Purpose or Case Report: Traumatic laryngotracheal transection is an uncommon occurrence most often secondary to blunt trauma to the neck. The most commonly described mechanism is a “clothesline” injury or strangulation, involving high speed impact of the neck across a chain, rope, chord, or strap, usually associated with the use of a motor or recreational vehicle. It is often instantaneously fatal, and those who survive may have severe respiratory compromise requiring immediate advanced airway placement, or astonishingly, they may be asymptomatic. Tracheal transection may be identified when laryngoscopic intubation fails, during the placement of a surgical airway, or during initial CT or bronchoscopic evaluation.

We describe an 8-year-old male who experienced blunt neck trauma and was intubated successfully in the pre-hospital setting. Initial radiographic evaluation was significant for severe subcutaneous emphysema and pneumomediastinum. Bilateral thoracostomy tubes were placed. Initial CT evaluation again showed extensive pneumomediastinum without pneumothorax. Four days after initial hospitalization the patient was extubated without difficulty. Post-extubation chest x-ray showed irregular tracheal borders with focal hyperlucency adjacent the mid-cervical trachea in the former position of the endotracheal tube cuff. Repeat CT of the chest showed complete tracheal transection of the mid-cervical trachea. The patient subsequently underwent surgical repair and was discharged without complication. This is the first reported case of traumatic tracheal transection not identified on initial CT examination secondary to the position of the endotracheal balloon, with subsequent discovery of the complete transection on the post-extubation radiograph.

There is 1 reported case of tracheal transection identified on initial CT evaluation in the presence of a well-positioned endotracheal tube. Additionally, there is 1 reported case of tracheal transection not identified on initial CT evaluation, however the patient was not intubated and had minimal symptoms. Tracheal transection was confirmed via bronchoscopy in that case.

Tracheal transection is rare traumatic injury that can be difficult to identify. High clinical suspicion and careful examination with multiple modalities is often necessary to make a definitive diagnosis.
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