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