Blunt neck trauma can be a life threatening injury due to the presence of many vital organs in the neck. Most patients may die on the scene due to respiratory tract obstruction. Blunt tracheal injury along with esophageal injury is rare. Adequate reports are not available to estimate the frequency of this type of cases using the literature [2]. This mechanism of laryngotracheal injury is secondary to that caused by a rope/wire (33% of cases) and that caused by a metal bar (4% of cases) [3]. Quick deceleration produces a trimming power that disrupts the trachea. Most medical centers will have limited experience of combined blunt tracheoesophageal injury. The finding of tracheal injury secondary to nonpenetrating trauma is frequently challenging to make, since maximum number of patients presents with broad-spectrum indications. Timely presentation at a hospital and high levels of multi-disciplinary cooperation is beneficial for accurate clinical diagnosis and therapy. Furthermore, it is equally important to prevent serious complications, such as shock, sepsis and laryngeal stenosis.
Clinical examination plays a decisive role in trauma patients, although radiological imaging is routinely used. Numerous indications related to tracheal injury comprise aphonia, hoarseness, hemoptysis as well as subcutaneous emphysema. However, medical indications are broad-spectrum, while the diagnosis of laryngeal injury is assumed based on the existence of subcutaneous emphysema and voice changes. In the case described, the main injuries on presentation of this patient were only neck ecchymosis and widespread subcutaneous emphysema. Esophageal injuries, especially cervical esophagus, present obscure symptoms, and are easily misdiagnosed. In this case there was a posterior tracheal tear, as well as an esophageal injury, at the time of initial neck trauma. However, the main injuries on presentation of this patient did not produce descriptive symptoms. Esophageal injury was found by accident during the operation. If cervical esophageal injury is not diagnosed, it may lead to morbidities, such as mediastinitis, esophageal stenosis as well as tracheoesophageal fistula.
Except for clinical signs, the CT scan indicated the presence of subcutaneous emphysema and pneumomediastinum, which should raise suspicion of injury to the cervical trachea. Bronchoscopy examination can verify the depth and length of injury. Esophageal injuries might need both endoscopy as well as upper gastrointestinal contrast to identify any perforation. Although flexible endoscopy can directly visualize esophageal mucosa perforation, the examination needs to be conducted in a manner that avoids exacerbation of the injury. In this case, flexible fiber-optic bronchoscopy revealed a 2–3 cm longitudinal tear in the posterior tracheal wall, with the contents of adipose tissue extending into the trachea. Furthermore, there was slow deterioration of subcutaneous emphysema indicating an on-going air leakage. These findings mandated an emergency operation rather than conservative treatment.
The repair of cervical tracheoesophageal injuries is challenging for the surgeon because these damages are rare. A multidisciplinary preoperative assessment was encouraged. Prompt surgical reparation is the favored method of treatment for most patients with a trachea transmural tear, exceeding a length of 2 cm [4]. [4]Conservative treatment may be appropriate for patients with short lacerations in the upper third of the trachea, particularly if it does not include the complete thickness of the tracheal wall. Esophageal injuries might be managed conservatively with or without drainage techniques or through initial reparation depending upon the degree of the laceration as well as the location of esophageal injury [5]. In this case, there was slow deterioration of neck subcutaneous emphysema and this indicates tracheal injury that cannot be treated conservatively. The 1-stage reconstruction method is advisable due to immediate diagnosis and the nonappearance of substantial contamination. Early oral feeding should be avoided, and nutrition support should be given either through simple enteral nutrition or parenterally via the central venous system.