What is the management and treatment for a patient with a thyroid cartilage fracture from trauma?

Management of Thyroid Cartilage Fractures from Trauma

Immediate airway assessment and stabilization is the absolute priority in thyroid cartilage fractures, with supplemental oxygen, head-up positioning, and preparation for emergency surgical airway if any signs of respiratory compromise develop, followed by CT imaging to classify fracture severity and guide definitive management.

Immediate Assessment and Stabilization

Airway management takes precedence over all other interventions. The primary concern with thyroid cartilage fractures is acute airway compromise from laryngeal edema, hematoma formation, or structural collapse 1.

Critical Initial Actions

• Administer high-flow supplemental oxygen immediately via non-rebreather mask and position the patient in a head-up (reverse Trendelenburg or sitting) position to optimize airway patency and reduce venous congestion 1, 2
• Assess for signs of airway compromise using clinical indicators: difficulty breathing, stridor (though this may be a late sign), tachypnea, oxygen desaturation, difficulty swallowing, anxiety/agitation, and rapidly expanding neck swelling 3, 2
• Call for immediate senior anesthesia and ENT/trauma surgery support if any signs of airway compromise are present—do not delay intervention waiting for their arrival 1, 4
• Ensure portable lighting and emergency airway equipment are immediately available at bedside, including equipment for emergency cricothyroidotomy 3, 1

Airway Management Algorithm

If signs of airway compromise develop:

• Notify senior anesthetist immediately and prepare for emergency airway intervention 3, 1
• Use videolaryngoscopy at first intubation attempt to maximize success, and limit the number of attempts as multiple attempts worsen outcomes 1
• Consider awake fiberoptic intubation in stable patients with anticipated difficult airway, performed by experienced operators 3
• If cannot intubate, cannot oxygenate (CICO) situation develops, proceed immediately to scalpel cricothyroidotomy: perform maximum neck extension (if no cervical spine concerns), make horizontal incision with wide scalpel blade (size 10 or 20) through cricothyroid membrane, insert bougie as guide for 5.0-6.0 mm cuffed tracheal tube 1

Diagnostic Evaluation

Once airway is secured or confirmed stable:

• Obtain urgent CT scan of the neck with thin cuts to evaluate fracture displacement, number of fracture lines, associated laryngeal injuries, and presence of subcutaneous emphysema or hematoma 5, 6
• Perform flexible fiberoptic laryngoscopy by an experienced operator to assess vocal cord mobility, mucosal integrity, and degree of laryngeal edema 3, 5
• Consider barium swallow study if there is concern for pharyngeal or esophageal injury, though this is typically not urgent 5

Do not transport unstable patients to radiology—clinical diagnosis is sufficient to proceed with airway intervention if compromise exists 4.

Classification and Treatment Strategy

Thyroid cartilage fractures are classified based on displacement and associated injuries, which directly determines management 7:

Non-Displaced Fractures with Minimal Associated Injuries

Conservative management is appropriate for stable, non-displaced fractures 5, 7:

• Admit for 24-48 hours of close airway monitoring with serial examinations, as edema can progress over the first 24 hours 2, 5
• Administer prophylactic broad-spectrum antibiotics to prevent infection, particularly if subcutaneous emphysema is present 1, 5
• Consider intravenous dexamethasone to reduce laryngeal edema, though onset is not immediate 3
• Maintain voice rest and NPO status initially, advancing diet as tolerated based on swallowing assessment 5
• Increase frequency of observations to monitor for delayed airway compromise 2

Moderately Displaced Fractures with Intralaryngeal Defects

Surgical reduction is indicated for fractures that are moderately displaced (but not freely mobile), have intralaryngeal mucosal tears, or demonstrate displacement but fewer than three fracture lines 6, 7:

• Perform open reduction and internal fixation using miniplates for stable fixation, which provides excellent functional and radiological outcomes 6
• Alternative fixation technique: wire-tube fixation may be used for younger patients with soft, unmineralized cartilage where miniplate fixation is difficult 8
• Repair associated mucosal injuries at the time of fracture fixation to prevent granulation tissue formation and stenosis 7

Severely Displaced Fractures with Intralaryngeal Avulsion

Immediate surgical exploration and repair is mandatory for fractures that are freely mobile on examination, have more than two fracture lines, or demonstrate displacement greater than the width of the thyroid cartilage 6, 7:

• Perform emergency open reduction with internal fixation using miniplates or wire-tube technique 6, 8
• Repair intralaryngeal avulsion injuries including mucosal tears, vocal cord injuries, and arytenoid dislocations 7
• Consider temporary tracheostomy if severe edema or extensive mucosal injury is present, as this protects the airway during healing and allows for stenting if needed 7

Post-Stabilization Care

• Transfer to ICU or step-down unit for close postoperative observation, particularly in the first 24-48 hours when edema peaks 1, 2
• Maintain head-up positioning and avoid unnecessary positive fluid balances to minimize airway edema 1, 2
• Perform serial examinations to monitor for delayed complications including hematoma expansion, infection, or progressive edema 2
• Follow-up fiberoptic laryngoscopy at 1 month to assess healing, vocal cord function, and rule out stenosis 5

Critical Pitfalls to Avoid

• Do not underestimate injury in younger patients: soft, unmineralized cartilage in younger individuals does NOT provide protection—they are equally at risk for thyroid cartilage fractures 8
• Stridor is a late sign: by the time stridor develops, airway compromise is already severe and immediate intervention is required 3, 2
• Do not rely on absence of direct neck trauma: thyroid cartilage fractures can occur from indirect mechanisms such as sudden neck hyperflexion or hyperextension without visible external injury 9
• Do not delay imaging in stable patients: even minor voice changes or odynophagia warrant CT evaluation, as fractures may be present without obvious external signs 5, 9
• Untreated moderately displaced fractures cause permanent voice changes: while they may not cause stenosis, they result in noticeable phonatory deficits that justify surgical fixation 8