The surgical airway

Traumatic airway injuries are rare in children, partly due to their unique anatomy. The larynx is well protected from direct blows behind the mandibular arch, and only a small portion of the trachea is unprotected above the manubrium due to the relatively short neck. Furthermore, the tracheobronchial tree is less prone to injuries as compared with adults due to its elasticity. A high index of suspicion is thus needed to adequately diagnose and manage pediatric airway injuries. Laryngotracheal injuries in particular may present with discreet initial symptoms that if undiagnosed may rapidly progress to loss of airway. The most important signs of laryngeal injury include hoarseness and subcutaneous emphysema. Tracheobronchial injuries often present with dramatic symptoms, the most common being pneumothorax, which does not resolve after placement of chest tube, or large persistent air leaks. Endoscopy is mandatory on suspicion of injury to the larynx, trachea, or bronchi. CT scan may be helpful in determining the extent of injury to the larynx. Correct management of the airway in laryngotracheal injuries has a direct impact on morbidity and mortality. Endotracheal intubation over a flexible bronchoscope during spontaneous ventilation and in halothane anesthesia is the method of choice in children, but it should be performed in the operating room with the possibility of emergency tracheotomy. Cricothyroidotomy should be avoided in all laryngotracheal injuries because this method may aggravate the injury. Most laryngotracheal injuries in children can be conservatively managed. Extensive injuries, including displaced fractures of the cartilage, injuries to the recurrent nerves, and laryngotracheal separation, require surgical intervention. Injuries to bronchi and the thoracic trachea that do not cause a persistent air leak, and where the lungs expand completely after insertion of chest tubes, may be managed conservatively. All other injuries to the tracheobronchial tree should be repaired surgically as soon as feasible. Induction of anesthesia and opening of the chest may make ventilation difficult and are best managed by selective intubation of the contralateral lung. Long-term outcome after laryngeal, tracheal, and bronchial injuries in children, if managed swiftly and accurately, is usually excellent unless other injuries are present. The final result is improved by early recognition and early surgical intervention. These children need to be followed endoscopically for months and sometimes years in order to diagnose and treat stenoses as soon as they occur. Long-term pulmonary function has been shown to be excellent. Children with bilateral recurrent nerve paralysis may not fully recover voice or airway.