[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Conditions](https://durgical.com/en/conditions/) › Laryngotracheal trauma

# Laryngotracheal trauma

Injury to the voice box or windpipe from a blow, a cut, strangling or a breathing tube. Voice change or neck air after trauma can mean airway danger.

Updated Nov 12, 2026

On this page

- The basics What it is
- Who gets it
- Causes
- Risk factors
- Pathophysiology
- Classification
- In anaesthesia

- Clinical Symptoms and signs
- Red flags
- Diagnosis
- Differential diagnosis
- Complications
- Prognosis

- Treatment Goal of treatment
- Treatment

- Study Test yourself

- Connections Connections

## What it is

Injury to the larynx or cervical [trachea](https://durgical.com/en/anatomy/trachea/) from blunt trauma (steering wheel, assault, sports, strangulation, clothesline injury), penetrating trauma (stab or gunshot) or iatrogenic causes (intubation, tracheostomy). It is rare but can obstruct the airway within minutes, and it is often missed among other injuries.

See it in 3D

- [Thyroid cartilage](https://durgical.com/en/anatomy/thyroid-cartilage/)
- [Cricoid cartilage](https://durgical.com/en/anatomy/cricoid-cartilage/)
- [Trachea](https://durgical.com/en/anatomy/trachea/)
- [Vocal folds](https://durgical.com/en/anatomy/vocal-fold/)

## +10

- [Arytenoid cartilages](https://durgical.com/en/anatomy/arytenoid-cartilage/)
- [Epiglottis](https://durgical.com/en/anatomy/epiglottis/)
- [Hyoid bone](https://durgical.com/en/anatomy/hyoid-bone/)
- [Cricothyroid membrane](https://durgical.com/en/anatomy/median-cricothyroid-ligament/)
- [Thyrohyoid membrane](https://durgical.com/en/anatomy/median-thyrohyoid-ligament/)
- [Recurrent laryngeal nerves](https://durgical.com/en/anatomy/recurrent-laryngeal-nerve/)
- [Esophagus](https://durgical.com/en/anatomy/esophagus-abdominal-part/)
- [Common carotid artery](https://durgical.com/en/anatomy/right-common-carotid-artery/)
- [Internal jugular vein](https://durgical.com/en/anatomy/internal-jugular-vein/)
- [Thyroid gland](https://durgical.com/en/anatomy/thyroid-gland/)

## Who gets it

Found in a small percentage of trauma patients but with high mortality; many die before reaching hospital. Blunt injury is typical in road traffic crashes and assaults; penetrating neck injury is relatively frequent in Colombia and Latin America because of interpersonal violence. Post-intubation injury is the most common cause of laryngotracheal stenosis in adults.

## Causes

- Blunt anterior neck impact: dashboard or steering wheel, punches or kicks, sports, motorcycle or clothesline injuries, hanging and strangulation
- Penetrating: stab and gunshot wounds of the neck
- Intubation: prolonged intubation, large or high-pressure cuffs, traumatic or repeated attempts (mucosal ulcer, arytenoid dislocation, granuloma, subglottic or tracheal stenosis)
- Tracheostomy and cricothyrotomy complications
- Inhalation burns and caustic ingestion

## Risk factors

- Unrestrained drivers and high-energy road crashes
- Interpersonal violence
- Prolonged intubation (more than about a week), oversized tubes and cuff overinflation
- Children (more cricoid and subglottic injuries; larynx is higher and more elastic, so fractures are rarer)
- Older adults (calcified, brittle cartilages fracture more easily)

## Pathophysiology

A blow compresses the larynx against the cervical spine. The [thyroid cartilage](https://durgical.com/en/anatomy/thyroid-cartilage/) fractures (vertically in younger patients, comminuted when calcified), the cricoid can collapse, and the trachea can separate from the cricoid (cricotracheal separation, with possible bilateral [recurrent laryngeal nerve](https://durgical.com/en/anatomy/recurrent-laryngeal-nerve/) injury). Mucosal tears and hematoma narrow the airway and air escapes into the soft tissues. In intubation injury, cuff and tube pressure above capillary perfusion pressure cause ischemic mucosal necrosis, perichondritis and later scar stenosis, especially at the posterior glottis and the subglottis.

## Classification

- Schaefer classification (blunt laryngeal trauma): group 1 minor endolaryngeal hematoma or laceration without fracture; group 2 edema, hematoma, minor mucosal disruption without exposed cartilage, non-displaced fracture; group 3 massive edema, large mucosal tears, exposed cartilage, displaced fracture or vocal cord immobility; group 4 as group 3 plus unstable or comminuted fracture or anterior commissure disruption; group 5 complete laryngotracheal separation
- Penetrating neck injury zones: zone I (clavicles to cricoid), zone II (cricoid to mandibular angle), zone III (above the angle)
- Iatrogenic: post-intubation laryngeal edema, arytenoid dislocation, granuloma, glottic or subglottic stenosis (Cotton-Myer grading), tracheal stenosis and tracheomalacia

## Symptoms and signs

- Hoarseness or voice change (the most common sign)
- Pain on speaking or swallowing, dysphagia
- Stridor, dyspnea, respiratory distress
- Hemoptysis
- Subcutaneous emphysema with crepitus in the neck
- Loss of the thyroid prominence, neck tenderness, bruising or seatbelt sign
- Air bubbling from a neck wound in penetrating trauma
- After extubation: stridor, voice change, later progressive dyspnea from stenosis

## Red flags

- Stridor, respiratory distress or inability to lie flat
- Expanding subcutaneous emphysema
- Air bubbling through a neck wound
- Hemoptysis
- Expanding hematoma, pulsatile bleeding or neurologic deficit (associated vascular injury)
- Progressive dyspnea weeks after prolonged intubation

## Diagnosis

**Clinical**
Primary survey (ATLS) with cervical [spine](https://durgical.com/en/anatomy/region/spine/) protection. Look for hoarseness, stridor, crepitus, tenderness and loss of cartilage landmarks. In a stable patient, flexible fiberoptic laryngoscopy assesses mucosal tears, hematoma, exposed cartilage and vocal cord mobility. In penetrating injury, 'hard signs' (airway compromise, air bubbling, massive bleeding, expanding hematoma) mean immediate surgery.

**Tests**
Bronchoscopy and esophagoscopy (or contrast swallow) to look for associated tracheal and esophageal injuries. Arterial blood gas as needed.

**Imaging**
CT of the neck in stable patients to define cartilage fractures and displacement; CT angiography when vascular injury is suspected (especially penetrating zone I and III injuries); cervical spine imaging. [Chest](https://durgical.com/en/anatomy/region/chest/) radiograph for pneumothorax and pneumomediastinum.

## Differential diagnosis

- Cervical spine injury
- Pharyngeal or esophageal perforation
- Vascular injury with hematoma compressing the airway
- Pneumothorax with subcutaneous emphysema
- Vocal cord paralysis from other causes
- Angioedema or inhalation injury

## Goal of treatment

Secure the airway without making the injury worse, find associated injuries, and repair the larynx early to preserve breathing, voice and swallowing.

## Treatment

**Acute**
Airway first: high-flow oxygen and upright position. With an unstable airway or major laryngeal disruption, an awake tracheostomy under local anesthesia is preferred; orotracheal intubation risks creating a false passage and should only be done by experienced operators under direct vision (ideally fiberoptic). Cricothyrotomy is avoided when the injury is at the cricoid or below.

**Acute**
Penetrating injury with hard signs: immediate surgical exploration; do not probe the wound or remove impaled objects outside the operating room.

**Follow-up**
Schaefer group 1 (and some group 2): observation with humidified air, voice rest, head elevation, antireflux medication and serial laryngoscopy; corticosteroids may reduce edema.

**Medical**
Post-intubation laryngeal edema: systemic corticosteroids before planned extubation in high-risk patients and nebulized epinephrine after extubation; a cuff-leak test helps predict it.

**Surgical**
Groups 3 to 5: tracheostomy and early open repair within 24 to 48 hours (mucosal repair, reduction and fixation of fractures, stenting for unstable fractures or [anterior commissure](https://durgical.com/en/anatomy/anterior-commissure/) injury); end-to-end anastomosis for cricotracheal separation.

**Surgical**
Late stenosis: endoscopic dilation or laser for short stenoses; tracheal or cricotracheal resection with reconstruction for longer ones. Refer to otolaryngology any patient with voice change or stridor after trauma or extubation.

## Complications

- Acute airway obstruction and death
- Laryngeal or tracheal stenosis
- Permanent dysphonia, vocal cord paralysis, arytenoid fixation
- Aspiration and dysphagia
- Mediastinitis, deep neck infection or chondritis
- Tracheoesophageal fistula

## Prognosis

Early recognition and repair give good airway and voice outcomes in most patients. Delayed diagnosis increases stenosis, permanent voice damage and tracheostomy dependence; complete laryngotracheal separation has high mortality.

## Test yourself

Think of the answer, then tap the question to see it.

## After a steering wheel impact, a driver has hoarseness, neck crepitus and stridor. What is the safest airway option?

Awake tracheostomy under local anesthesia (avoid blind intubation and cricothyrotomy when the larynx is disrupted).

## What is the most common symptom of laryngeal trauma?

Hoarseness or voice change.

## In the Schaefer classification, what defines group 5?

Complete laryngotracheal separation.

## Which zone of the neck lies between the cricoid cartilage and the angle of the mandible?

Zone II.

## A patient intubated for 3 weeks develops progressive stridor 1 month after extubation. Most likely diagnosis?

Post-intubation subglottic or tracheal stenosis.

[Add to my cards (5)](https://durgical.app/estudiar/?add=/en/conditions/laryngotracheal-trauma/)

## In anaesthesia

- [Cannot intubate, cannot oxygenate: front-of-neck access](https://durgical.com/en/anaesthesia/cannot-intubate-cannot-oxygenate-front-of-neck-access/)

## Connections

## Related conditions 11

- [Penetrating trauma (stab and gunshot wounds)](https://durgical.com/en/conditions/penetrating-trauma/)
- [Major trauma (polytrauma): ATLS primary survey](https://durgical.com/en/conditions/major-trauma-atls-primary-survey/)
- [Cervical spine fracture](https://durgical.com/en/conditions/cervical-spine-fracture/)
- [Subglottic stenosis](https://durgical.com/en/conditions/subglottic-stenosis/)
- [Vocal fold paralysis (recurrent laryngeal nerve injury)](https://durgical.com/en/conditions/vocal-fold-paralysis/)
- [Oesophageal perforation (Boerhaave syndrome)](https://durgical.com/en/conditions/oesophageal-perforation/)
- [Pneumothorax](https://durgical.com/en/conditions/pneumothorax/)
- [Mediastinitis (acute and fibrosing)](https://durgical.com/en/conditions/mediastinitis/)
- [Foreign-body airway obstruction (choking)](https://durgical.com/en/conditions/foreign-body-airway-obstruction/)
- [Deep neck infection and Ludwig angina](https://durgical.com/en/conditions/deep-neck-infection-and-ludwig-angina/)
- [Traumatic brain injury](https://durgical.com/en/conditions/traumatic-brain-injury/)

Educational information, not medical advice. For any symptom, see a health professional.

Sources: [Laryngeal Fracture](https://www.ncbi.nlm.nih.gov/books/NBK562276/) (StatPearls (NCBI Bookshelf), 2023); [Laryngeal Injury](https://www.ncbi.nlm.nih.gov/books/NBK556150/) (StatPearls (NCBI Bookshelf), 2023); [Neck Trauma](https://www.ncbi.nlm.nih.gov/books/NBK470422/) (StatPearls (NCBI Bookshelf), 2023); [Tracheal Trauma](https://www.ncbi.nlm.nih.gov/books/NBK500015/) (StatPearls (NCBI Bookshelf), 2024); [Post-Intubation Laryngeal Edema](https://www.ncbi.nlm.nih.gov/books/NBK560809/) (StatPearls (NCBI Bookshelf), 2026).

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Representative model, for educational purposes only.

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Source: https://durgical.com/en/conditions/laryngotracheal-trauma/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/conditions/laryngotracheal-trauma/