Complete hyolaryngeal separation: A case report

INTRODUCTION

Penetrating neck injuries account for approximately 5–10% of all traumatic injuries but carry disproportionately high morbidity and mortality due to the presence of vital vascular, aero-digestive, and neurological structures within a confined anatomical space.¹ Among these, laryngeal trauma with hyolaryngeal separation is exceedingly rare and carries a high risk of airway compromise, aspiration, and long-term phonatory dysfunction.²

Self-inflicted sharp neck injuries add further complexity due to associated psychiatric comorbidities and delayed presentation in some cases. Prompt airway management, early surgical exploration, and precise anatomical reconstruction remain the cornerstones of management.³ We present a rare case of self-inflicted sharp neck trauma with hyolaryngeal separation successfully managed with emergency surgical intervention.

CASE REPORT

A 60-year-old male presented to the trauma and Emergency Department of our hospital approximately one hour after sustaining a self-inflicted horizontal incised wound over the anterior neck (zone II) using a kitchen knife. He was initially treated at the district hospital, where he received intravenous fluid resuscitation with securing peripheral lines, one dose of intravenous ceftriaxone (1 g), analgesics, and suturing of the incised wound with silk sutures was performed.

On arrival, the patient was conscious and oriented with a blood pressure of 126/78 mmHg, pulse rate of 88/min, respiratory rate of 18/min, and oxygen saturation of 98% on room air. The airway was patent; however, hoarseness of voice was present. In view of the isolated penetrating neck injury without a blunt trauma component, cervical spine injury was clinically ruled out based on the absence of neck tenderness, neurological deficits, and distracting injuries.

Secondary survey demonstrated a sutured horizontal incised wound measuring approximately 7 × 1 cm over zone II of the neck without active bleeding [Figure 1], no subcutaneous emphysema, no neurological deficits, no other external injury, and unremarkable abdominal and systemic examinations. According to the patient’s relative, he had never sought medical consultation for his depressive symptoms with social withdrawal and consequently was not on any regular psychiatric medication. He was a known case of bronchial asthma on regular inhalational therapy and had a history of chronic tobacco use for 30 years.

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Figure 1: A sutured incised wound over zone II of the anterior neck at presentation. The external appearance masked the severity of the underlying laryngeal injury, highlighting the risk of missed aero-digestive trauma following premature wound closure.

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Given the mechanism of injury, hoarseness of voice, and exposed deep cervical structures despite primary wound closure, a high index of suspicion for occult laryngeal injury was maintained. In accordance with Advanced Trauma Life Support principles, emergency surgical exploration was undertaken without preoperative imaging.

After shifting the patient to the operating theatre, the previously placed neck wound sutures were carefully opened, revealing exposed laryngeal structures [Figure 2]. In order to avoid further exacerbation of the existing laryngeal disruption and to prevent creation of a false passage, definitive airway control was achieved by passing an endotracheal tube through the neck wound under direct vision, followed by a formal distal tracheostomy. Orotracheal intubation was deliberately avoided due to the high risk of worsening the laryngeal injury.

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Figure 2: Neck wound after removing sutures with exposed larynx and other deeper structures.

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Surgical exploration revealed complete hyolaryngeal separation, transacted strap muscles, visible thyroid cartilage and superior poles of the thyroid gland, a transacted epiglottis separated from the thyroid cartilage, an intact posterior hypopharyngeal wall, preserved vocal cord mobility, and no injury to the carotid vessels, jugular veins, esophagus, or trachea [Figure 3]. A distal tracheostomy was done for definitive airway control, and the endotracheal tube was removed. Laryngo-hypopharyngeal reconstruction with thyrohyoidopexy was done with interrupted PDS 3-0 sutures, along with placement of a subplatysmal suction drain under general anesthesia [Figure 4].

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Figure 3: Distal tracheostomy done for a definitive airway.

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Figure 4: Intraoperative disruption of the thyrohyoid membrane with visible thyroid cartilage and the superior pole of the thyroid. Laryngo-hypopharyngeal reconstruction with thyrohyoidopexy done with interrupted PDS 3-0 sutures

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Postoperatively, the patient was successfully weaned off mechanical ventilation on postoperative day (POD) 3 and continued on room air with the tracheostomy in situ. Enteral nutrition was administered via a nasogastric tube. The suction drain was removed on POD 6. Subsequent otorhinolaryngology assessment with indirect laryngoscopy performed on POD 14 demonstrated intact epiglottic mobility and preserved vocal cord movement. The patient showed progressive clinical improvement, with stable respiratory parameters and a well-healed neck wound. Psychiatric evaluation was undertaken, and antipsychotic and anxiolytic therapy were initiated. He was discharged while tolerating nasogastric feeds, with the tracheostomy tube left in situ for continued airway protection.

The Patient was advised OPD follow-up for decannulation of the tracheostomy tube and swallowing assessment; however, he chose to consult the same specialist at an outside hospital and was subsequently managed according to their recommendations.

DISCUSSION

Penetrating neck injuries constitute a challenging subset of trauma due to the high density of vital vascular, aero-digestive, and neurologic structures within a confined anatomical space. Although they represent a small proportion of overall trauma cases, they are associated with significant morbidity and mortality, particularly when the larynx and hypopharynx are involved.¹ Self-inflicted sharp neck injuries are relatively uncommon and are frequently associated with underlying psychiatric illness, delayed presentation, and complex injury patterns.²

This case illustrates the risk of missed laryngeal injury following premature wound closure. Primary suturing at the initial treating facility obscured the severity of internal damage, delaying definitive diagnosis and emphasizing the importance of advanced trauma life support (ATLS)-based airway assessment before wound closure.

The presence of hoarseness, exposed cartilage, and suspected structural laryngeal disruption constitutes hard signs mandating immediate surgical exploration. In such cases, bypassing imaging in favor of prompt exploration is consistent with established trauma guidelines.

Airway management in complex laryngeal trauma remains controversial. While orotracheal intubation may be considered in select cases, tracheostomy is widely regarded as the safest definitive airway in severe laryngeal injuries.

Early anatomical reconstruction is crucial, with studies demonstrating improved phonatory and swallowing outcomes when repair is performed within 24 hours.²

In the present case, the airway was initially threatened in view of hoarseness of voice, and the extent of laryngeal disruption warranted definitive airway control. Tracheostomy was preferred over endotracheal intubation to avoid further laryngeal injury and to facilitate postoperative airway management, consistent with current recommendations for complex laryngeal trauma.^4,5

Traditional management of penetrating neck injuries relied on mandatory exploration based on anatomical zones. However, contemporary practice supports a selective approach guided by clinical findings and imaging.³ The presence of hard signs such as exposed cartilage, air leak, and structural laryngeal disruption remains an absolute indication for immediate surgical exploration.^1,3 In this patient, operative exploration revealed preserved vocal cord mobility and an intact posterior hypopharyngeal wall, allowing for definitive single-stage reconstruction.

Anatomical restoration is the cornerstone of laryngeal trauma management. Early primary repair within 24 hours has been shown to significantly improve outcomes related to airway patency, voice quality, and swallowing.⁴ Thyrohyoidopexy was performed in this case to restore laryngeal suspension and continuity, which is essential for normal phonation and deglutition. Preservation of vocal cord mobility likely contributed to the favorable functional outcome observed.⁵

Self-inflicted cut-throat injuries constitute a distinct subset of penetrating neck trauma and are commonly associated with underlying psychiatric illness, including depression, psychosis, and acute psychosocial stress. Kumar et al.⁶ highlighted that such injuries frequently occur during periods of emotional distress and may be complicated by delayed recognition or incomplete initial evaluation, increasing the risk of missed aero-digestive tract injury. Unlike accidental or assault-related neck trauma, suicidal neck injuries often demonstrate variable wound depth and unpredictable internal damage. Survival and favorable outcomes depend not only on timely airway control and surgical repair but also on early psychiatric evaluation and intervention to address suicidal intent and prevent recurrence. The present case reinforces the importance of incorporating structured psychiatric assessment and treatment as an integral component of multidisciplinary trauma care.⁶

Hyolaryngeal separation is a rare laryngeal injury, most commonly reported after high-energy blunt trauma, with sharp penetrating and self-inflicted mechanisms being uncommon.^2,4,5 Previously reported cases frequently describe associated vascular or aero-digestive injuries and poorer functional outcomes when diagnosis or repair is delayed.^1,2

In contrast, the present case involved a survivable self-inflicted sharp neck injury with preserved vocal cord mobility, enabling successful single-stage thyrohyoidopexy and favorable early phonatory and swallowing outcomes. The additional psychiatric comorbidity, as emphasized by Kumar et al. highlights the need for integrated surgical and psychiatric management in such cases.⁶

Postoperative care requires a multidisciplinary approach involving otolaryngology, psychiatry, and speech and swallow therapy.⁷ Common complications include aspiration, laryngeal stenosis, infection, and dysphonia.^4,7 Gradual improvement in phonation and swallowing in the present case underscores the importance of meticulous surgical repair and coordinated postoperative management. Psychiatric evaluation is particularly crucial in self-inflicted injuries to address underlying mental health disorders and prevent recurrence.²

This case highlights that even severe laryngeal trauma with hyolaryngeal separation can have favorable outcomes when managed with early airway control, prompt surgical exploration, and meticulous anatomical reconstruction within a multidisciplinary framework.

LIMITATIONS

Objective assessments of voice and swallowing function, such as Voice Handicap Index, Fiberoptic Endoscopic Evaluation of Swallowing (FEES), or video fluoroscopic swallow study, were not performed due to logistical constraints.

CONCLUSION

Self-inflicted penetrating neck trauma with hyolaryngeal separation is rare and potentially fatal. Early recognition, secure airway management, prompt surgical exploration, and meticulous reconstruction can result in favorable functional outcomes. This case highlights successful management despite the severity of injury and reinforces adherence to structured trauma protocols.