P. J. Ong, Z. Burton, R. Verma, Z. Green

Sheffield Children's NHS Foundation Trust, UK


A previously healthy 6 year old boy, presented with sudden onset of marked facial and neck swelling after blunt anterior neck trauma from falling directly onto a table edge. On arrival in the emergency department, he was noted to have significant subcutaneous emphysema to his face, scalp, neck, chest, abdomen and thighs with associated dysphonia. He was very distressed due to language barriers and inability to open his eyes. He was transferred to theatre for urgent airway management with ENT support. Successful oral intubation was achieved using a modified rapid sequence induction and a combined videolaryngoscope-flexible bronchoscope technique using a hyperangulated paediatric C-MAC blade. Initial bronchoscopy did not reveal any obvious tracheo-bronchial injury. CT scan showed a 4 mm right posterolateral tracheal lesion at the level of T1, plus small bilateral pneumothoraces and pneumomediastinum.

The endotracheal tube was advanced to ensure that the cuff was distal to the lesion, to prevent worsening of subcutaneous emphysema from positive pressure ventilation. The patient remained intubated for three days before a further microlaryngotracheobronchoscopy (MLTB) and oesophagogastroduodenoscopy (OGD). A small healing lesion midway along the right posterolateral trachea was noted.

He was extubated on day 4 and discharged home on day 7. He made a full recovery with no signs of aero-digestive injury at 4 week follow-up.


Major blunt cervical trauma is uncommon in children. Potential mechanisms of injury include falling and striking the neck on hard surfaces, bicycle handles, sports injuries and road traffic accidents (1). The superior position of the larynx and relatively mobile nature of the paediatric airway structures offer some protection in preventing serious laryngo-tracheal injuries (1,2). However, these injuries carry significant risk for morbidity and mortality because of associated damage to aero-digestive, vascular and neural structures in the neck.

Airway management in the presence of red flag symptoms (significant neck swelling, stridor, dysphonia, odynophagia) can be challenging (3) and airway strategies must be carefully considered in the paediatric population. Blind placement of an endotracheal tube can be risky due to the potential for creating a false passage. A combined videolaryngoscope-flexible bronchoscopy technique was chosen as it allowed rapid control of the airway under direct visualisation despite extensive swelling causing extremely restricted neck mobility.

Key points from our case study include the importance of keeping the child comfortable and calm by maintaining parental presence, close communication with the parent despite language barriers, and creating a safe and clearly communicated difficult airway management strategy. Pre-procedure communication of potential challenges and human factors facilitated good teamworking between Anaesthetics, ENT and the wider theatre team.


We thank the patient and his family for providing consent to the publication of this case report.


  1. The Paediatric Trauma Manual: blunt and penetrating neck trauma [Internet]. The Royal Children’s Hospital Melbourne [cited 2024 Jan 30]. Available from: https://www.rch.org.au/trauma-service/manual/Blunt_and_penetrating_neck_trauma/
  2. Marathe US, Tran LP. Pediatric neck trauma causing massive subcutaneous emphysema. The Journal of Trauma: Injury, Infection, and Critical Care. 2006 Aug;61(2):440–3. doi:10.1097/01.ta.0000229909.39338.ce
  3. Shilston J, Evans DL, Simons A, Evans DA. Initial management of blunt and penetrating neck trauma. BJA Education. 2021 Sept;21(9):329–35. doi: 10.1016/j.bjae.2021.04.002
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