Bottom Line

• Recognize a threatened airway and mobilize expert help before imaging.
• Use CT for the framework and endoscopy for mucosa and function.
• Use ultrasound to add findings; never use a negative scan to clear suspected injury.
• Reassess and observe for evolving swelling; plan ENT follow-up.

Why It Matters

After anterior neck trauma, hoarseness, painful swallowing or focal laryngeal tenderness should trigger concern even when the patient looks comfortable. Cartilage displacement, bleeding and progressive edema can narrow the airway; the external examination may understate the injury. Ultrasound can add information, but it cannot clear the larynx.

Assess voice, work of breathing, stridor, oxygenation, neck swelling and crepitus. Stridor with respiratory distress, rapidly expanding swelling or emphysema, significant airway bleeding, or worsening oxygenation requires immediate expert airway management. Call ENT, anesthesia and the trauma team early. Do not send a deteriorating patient to CT or spend time obtaining ultrasound views. These priorities are supported by a 22-patient laryngotracheal-trauma series.

Traditional Tools

In a stable patient, CT and flexible laryngoscopy answer different questions. Arrange both according to the injury and specialist assessment; a reassuring result from one does not replace the other.

• CT neck: defines fractures, displacement, airway narrowing and associated soft-tissue injury. Use appropriate thin-section reconstructions. Select contrast or CT angiography when associated vascular injury is suspected, with trauma/radiology input. Buch et al. describe CT fracture patterns.
• Flexible laryngoscopy: evaluates mucosal injury, edema, airway patency and vocal-fold movement. It can often be performed awake; tolerance and airway stability determine the setting. See the pediatric laryngeal-ultrasound cohort.
• Ultrasound: may reveal an accessible anterior cartilage defect or abnormal motion at the bedside. Posterior injury, subcutaneous air, calcification and operator limitations can conceal pathology. It is an adjunct, not a substitute for CT/endoscopy.

Persistent clinical concern warrants specialist review despite a negative scan. Significant dysphagia, bleeding or suspicious imaging also raises concern for associated pharyngeal, esophageal or tracheal injury; targeted endoscopic evaluation is a specialist decision.

Ultrasound: Clinical Strengths

The useful bedside finding is a visible abnormality that increases concern: a discontinuity or step-off in the anterior cartilage contour, adjacent hematoma, or asymmetric vocal-fold movement. An apparent defect should be checked in a second plane and interpreted with the mechanism and examination.

Published trauma experience includes four adult cases reported by Adi et al. and 12 children reported by Jakubowska et al.. These demonstrate feasibility and complementary findings. They do not establish sensitivity, specificity or a safe negative-scan discharge rule.

 Pediatric Advantage

Less calcified cartilage may provide better acoustic windows in children. That technical advantage does not establish better trauma outcomes or remove the need for endoscopic assessment. A small airway also has less reserve when swelling develops.

In the 12-child trauma series, ultrasound demonstrated thyroid-cartilage fracture with local hematoma in two children and contributed information on vocal-fold movement. Immobility is a finding, not a diagnosis of nerve paralysis: joint injury or mechanical fixation may also impair movement. Specialist evaluation is needed.

How to Scan (Bedside POCUS)

1. Check that scanning is safe. Use only while airway assessment and definitive evaluation proceed. Stop if breathing, voice or swelling worsens.
2. Protect the neck. Maintain indicated cervical-spine precautions and the position that best preserves airway safety. Do not routinely extend an uncleared trauma neck. Follow NICE spinal-injury guidance.
3. Use a high-frequency linear probe (approximately 7–15 MHz), a shallow depth and gentle contact. Obtain transverse and longitudinal views of accessible thyroid and cricoid cartilage.
4. Look for contour disruption and adjacent soft-tissue abnormality. Compare the sides and confirm suspicious findings in another plane. Air and calcification can make the examination nondiagnostic.
5. If tolerated, assess vocal-fold movement during quiet breathing and brief phonation. Save labeled stills/clips and document which structures were not adequately seen.

Parmar et al. describe normal airway sonoanatomy in healthy adults; trauma findings are illustrated in Adi et al. Healthy-volunteer positioning and scanning feasibility must not override trauma precautions.

Diagnostic Accuracy

Vocal-fold-motion accuracy is not fracture accuracy. Studies by Izadi et al. and Friesen et al. report variable performance in non-trauma pediatric populations. Neither validates ultrasound to exclude traumatic cartilage fracture.

A negative or incomplete ultrasound leaves the clinical question open. It should not reduce the urgency of indicated CT, laryngoscopy or observation. Ultrasound-based injury grading and outcome benefit remain insufficiently validated.

Role in Airway Management

The airway plan follows the injury, not the ultrasound image. Distorted anatomy makes instrumentation hazardous. Avoid repeated blind attempts; an experienced airway team should choose the technique, with immediate surgical-airway capability. Depending on anatomy and urgency, this may involve endoscopically guided intubation or tracheostomy below the injury. A specialist case series and management strategy describes this individualized approach.

Ultrasound can help locate the cricothyroid membrane in selected settings. The randomized landmark-identification trial was not a laryngeal-trauma rescue trial and does not establish that scanning prevents failed intubation.

After initial stabilization: nondisplaced injuries with a stable airway may be managed conservatively under ENT supervision. Confirmed fractures generally warrant monitored observation with serial clinical and endoscopic reassessment, commonly for at least 24 hours; extend monitoring for evolving or extensive injury. The 80-patient Helsinki cohort documented delayed airway problems.

Displacement, unstable framework, substantial mucosal injury, exposed cartilage or vocal-fold immobility warrants urgent specialist consideration of operative evaluation and repair. A 2025 Australian cohort supports individualized decisions rather than a universal operation for every fracture. Steroids, acid suppression and other adjuncts vary by injury and local practice; they do not replace airway protection. Arrange follow-up for voice, swallowing and airway symptoms.

For examples of trauma sonography, see the focused-airway ultrasound case series.

Sources:

• Adi O. et al. Novel role of focused airway ultrasound in early airway assessment of suspected laryngeal trauma. The Ultrasound Journal. 2020;12:37. Four-patient case series.
• Jakubowska A., Zawadzka-Głos L., Brzewski M. Usefulness of ultrasound examination in larynx traumas in children. Polish Journal of Radiology. 2011;76(2):7–12. Twelve-child series.
• Izadi S. et al. Diagnostic Accuracy of Laryngeal Ultrasound for Evaluating Vocal Fold Movement Impairment in Children. Journal of Pediatric Surgery. 2024;59(1):109–116. doi:10.1016/j.jpedsurg.2023.09.017.
• Friesen T.L. et al. Feasibility and accuracy of laryngeal ultrasound for the assessment of vocal cord mobility in children. International Journal of Pediatric Otorhinolaryngology. 2022;159:111193.
• Parmar S.B. et al. Ultrasound: A novel tool for airway imaging. Journal of Emergencies, Trauma, and Shock. 2014;7(3):155–159. Healthy-volunteer sonoanatomy study.
• Buch K. et al. CT-based assessment of laryngeal fracture patterns and associated soft tissue abnormality. European Radiology. 2021;31(7):5212–5221.
• Marinone Lares S.G. et al. Paediatric Laryngeal Ultrasound: A Retrospective Cohort Study in Aotearoa New Zealand and an International Survey. Clinical Otolaryngology. Published online September 30, 2024. doi:10.1111/coa.14237.
• Siddiqui N. et al. Ultrasound Is Superior to Palpation in Identifying the Cricothyroid Membrane in Subjects with Poorly Defined Neck Landmarks: A Randomized Clinical Trial. Anesthesiology. 2018;129(6):1132–1139.
• Shaker K., Winters R., Jones E.B. Laryngeal Injury. StatPearls. Updated July 4, 2023.
• Glauser J., Effron D. Laryngeal Injuries: An Introduction. ACEP Now. October 2023:21–23.

• Pincet L, Lecca G, Chrysogelou I, Sandu K. External laryngotracheal trauma: a case series and an algorithmic management strategy. European Archives of Oto-Rhino-Laryngology. 2024;281:1895–1904. doi:10.1007/s00405-024-08456-9. Retrospective 22-patient series.
• Mäkitie RE, Nyman K, Ilmarinen T, Tapiovaara L. Changes in occurrence and management of laryngeal fractures at the Helsinki University Hospital during 25 years. European Archives of Oto-Rhino-Laryngology. 2024;281:915–924. Retrospective 80-patient cohort.
• Wong S, Hasan Z, Choo J, De Alwis N, Tudge S, Prasad J. Laryngeal fractures: a 5-year experience from an Australian major trauma centre. Australian Journal of Otolaryngology. 2025. doi:10.21037/ajo-24-78. Retrospective 24-patient cohort.