Approximately 85% of patients with blunt tracheal injury reportedly have subcutaneous emphysema, although the onset may be delayed ( Fig 112.9 ) However, airway injuries may be subtle and not apparent with initial history or physical examination but progress to severe abnormalities such as airway obstruction from tracheal edema as late as 48 to 72 hours after the injury The esophagus is mobile and is usually collapsed as it courses through the neck but may be dilated while eating This mobility helps protect the esophagus, but its delicate mucosal walls can be damaged easily by blunt traumatic events Iatrogenic esophageal injuries can result from endoscopy, passage of a nasogastric or orogastric tube, vigorous suctioning, and difficult intubations Esophageal injuries can also be seen with ingested foreign bodies and caustic chemicals The injuries, which can be subtle, occult, and difficult to diagnose, can lead to increased morbidity and mortality if not identified Isolated or concurrent hyoid bone injuries are also possible, but rare The hyoid is mobile and fairly well protected, which explains the paucity of isolated injury As with other injuries, these symptoms and signs can be subtle initially, with progressive edema and airway obstruction Vascular injuries are also rare with blunt trauma These injuries are often unsuspected and undiagnosed on routine examination Risk factors for injury have been reported to include Glasgow Coma Scale (GCS) score of less than 8; head injury; basilar skull fracture; and facial, neck, thorax, or abdominal injury The cervical seatbelt sign, bruising, and/or abrasions in the distribution of the seat belt along the neck are not predictive of cerebrovascular injury The most common vascular structure injured with blunt trauma is the common carotid artery The vertebral arteries are rarely injured by blunt forces unless a concurrent transverse process or other cervical spine fracture occurs Atlantooccipital dislocation can also be associated with vertebral artery injury, which if occurs frequently leads to early death in the field Vascular contusions with intimal damage may also be seen with blunt neck trauma The glandular structures in the neck, including the thyroid, parathyroid, parotid, and submandibular glands, may also be injured While these organs may be traumatized, they are rarely completely destroyed Clinical Considerations Clinical Recognition In the presence of blunt neck trauma, the triad of dyspnea, stridor, and hemoptysis suggests laryngeal injury Injuries above the glottis often demonstrate cervical emphysema, dysphagia, hoarseness, and progressive airway obstruction, whereas