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G. Cricotracheal (Laryngotracheal) Separation

Cricotracheal (laryngotracheal) separation, also known as a Group 5

injury, is the least common but most life-threatening laryngeal injury.

Most often, it occurs from “clothesline injuries” (i.e., when the neck

contacts a taut line, such as a clothesline or wire support), and results

in the separation of the larynx from the trachea at either the cricothy-

roid membrane or the cricotracheal junction.

Most patients with laryngotracheal separation present with significant

respiratory distress and require a tracheotomy. Performance of the

tracheotomy can be extremely difficult, however, because of the altered

anatomy that results from this injury. After laryngotracheal separation,

the larynx usually pulls upward and the trachea retracts into a position

behind the sternum, necessitating a low tracheotomy incision. After

successful tracheotomy, further radiologic testing, including chest x-ray

and CT scans, may be performed. Pneumothorax commonly accompa-

nies a laryngotracheal separation and must be promptly identified and

treated.

Following appropriate trauma evaluation and radiologic studies, the

patient should return to the operating room for direct laryngoscopy,

esophagoscopy, and tracheal repair. The severed ends of the laryngotra-

cheal complex should be freshened and then closed with nonabsorb-

able sutures with the knots placed extraluminally. Suprahyoid or

infrahyoid release maneuvers may be required in order to allow for a

tension-free anastamosis.

Most patients with laryngotracheal separation will also have bilateral

vocal cord paralysis due to stretching or tearing of the recurrent

laryngeal nerves. If the severed ends of the nerves can be located, they

should be repaired primarily.

H. Emergency Airway Management

Obtaining and maintaining a stable airway is the first and most impor-

tant goal in managing laryngeal trauma. When evaluating the stability

of the airway, it is important to remember that initially mild signs and

symptoms may accompany a very severe laryngeal injury. Further,

laryngeal injuries may evolve, progress, and worsen in a relatively short

period of time. Therefore, carefully performed flexible fiberoptic

laryngoscopy is a critical tool in the initial evaluation of the injured

airway.