial), stable laryngeal skeleton with an intact endolarynx Table 1.

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