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Case Report/Case Series |

Laryngeal Fractures in Lacrosse Due to High Speed Ball Impact FREE

Christopher French, MD1; Richard Kelley, MD1
[+] Author Affiliations
1Department of Otolaryngology, State University of New York (SUNY) Upstate Medical Center, Syracuse, New York
JAMA Otolaryngol Head Neck Surg. 2013;139(7):735-738. doi:10.1001/jamaoto.2013.3565.
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Published online

Importance  Men’s lacrosse is a fast-paced, high-collision sport with ball speeds in excess of 90 mph. Laryngeal fractures in lacrosse are a rarely reported injury. To increase awareness of this potential injury, we describe 3 male lacrosse players who sustained laryngeal fractures from lacrosse ball trauma to the neck.

Observations  The first patient sustained a minimally displaced, paramedian thyroid cartilage fracture and was managed with observation alone. The second patient sustained a depressed fracture of the left thyroid ala and was managed with closed reduction. The third case sustained a mildly displaced transcricoid fracture. He was managed with open reduction and internal fixation. All 3 patients returned to regular activities with near normal voice results by final follow-up.

Conclusions and Relevance  This is the first report of laryngeal fractures following lacrosse ball trauma to the neck. Lacrosse players are at risk for laryngeal injuries, and neck protection is only worn by the goalie. It is our hope that this series will raise awareness of this potentially lethal injury and prompt the sport to consider mandatory neck protection for all players.

Figures in this Article

Men’s lacrosse is a fast-paced, high-collision team sport that uses sticks to pass, catch, run, and score with a ball. The solid rubber ball, weighing 145 g (approximately 5 oz) and 63 mm in diameter, can reach speeds in excess of 90 mph when shot at the goal. Both offensive and defensive players can be in the path of shots on goal. Helmets, face masks, mouth guards, gloves, and upper body padding are required for all field players.1 Although lacrosse facemasks are elongated to offer some neck protection, actual throat protection is only required for the goalie, leaving the anterior necks of all other players potentially vulnerable to trauma.

Only 1 case of a lacrosse-related laryngeal fracture exists in the literature, and this was due to a stick injury.2 In recent years, 3 distinct cases of laryngeal fractures from lacrosse balls were managed at our institution with 3 separate treatment modalities. This series serves to increase awareness of this potential injury and to promote wider adoption of neck protection in this increasingly popular sport.

Case 1

A 20-year-old man with no significant medical history was struck on the right side of his neck by a high-speed lacrosse ball twice during practice. Immediately following the second trauma, he developed voice changes, hemoptysis, dyspnea, and odynophagia. He denied loss of consciousness or difficulty with neck flexion or extension. He was taken to a level I trauma center, where on arrival, his dyspnea had resolved and he was in no apparent distress. He was breathing comfortably without stridor, and vital signs including pulse oximetry were within normal limits.

He complained of right-sided neck pain and odynophagia. Examination revealed a tender, 3.5-cm area of ecchymosis overlying the thyroid cartilage. No subcutaneous emphysema or step-offs were detected by palpation. Flexible laryngoscopy revealed mild arytenoid edema and no mucosal lacerations, and both true vocal folds were symmetric and mobile. Computed tomographic (CT) imaging of the neck revealed a left-sided, minimally displaced, paramedian thyroid cartilage fracture without evidence of hematoma (Figure 1).

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Figure 1.
Case 1: Computed Tomographic Scan

Computed tomographic scan of the neck reveals a left-sided, minimally displaced, paramedian thyroid cartilage fracture.

Graphic Jump Location

The patient was admitted to the intensive care unit for overnight airway observation. He was treated with dexamethasone, antireflux medications, humidified oxygen, and voice rest, with continuous pulse oximetry. No desaturations were noted overnight, and his voice quality and odynophagia had improved by the next day. He was discharged home on the second hospital day with a tapering dosing of corticosteroids, antireflux precautions, and absolute voice rest. The patient remained asymptomatic and returned to playing lacrosse 5 months following the injury.

Case 2

An otherwise healthy 16-year-old male adolescent was struck on the anterior neck by a high-speed lacrosse ball during a game. Immediately following the injury, he developed odynophagia and changes in vocal quality. He was taken to a level I trauma center, where on arrival, he denied dyspnea and was in no apparent distress. He was breathing comfortably without stridor, and his vital signs, including pulse oximetry, were within normal limits. On examination, his voice was noted to be “raspy” in quality. His thyroid cartilage was tender to palpation without ecchymosis, subcutaneous emphysema, or palpable step-offs. Flexible laryngoscopy with stroboscopy revealed full mobility of both true vocal folds; however, there was a lack of vibration along the left true vocal fold. The posterior aspect of the left true vocal fold contained ecchymosis, diffuse edema, and a small mucosal laceration. Computed tomography of the neck revealed a depressed fracture of the left thyroid ala, along with a soft-tissue swelling in the posterior glottis (Figure 2A).

Place holder to copy figure label and caption
Figure 2.
Case 2: Computed Tomographic Scan and Intraoperative Photograph

A, Computed tomographic scan of the neck revealing a depressed fracture of the left thyroid ala. B, Intraoperative photograph during microdirect laryngoscopy demonstrating a posterior laceration of the left true vocal fold with an avulsed vocal process.

Graphic Jump Location

Intravenous dexamethasone was administered, and the patient was immediately taken to the operating room for microdirect laryngoscopy. This revealed ecchymosis and edema throughout the larynx, with a laceration along the medial margin of the anterior one-third of the left true vocal fold. In addition, a posterior laceration with avulsion of the left vocal process was noted (Figure 2B). A straight blade laryngoscope was used to perform closed reduction of the depressed thyroid alar segment. The anterior laceration was debrided, and the edges were reapproximated. The posterior laceration and avulsed arytenoid fragment were secured in place with suture repair. Postoperatively, the patient was monitored overnight in the intensive care unit and discharged the next day on absolute voice rest, antibiotics, and antireflux precautions. Three weeks later, stroboscopic examination demonstrated improved vibration of his left vocal fold. By 2 months, the patient had symmetric in-phase vibration, even in the upper registers.

Case 3

A 17-year-old male adolescent with no significant medical history was struck on the left anterior neck with a lacrosse ball during a game. Immediately following the injury, he noted throat pain, dysphagia, and changes in vocal quality. He was taken to a level I trauma center, where on arrival, he was in no apparent distress and was breathing comfortably without stridor, and his vital signs including pulse oximetry were within normal limits. Examination revealed tenderness over his anterior neck without ecchymosis or subcutaneous emphysema. Flexible laryngoscopy revealed ecchymosis and immobility of the left true vocal fold. A CT scan of the neck revealed a mildly displaced transcricoid fracture (Figure 3).

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Figure 3.
Case 3: Computed Tomographic Scan

Computed tomographic scan of the neck revealing a mildly displaced transcricoid fracture.

Graphic Jump Location

Stroboscopic evaluation revealed mild ecchymosis and edema of the left true vocal fold with minimal movement of the left arytenoid. However, his left true vocal fold demonstrated normal vibratory behavior. The patient was then taken to the operating room for further evaluation and management. Microdirect laryngoscopy revealed symmetrical positioning of the true vocal folds without visible mucosal lacerations. Palpation of the left arytenoid cartilage revealed hypermobility. The subglottic examination was notable for ecchymosis of the anterior right and posterior left regions, without hematoma or stenosis. Open exploration through an anterior neck incision was then performed. The right, anterior aspect of the cricoid cartilage contained an obvious fracture with 3 to 4 mm of displacement. The fracture was reduced and secured with a 2-0 polypropylene (Prolene; Ethicon Inc) suture in a figure-eight configuration. The wound was irrigated and closed. Microdirect laryngoscopy was then repeated, which revealed a symmetric subglottis with no obvious signs of submucosal collections or edema.

The patient was observed postoperatively in the intensive care unit, during which time no airway issues arose. He was discharged on absolute voice rest, antibiotics, and antireflux precautions. An additional stroboscopic examination on postoperative day 6 revealed resolving ecchymosis with continued immobility of the left vocal fold. Despite this, he was able to achieve complete glottic closure. Six weeks postoperatively, his speaking voice was improved, and he continued to achieve glottic closure. His left true vocal fold mobility remained limited at that time. Eight months after injury, the patient believed that his voice was “near normal.” Stroboscopy at that time revealed improvement in his left vocal fold paresis with continued complete glottic closure.

Laryngeal fractures can be life threatening if not identified and managed in a timely fashion. Ratstatter and colleagues2 reported a single case of a laryngeal fracture from a lacrosse stick. To our knowledge, our review is the first to specifically describe laryngeal fractures occurring in patients being struck by a ball. This case series demonstrates the broad spectrum of management options, including observation of a nondisplaced fracture, closed reduction of a depressed thyroid alar fracture with primary repair of mucosal laceration and vocal process avulsion, and open reduction with internal fixation of a displaced cricoid cartilage fracture. All modalities led to successful outcomes in these patients.

Tracheotomies were not necessary in any of the cases because airway distress was not present on arrival to the trauma center. This may be partially attributed to the prompt recognition of the injury, followed by immediate transfer to the emergency department and early administration of corticosteroids. Signs and symptoms suggestive of laryngeal trauma include respiratory distress, dysphagia, hemoptysis, stridor, subcutaneous emphysema, neck ecchymoses, inflammation, loss of the laryngeal prominence, and hyoid elevation.3 Any of these should alert coaches and trainers of impending laryngeal edema, and transfer to an emergency center for immediate airway evaluation and management should be a top priority. Although this series focuses on laryngeal fractures, blunt neck trauma can also involve other nearby structures including the carotid artery, leading to potentially serious consequences if not promptly recognized.4

In addition to promoting awareness of this rarely reported injury, this article also highlights the inadequacy of the required protective equipment for men’s lacrosse. Helmets have evolved to better protect players from concussion, and they contain a lower chin profile to better cover the mandible and anterior neck. However, as this report highlights, this protection can be inadequate. The resting neck height of players can vary, and changing head position during play may leave some areas of the neck exposed and susceptible to injury. At present, throat guards are commercially available, but they are only required for lacrosse goalies. Because shot balls travel the same velocity at all players in front of the goal, the topic of mandatory throat protection should be addressed at a national level and brought to the attention of lacrosse rulemaking committees. Resistance to this change may occur, as interviews with local players revealed that vanity was the most common reason for not wearing a throat protector. In addition, there is concern that neck protectors may limit downward neck motion, requiring the player to bend more at the hip to look at the ground.

Although these cases highlight this injury in male lacrosse players, female lacrosse players may also be at risk. Female lacrosse allows less physical contact and provides less protective equipment. However, as seen in this series and others, no physical contact is necessary for ball-related fractures.1,5 The ball in female lacrosse travels slightly slower, reaching speeds of 60 mph.1 Whether this can cause a laryngeal fracture is unknown at this time.

Hockey is another sport that involves a goaltender, players in front of the goal, and high-speed shots. Similar to lacrosse, a hockey puck weighs 170 g (approximately 6 oz), has a diameter of 76 mm, and can reach speeds in excess of 100 mph when shot at the goal. However, in hockey, most passes and shots are kept fairly close to the ice. The hockey goal is 1.2 m in height. In lacrosse, the ball is “cradled” and passed at shoulder level, and shots on the 1.8-m tall goal are made overhand, often at neck level. Similar to our series, Liberman and colleagues6 described 3 cases of laryngeal fractures occurring during ice hockey games, 2 of which were from shot pucks. Nevertheless, given the similarities between these series, ice hockey players other than the goalie may also benefit from improved neck protection.

In conclusion, although most lacrosse injuries occur from player-to-player contact,5 this series demonstrates 3 cases of laryngeal fractures in the absence of physical contact. Laryngeal fractures in lacrosse are a rarely reported injury. The possible consequences of this injury mandate that all coaches and trainers are familiar with the presenting signs and symptoms, allowing early identification and management of the airway if necessary. It is our hope that this series will raise awareness of this potentially lethal injury and prompt the sport to consider mandatory neck protection for all players.

Corresponding Author: Richard Kelley, MD, Department of Otolaryngology, SUNY Upstate Medical Center, 750 E Adams St, Syracuse, NY 13210 (KelleyR@upstate.edu).

Submitted for Publication: January 21, 2013; final revision received February 24, 2013; accepted March 4, 2013.

Author Contributions: Both authors had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Both authors.

Acquisition of data: Both authors.

Analysis and interpretation of data: Both authors.

Drafting of the manuscript: French.

Critical revision of the manuscript for important intellectual content: Both authors.

Administrative, technical, and material support: Both authors.

Study supervision: Kelley.

Conflict of Interest Disclosures: None reported.

Lincoln  AE, Hinton  RY, Almquist  JL, Lager  SL, Dick  RW.  Head, face, and eye injuries in scholastic and collegiate lacrosse: a 4-year prospective study. Am J Sports Med. 2007;35(2):207-215.
PubMed   |  Link to Article
Rastatter  J, Jatana  K, Leininger  L, Hall  J, Lowery  J.  Lacrosse-related laryngeal injury. Int J Pediatr Otorhinolaryngology Extra. 2009;4(2):96-99.
Link to Article
Sidell  D, Mendelsohn  AH, Shapiro  NL, St John  M.  Management and outcomes of laryngeal injuries in the pediatric population. Ann Otol Rhinol Laryngol. 2011;120(12):787-795.
PubMed
Schievink  WI, Atkinson  JL, Bartleson  JD, Whisnant  JP.  Traumatic internal carotid artery dissections caused by blunt softball injuries. Am J Emerg Med. 1998;16(2):179-182.
PubMed   |  Link to Article
Hinton  RY, Lincoln  AE, Almquist  JL, Douoguih  WA, Sharma  KM.  Epidemiology of lacrosse injuries in high school-aged girls and boys: a 3-year prospective study. Am J Sports Med. 2005;33(9):1305-1314.
PubMed   |  Link to Article
Liberman  M, Mulder  DS.  Airway injuries in the professional ice hockey player. Clin J Sport Med. 2007;17(1):61-67.
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure 1.
Case 1: Computed Tomographic Scan

Computed tomographic scan of the neck reveals a left-sided, minimally displaced, paramedian thyroid cartilage fracture.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.
Case 2: Computed Tomographic Scan and Intraoperative Photograph

A, Computed tomographic scan of the neck revealing a depressed fracture of the left thyroid ala. B, Intraoperative photograph during microdirect laryngoscopy demonstrating a posterior laceration of the left true vocal fold with an avulsed vocal process.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.
Case 3: Computed Tomographic Scan

Computed tomographic scan of the neck revealing a mildly displaced transcricoid fracture.

Graphic Jump Location

Tables

References

Lincoln  AE, Hinton  RY, Almquist  JL, Lager  SL, Dick  RW.  Head, face, and eye injuries in scholastic and collegiate lacrosse: a 4-year prospective study. Am J Sports Med. 2007;35(2):207-215.
PubMed   |  Link to Article
Rastatter  J, Jatana  K, Leininger  L, Hall  J, Lowery  J.  Lacrosse-related laryngeal injury. Int J Pediatr Otorhinolaryngology Extra. 2009;4(2):96-99.
Link to Article
Sidell  D, Mendelsohn  AH, Shapiro  NL, St John  M.  Management and outcomes of laryngeal injuries in the pediatric population. Ann Otol Rhinol Laryngol. 2011;120(12):787-795.
PubMed
Schievink  WI, Atkinson  JL, Bartleson  JD, Whisnant  JP.  Traumatic internal carotid artery dissections caused by blunt softball injuries. Am J Emerg Med. 1998;16(2):179-182.
PubMed   |  Link to Article
Hinton  RY, Lincoln  AE, Almquist  JL, Douoguih  WA, Sharma  KM.  Epidemiology of lacrosse injuries in high school-aged girls and boys: a 3-year prospective study. Am J Sports Med. 2005;33(9):1305-1314.
PubMed   |  Link to Article
Liberman  M, Mulder  DS.  Airway injuries in the professional ice hockey player. Clin J Sport Med. 2007;17(1):61-67.
PubMed   |  Link to Article

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Laryngeal fractures in lacrosse due to high speed ball impact. JAMA Otolaryngol Head Neck Surg 2013;139(7):735-8.