TRAUMA TO THE LARYNX AND TRACHEA Foreign Body Goals of Treatment Laryngeal or tracheal foreign bodies can result in life-threatening partial or complete airway obstruction The goal is to safely remove the object as soon as possible to prevent or reverse any respiratory compromise Care must be taken to avoid converting a partial airway obstruction into complete airway compromise, and to avoid advancing the foreign material with resultant aspiration into the lung CLINICAL PEARLS AND PITFALLS Disc batteries should be removed as soon as possible to avoid caustic injury Clinicians should have a high suspicion for foreign body in a child with sudden onset of stridor, persistent cough, or respiratory distress Back blows and the Heimlich maneuver are not performed on the breathing child as these can cause the object to lodge further into the airway These techniques are reserved for complete airway obstruction Current Evidence Foreign bodies lodged in the laryngeal inlet or trachea cause severe distress and often present with coughing, wheezing, and biphasic stridor Tracheal/bronchial foreign bodies can cause either lung hypoventilation due to compete obstruction or hyperinflation due to a check-valve effect of the object Clinical Considerations Clinical Recognition Foreign bodies trapped in the laryngeal inlet can cause significant acute upper airway obstruction The child usually presents with severe coughing, hoarseness, and significant respiratory distress The larger challenge for emergency clinicians is recognizing foreign body aspiration when the event was not witnessed directly, and the child is not acutely compromised Presenting symptoms such as cough, stridor, and examination findings such as wheezing and decreased aeration are nonspecific and seen commonly in routine pediatric illnesses such as croup, bronchiolitis, and asthma One should be suspicious of airway foreign body in any child with sudden onset of symptoms or when there is a history consistent with ingestion or aspiration Triage Children with a laryngeal or tracheal foreign body usually present in distress with hoarseness, coughing, stridor, or wheezing If the child is able to phonate, air is moving through his or her larynx, indicating only partial obstruction Efforts should be made to allow the child to assume a position of comfort Invasive examination and interventions such as IV placement should be avoided when possible, as crying may result in worsening of the airway obstruction Complete or near complete obstruction requires emergency airway management Initial Assessment The history may include a witnessed ingestion or sudden onset of the above symptoms with no other etiology noted Examination findings may include stridor with upper airway foreign bodies, and wheezing, persistent cough, focal decreased aeration with lower airway foreign bodies Asymmetric hyperinflation or areas of lung collapse are rarely detectable without radiologic evaluation Management Do not perform back blows or Heimlich maneuver to treat the child who is still breathing as objects may become further lodged in the airway Children in severe distress should be taken to the OR for emergent removal under direct laryngoscopy and bronchoscopy For children who are not breathing, back blows or the Heimlich maneuver should be done If unsuccessful with resultant progression to depressed mental status, laryngoscopy should be performed to assess for glottic foreign material that can be removed with forceps For those in mild or moderate distress, plain films may help identify radiopaque objects or show low lung volumes or hyperinflation in the setting of radiolucent objects (see Fig 106.3 ) A normal chest radiograph does not rule out foreign body In stable patients, fluoroscopy or CT can add diagnostic value though this needs to be balanced against the higher doses of ionizing radiation for these studies, and the likelihood that findings will influence subsequent management Alternatively, if there is high clinical concern for foreign body despite negative radiographs, consideration should be given to urgent bronchoscopy without further imaging Those with low suspicion of foreign body should have thorough follow-up and reevaluation Development of symptoms in the interim period should prompt appropriate further investigations as indicated FIGURE 106.3 Chest radiograph of a child with bronchial foreign body A: Inspiratory film demonstrates only subtle hyperaeration of right lung B: Expiratory film shows accentuated hyperaeration on the right side secondary to air trapping (“check-valve” phenomenon) by the foreign body in the right mainstem bronchus In addition, the mediastinum is displaced to the left LARYNGEAL AND TRACHEAL TRAUMA Goals of Treatment Blunt and penetrating laryngeal and tracheal should be promptly identified to prevent and reverse any respiratory compromise from obstruction or bleeding The primary goal for the emergency clinicians is to determine who requires urgent airway management and how to most safely accomplish this Fiberoptic visualization or surgical intervention may be required When acute airway management is not a concern, the aim is to identify which patient with minimal or no symptoms warrants advanced imaging and/or surgical consultation to avoid missing injuries to these critical structures that have the potential to progress (see Chapter 112 Neck Trauma for further details) CLINICAL PEARLS AND PITFALLS Patients with blunt trauma to the anterior neck should also be evaluated for cervical spine injury Any patients with penetrating injuries to the central third (i.e., zone 2) of the neck should be considered for surgical exploration even if stable Patients with penetrating injuries to zones and of the neck should initially undergo MRA/MRV to assess for vascular injury prior to other interventions including exploration Current Evidence Blunt trauma can cause mucosal lacerations, hematomas, vocal cord injury, or fractures of the bony or cartilaginous larynx and trachea Penetrating trauma results in additional risk to the airway and vasculature, as covered in Chapter 112 Neck Trauma Clinical Considerations Clinical Recognition Blunt injuries to the neck often present with neck pain, hoarseness, cough, or hemoptysis Some patients may have relatively mild symptoms despite injury Neck swelling, or visible injury such as ecchymosis and abrasions may be identified on examination Triage Patients with significant respiratory distress or penetrating injuries to the neck should be emergently evaluated and surgical specialty consultation pursued Those without acute compromise of the airway, breathing, or circulation should be seen expeditiously and monitored frequently for clinical deterioration ... may result in worsening of the airway obstruction Complete or near complete obstruction requires emergency airway management Initial Assessment The history may include a witnessed ingestion or... prevent and reverse any respiratory compromise from obstruction or bleeding The primary goal for the emergency clinicians is to determine who requires urgent airway management and how to most safely