Contrast esophagram is helpful in evaluating the esophagus for tears or perforations, but false-negative rates of up to 50% have been reported Evaluation can also include indirect mirror laryngoscopy to assess the larynx, vocal cord mobility, presence of mucosal edema, ecchymosis, and mucosal tears, as well as direct endoscopy to examine for tracheal, bronchial, and esophageal damage Flexible endoscopy may be less invasive and easier to accomplish, but rigid endoscopy offers the most complete examination Even rigid endoscopy, however, is not 100% sensitive in detecting tracheal and esophageal injuries As mentioned, operative evaluation is mandatory for some patients and optional for others Determinants of specific management direction include mechanism of injury, wound size and type, patient signs and symptoms, and relative stability Clinical Indications for Discharge or Admission Patients can be discharged if they not have a significant injury without platysmal penetration, are hemodynamically stable, without airway compromise, able to tolerate oral intake, and no indication or risk of abusive trauma or neglect is present Otherwise, admission is indicated BLUNT TRAUMA Goals of Treatment To ensure airway patency, respiratory sufficiency, hemorrhage control, cervical spine stability, and identify and prevent progression of injuries to all structures and tissues within the neck, including the airway, major blood vessels, neurologic, and osseous structures CLINICAL PEARLS AND PITFALLS Direct blunt trauma may cause airway injury due to the anterior position of the larynx and trachea Dyspnea, hemoptysis, and stridor suggest laryngeal airway injury Cervical emphysema, dysphagia, and progressive airway obstruction characterize supraglottic injuries Hemoptysis and persistent air leak suggest injuries inferior to the glottis Early intubation should be considered for patients with facial and neck burns Vascular injuries are less common compared to penetrating trauma, but are also missed on routine examination Maintain a high index of suspicion The cervical spine should be immobilized if indicated by mechanism of injury, inability to clinically clear, or in the presence of significant head/neck trauma Current Evidence Blunt trauma is often the result of a motor vehicle accident, although it can also result from sports-related injuries; clothesline and handlebar injuries from bicycles, motorcycles, all-terrain vehicles, and snowmobiles; strangulation; hanging; direct blows; and various forms of child abuse ( Table 112.1 ) Pediatricspecific mechanisms of injury as well as the fact that children have a relatively short neck, mobile laryngotracheal structures, and a superior-positioned larynx protected by the mandibular arch make it less likely for children to sustain airway fractures and may impact overall severity of injury On the other hand, the small and narrow airway increases the risk of airway-related morbidity secondary to airway edema, bleeding, swelling, and obstruction Blunt trauma is often associated with extracervical injuries, especially maxillofacial, head, chest, and aerodigestive injuries, but is less likely than penetrating trauma to involve multiple structures within the neck or cause vascular damage The airway may be injured with direct blunt trauma in part as a result of the anterior and relatively fixed position of the larynx and trachea High-impact blunt trauma to the trachea has been associated with a mortality rate of approximately 15%, although this is likely higher when one considers patients who die at the scene but occurs infrequently in pediatric trauma patients Laryngotracheal injury severity is graded I–V depending on the extent of tissue damage The anterior neck is relatively well protected by bony structures, unless the neck is extended With neck extension, the larynx, trachea, and esophagus are exposed to direct trauma and a blunt force may crush these structures against the posterior spinal column A tracheal tear or rupture may occur from a sudden increase in intratracheal pressure against a closed glottis, direct blunt trauma, crush, or acceleration/deceleration injury Shearing forces can cause edema, submucosal hematoma, laceration, perforation, vocal cord injury, and, less commonly, partial or complete airway transection A prime target for airway fracture is the cricoid ring, which is the only complete tracheal ring FIGURE 112.8 Seventeen-year-old female patient with COL3A1 gene mutation being evaluated for dissection associated with Ehlers–Danlos syndrome A: Axial imaging demonstrates the normal bilateral common carotid (arrowheads ) and vertebral arteries (arrows ) B: Curved planar reformatted images of the left carotid artery allow visualization of the entire common and internal carotid artery to simplify evaluation C: The same reconstruction of the right vertebral ... snowmobiles; strangulation; hanging; direct blows; and various forms of child abuse ( Table 112.1 ) Pediatricspecific mechanisms of injury as well as the fact that children have a relatively short... this is likely higher when one considers patients who die at the scene but occurs infrequently in pediatric trauma patients Laryngotracheal injury severity is graded I–V depending on the extent