What is the best diagnostic modality for a patient with neck pain, dysphagia, hoarse voice, stridor, and crepitus after a motor vehicle collision (MVC)?

Diagnostic Approach for Neck Trauma with Airway Compromise

Fiberoptic laryngoscopy is the most appropriate initial diagnostic modality for this patient with neck trauma presenting with dysphagia, hoarse voice, stridor, and subcutaneous emphysema.

Clinical Presentation Analysis

The 23-year-old male patient presents with concerning symptoms following motor vehicle collision:

• Neck pain
• Dysphagia (difficulty swallowing)
• Hoarse voice
• Anterior neck tenderness
• Stridor (abnormal, high-pitched breathing sound)
• Subcutaneous emphysema (crepitus around the neck)

These findings strongly suggest laryngeal trauma with potential airway compromise, which requires immediate evaluation.

Diagnostic Modality Selection

Fiberoptic Laryngoscopy

• Primary indication: The constellation of symptoms (hoarse voice, stridor, crepitus) suggests direct laryngeal injury that requires immediate visualization 1
• Allows direct assessment of:
  • Vocal fold mobility
  • Laryngeal mucosal integrity
  • Airway patency
  • Extent of trauma to laryngeal structures
• Critical for evaluating laryngeal patency after trauma to assess need for surgical intervention (e.g., tracheotomy) 1
• Plays a crucial role in determining the need for immediate airway intervention

Why Not Other Modalities?

1. Cervical Spine CT

   • While valuable for bony injuries, it does not adequately visualize laryngeal soft tissue injuries
   • Should be performed after airway assessment in this case
   • Cannot evaluate vocal fold function or mobility

2. Neck Radiographs

   • Limited sensitivity for laryngeal injuries
   • Cannot assess functional impairment of vocal cords
   • Suboptimal for soft tissue evaluation 1

3. Neck Ultrasound

   • Limited in evaluating deep laryngeal structures
   • Cannot adequately assess airway patency in acute trauma
   • Not recommended as first-line for suspected laryngeal injury

Management Algorithm

1. Initial Airway Assessment

   • Immediate fiberoptic laryngoscopy to evaluate laryngeal injury and airway patency 1
   • Prepare for possible emergency airway intervention if severe injury identified

2. Secondary Imaging

   • After airway is secured/assessed, obtain CT imaging of neck with IV contrast
   • CT will help evaluate:
     • Cervical spine integrity
     • Vascular structures
     • Extent of laryngeal/tracheal injury
     • Associated soft tissue injuries

3. Further Management Based on Findings

   • Mild injury: Observation, voice rest, steroids
   • Moderate-severe injury: Possible surgical intervention
   • Airway compromise: Secure airway (intubation or surgical airway)

Important Clinical Considerations

• Subcutaneous emphysema (crepitus) is a "hard sign" of aerodigestive tract injury that requires immediate evaluation 2
• Stridor indicates significant airway narrowing and is a medical emergency
• Hoarseness after trauma suggests vocal cord dysfunction or injury 3
• Multiple attempts at intubation can worsen laryngeal edema; early progression to surgical airway may be necessary if intubation is difficult 2

Pitfalls to Avoid

• Delay in airway assessment: Laryngeal injuries can progress rapidly with worsening edema
• Premature intubation: Unnecessary intubation can worsen laryngeal injury; FFL can help determine if intubation is truly needed 4
• Focusing only on cervical spine: While c-spine injury is common in MVC, the presenting symptoms strongly suggest direct laryngeal trauma requiring immediate evaluation
• Missing associated injuries: After airway assessment, comprehensive imaging is needed to evaluate for vascular or esophageal injuries

Fiberoptic laryngoscopy provides the most direct and immediate assessment of the laryngeal structures and airway patency in this patient with signs of significant laryngeal trauma, making it the most appropriate initial diagnostic modality.