High-velocity injuries such as firearms injuries (particularly high-velocity hunting or military rifle rounds) are uniformly devastating, fragmenting and destroying tissues of the larynx and surrounding structures. Lower-velocity penetrating injuries such as knife wounds may be minimally symptomatic initially, but post-injury edema or hematoma may lead to airway compromise. The severity will again depend on the mechanism. Airway obstruction can result immediately due to structural deformities, or can present later as post-injury edema increases and patients become symptomatic due to delayed airway obstruction. Less severe blunt laryngeal injuries can be sustained during sports or fisticuffs and may cause submucosal endolaryngeal injuries due to shearing forces that may not be immediately obvious on external examination, or may cause hyoid fractures. This can also lead to laryngotracheal separation due to shearing forces. This applies significant forces over a small area and can lead to severe crushing injury to the laryngeal (and/or tracheal) cartilage resulting in airway obstruction. The most severe case is the "clothesline" injury, and the classic scenario is a motorbike or snowmobile rider who strikes a small, stationary object such as a fence wire or tree branch that impacts the anterior neck below the helmet line. High-velocity injuries can fracture laryngeal and/or tracheal cartilages and lead to structural deformities of the larynx and trachea. The degree of severity often corresponds to the force applied as well as the area over which it is applied. It is usually evident by history or by primary trauma survey whether a patient has sustained a blunt versus penetrating neck trauma, but it is wise to remain vigilant and have a very low threshold to secure a surgical airway in any case of anterior neck trauma. Penetrating neck injuries have a formal algorithm discussed in another article, and the larynx is at risk for injury. Injury can occur when the neck is hyperextended due to trauma, such as in a rear-end automobile collision with a whiplash-type injury, or "clothesline"-type injuries where the exposed neck is impacted by a narrow-gauge object such as a tree branch or fence wire (often in the setting of motorcycle riding or snowmobiling), or when the larynx is intentionally targeted for damage during an assault (a direct strike to the neck to intentionally incapacitate the victim, or in strangulation). The larynx is typically protected from blunt trauma by the sternum and the mandible. Iatrogenic laryngeal injury can occur during bronchoscopy, emergent intubation, or percutaneous tracheostomy, and is discussed elsewhere in additional articles. Other causes include penetrating trauma, assault, attempted strangulation, near hanging, and clothesline-type injuries. Motor vehicle accidents are the primary cause of laryngeal injury, though the frequency has been dramatically reduced with the advent of seatbelts, airbags, and other advances in automotive safety equipment.
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