Vol.2, No.9, 502-504 (2013) Case Reports in Clinical Medicine
Tracheal rupture developing after blunt thoracic
Hasan Kara*, Aysegul Bayir, Ahmet Ak, Necmettin Tufekci, Selim Degirmenci, Murat Akinci
Department of Emergency Medicine, Faculty of Medicine, Selçuk University, Konya, Turkey;
*Corresponding Author: hasankara42@gmail.com
Received 17 October 2013; revised 17 November 2013; accepted 7 December 2013
Copyright © 2013 Hasan Kara et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In accor-
dance of the Creative Commons Attribution License all Copyrights © 2013 are reserved for SCIRP and the owner of the intellectual
property Hasan Kara et al. All Copyright © 2013 are guarded by law and by SCIRP as a guardian.
Tracheal and bronchial injuries are life-threat-
ening traumas that usually develop after traffic
accidents or a fall from heights. The most com-
mon cause is motor vehicle accidents. Trache-
obronchial injuries develop in 1% - 2% of blunt
thoracic traumas. The mortality rate is 30% in
these patients and deaths usually occur within
the first hours. Sixty five percent of surviving
patients are diagnosed in later periods where
complications are frequent. In conclusion, clini-
cal evaluation and diagnostic tests should be
performed immediately and carefully. In this
study, a patient who developed tracheal rupture
after blunt cervical and thoracic trauma was pre-
Keyw ords: Blunt Cervical Traum a; Blunt Thoracic
Trauma; Tracheal Rupture
Tracheal and bronchial injuries usually develop as the
result of traffic accidents, a fall from heights, being
crushed, stab wounds or gunshot wounds. Tracheobron-
chial injuries may also develop due to elevated intratho-
racic pressure and rib fractures during cardiopulmonary
resuscitation. Tracheobronchial injuries develop in 1% -
2% of thoracic traumas. Approximately, 15% - 27% of
tracheobronchial injuries are tracheal ruptures which
have high morbidity and mortality rates [1]. Because of
the protective surrounding structures, mobility, elasticity
and cartilage support of the trachea, it is difficult to in-
jure. Tracheobronchial injuries may occur in varying
degrees and in different localizations from a simple tear
to total rupture [2]. The “fallen lung” sign may be ra-
diologically observed in total bronchial ruptures. Com-
puted tomography has proved to be beneficial in the de-
tection of pathologies in patients with thoracic trauma [3].
In tracheobronchial injuries, the best diagnostic method
is bronchoscopy. Treatment is the primary repair of the
tracheobronchial tree with the preservation of pulmonary
tissue. In tracheobronchial injuries, delay or the oversight
of diagnosis can lead to death or potentially fatal com-
plications such as respiratory insufficiency, mediastinitis,
sepsis, airway stenosis, bronchiectasis, recurrent pulmo-
nary infections and premanent pulmonary dysfunction.
Tracheobronchial injuries are an important issue to be
discussed due to the high mortality rates, the difficulties
in diagnosis and the continuing controversy with regards
to treatment methods.
A 25-year-old male patient was admitted with the
complaints of hoarseness and swelling in the cervical
region following a blunt cervical and thoracic trauma due
to an in-vehicle traffic accident. The Patient had no his-
tory of any disease. On admission, the patient was con-
scious, in good general condition, oriented, cooperative
and his Glasgow Coma Scale score was 15. His blood
pressure was 118/75 mmHg, RR was 18/min, heart rate
was 76 bpm and SO2 was 84%. On inspection, there
were superficial abrasions and lacerations of 2 cm on the
frontal midline region and of 1 cm on the dorsal aspect of
the nose and a swelling on the anterior of the neck. Res-
piratory sounds were equal in both hemithorax. On pal-
pation, there were crepitations consistent with subcuta-
neous emphysema in the anterior aspect of the neck.
Respiratory sounds were normal on auscultation. Other
systemic examinations were normal. With intravenous
contrasted cervical tomography, extensive air densities
were observed in the skin and subcutaneous soft tissues
Copyright © 2013 SciRes. OPEN ACCESS
H. Kara et al. / Case Reports in Clinical Medicine 2 (2013) 502-504 503
in the paratracheal and retropharyngeal regions and an
image consistent with tracheal rupture was observed at
the level of the 7th cervical vertebra and first thoracic
vertebra (Figures 1-3). On bronchoscopy, granulation
tissue at a 9 - 11 o’clock level, 1 - 2 cm distal to the vo-
cal cords and a covered rupture area were observed.
There was no air leakage at this point and the wound was
left for secondary recovery. The patient was hospitalized
at the Department of Thoracic Surgery for follow up and
treatment. The thorax tomography obtained a day later
revealed pneumomediastinum and subcutaneous emphy-
sema findings. The patient improved clinically and was
discharged 7 days later.
Thoracic traumas account for approximately 25% -
31% of all traumas. Tracheobronchial injury occurs in 1%
- 2% of blunt thoracic traumas [1,4]. In literature, various
information regarding the localization of tracheobronchial
injuries is available. While there are studies indicating
that injuries are most common in the trachea, some others
indicate that injuries are more common in the left bron-
chus and its branches. Injuries can be transverse, longitu-
dinal and complex [5,6]. In our blunt thoracic trauma case,
the tracheal rupture was located 1 - 2 cm distal of the vo-
cal cords.
Various mechanisms have been suggested for tracheo-
bronchial injuries. Hood et al. suggested that sudden chest
compression was the most important mechanism. With
rapid impact trauma, the antero-posterior diameter of the
thorax decreases and the transverse diameter increases.
With this effect, the lungs are separated from eachother
and bronchial rupture occurs due to the created tension
force at fixation points such as the carina and cricoid. In
addition, rupture may occur as the result of increased in-
trabronchial pressure due to the compression of the tra-
cheobronchial system between the sternum and coulumna
vertebralis [7]. Respiratory distress and subcutaneous
Figure 1. With intravenous contrasted cervical CT imaging.
White arrow; trachea, yellow arrow; tracheal rupture area, red
arrow; air density in the paratracheal area.
Figure 2. With intravenous contrasted cervical CT imaging.
White arrow; trachea, yellow arrow; tracheal rupture area, red
arrow; air density in the paratracheal area, green arrow; air
density in the subcutaneous soft tissues, blue arrow; air density
in the retrofarangial areas.
Figure 3. With intravenous contrasted cervical CT imaging.
White arrow; trachea, red arrow; air density in the paratracheal
emphysema are the most common findings in patients
with tracheobronchial injury. In tracheobronchial ruptures,
mediastinal and cervical emphysema can be seen without
pneumothorax development if the mediastinal pleura is
durable [8,9]. Our patient had subcutaneous emphysema
without penumothorax. We associated the absence of res-
piratory distress with the perforation being partial and co-
Complications such as total rupture can occur in cases
with partial tracheal and bronchial rupture during intuba-
tion. In bronchial ruptures, intubation in the healthy side
of the bronchus should be performed with a double lumen
tube. Our patient did not require intubation.
In tracheobronchial injuries, definite diagnosis can be
made with bronchoscopy. However, 3-dimensional spiral
tomography is also important for diagnosis. Diagnosis is
difficult if the mediastinal pleura is intact. Bronchoscopy
Copyright © 2013 SciRes. OPEN ACCESS
H. Kara et al. / Case Reports in Clinical Medicine 2 (2013) 502-504
Copyright © 2013 SciRes. OPEN ACCESS
may give 20% - 40% false negative results and this ratio
increases if the bronchial injury is associated with other
organ injuries. Fiberoscopy is preferred in patients with
head-neck and cervical injuries. This also increases the
ratio of false negativity. So bronchoscopy should be re-
peated if the suspicion of rupture continues [5,8]. Our
patient had a nasal fracture in addition to the tracheal
rupture. On bronchoscopy, granulation tissue and covered
rupture site were observed at a 9 - 11 o’clock level, 1 - 2
cm distal to the vocal cords.
Treatment of tracheobronchial injuries is divided into
two methods: surgical and conservative. Care should be
taken to preserve lung parenchyma during operative pro-
cedures and bronchoscopic techniques should be per-
formed. Conservative treatment is sufficient if the bron-
choscopic trauma is at a perimeter less than 1/3 of the
trachea or bronchus, if air leakage is prevented with tube
drainage and if total lung expansion is obtained. Conser-
vative treatment methods include intubation, tracheo-
stomy and patient monitorization [8]. Our patient did not
have primary repair. The wound was left to recover sec-
ondary. Secondary repairs are required due to delays in
diagnosis in 17% - 27% of patients. Patients on average
apply to hospitals within 1 - 3 months. The lungs can be
expanded by a successful primary anastomosis even if
there is a delay in diagnosis and on average can become
functional at the end of 2 - 6 months [10,11]. In some
patients, stenosis may develop at the anastomosis site
following primary repair of the ruptured area. Endoscopic
dilation [bronchoscopic dilation, laser, cryotherapy, elec-
trocautery and stent implantation] may be performed in
patients who develop anastomotic stenosis [12].
In conclusion, the early diagnosis of tracheobronchial
ruptures, which may vary from simple tears to total rup-
tures and present with different clinical signs, is important.
Clinical evaluation and diagnostic tests should be per-
formed carefully and rapidly. Tracheobronchial rupture
should be suspected in all patients who have massive air
leakage after blunt thoracic trauma, mediastinal or subcu-
taneous emphysema with penumothorax and non-ex-
pansed lungs. Bronchoscopic evaluation should only be
performed under conditions where emergency surgery can
be performed. This life-threatening condition may be
controlled with intubation or tracheostomy. In addition,
care should be taken on the follow-ups after discharge in
patients with thoracic trauma and intervals should be fre-
quent within the first 3 months after trauma. Thus, the
injuries overlooked on the initial assessment may be rec-
ognized at a later period.
[1] Lee, R.B. (1997) Traumatic injury of the cervicothoracic
trachea and major bronchi. Chest Surgery Clinics of
North America, 2, 285-304.
[2] Grillo, H.C. (2000) Management of nonneoplastic dis-
eases of the trachea. In: Shields, T.W., LoCicero III, J.
and Ponn, R.B., Eds., General Thoracic Surgery, 5th Edi-
tion, Lippincott W&W Company, Philadelphia.
[3] Karaaslan, T., Meuli R., Androux, R., Duvoisin, B., Hess-
ler, C. and Schnyder P. (1995) Traumatic chest lesions in
patients with severe head trauma: A comparative study
with computed tomography and conventional chest ro-
entgenograms. Journal of Trauma, 39, 1081-1086.
[4] Tom ınaga, G.T., Waxman, K., Scannell, G., Annas, C., Ott,
R.A. and Gazzanıga, A.B. (1993) Emergency thoraco-
tomy with lung resection following trauma. Am Surg, 59,
[5] Yavuzer, Ş., Akay, H., Akalin, H., Aslan, R., Özyurda, Ü.,
Isın, E., et al. (1978) Trakeobronkial yaralanmalar. Mavi
Bülten (Turkish Art icle), 10, 211-225.
[6] Oto, Ö., Açıkel, Ü., Tuzun, E., Silistreli, E., Gürcan, U.,
Karabay, Ö., et al. (1997) Repair of bronchial disruption
in a young patient and new horizons in diagnostic tech-
niques. Turkish Journal of Thoracic and Cardiovascular
Surgery, 5, 292-295.
[7] Hood, M.R. (1989) Injury to the trachea and major bron-
chi. In: Hood, M.R., Arthur, B.D. and Culliford, A.T., Eds.,
Thoracic Trauma, WB Saunders Company, Philadelpia.
[8] Kaptanoğlu, M., Nadir, A., Erbaş, E., Gönlügür, U., Sey-
fikli, Z., Doğan, K., et al. (2001) Tracheobronchial inju-
ries: A review of 15 cases. Turkish Thoracic Journal, 2,
[9] James, L.G. and James, N.A. (1977) Major airway injury
in closed chest trauma. Chest, 72, 63-66.
[10] Petrowskij, B.W., Perelman, M.I. and Sedowa, T.N. (1976)
Reconstruction surgery in post-traumatic constrictions
and stenoses of the main bronchus. Zentralblatt fur Chi-
rurgie, 1, 897-905.
[11] Logeais, Y., Florent, G.D., Danrigal, A., Barre, E., Maurel,
A., Vanetti, A., et al. (1970) Traumatic rupture of the right
main bronchus in an eight-year-old child successfully re-
paired eight years after injury. Annals of Surgery, 172,
[12] Maiwand, M.O., Zehr, K.J., Dyke, C.M., Peralta, M., Ta-
djkarimi, S., Khagani, A., et al. (1997) The role of cryo-
therapy for airway complications after lung and heart-
lung transplantation. European Journal of Cardio-Tho-
racic Surgery, 12, 549-554.