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\begin{document}

\title{Life Threatening Laryngeal Injury in Elite Rugby Union: Prevention and
management}



\author[1]{Bamidele Famokunwa}%
\author[2]{Simon  Kemp }%
\author[3]{Julia Selby}%
\author[4]{Gitta Madani}%
\author[4]{Guri Sandhu}%
\author[5]{James Hull}%
\affil[1]{Wexham Park Hospital}%
\affil[2]{Rugby Football Union}%
\affil[3]{Royal Brompton Hospital}%
\affil[4]{Imperial College Healthcare NHS Trust}%
\affil[5]{Royal Brompton and Harefield NHS Foundation Trust}%


\vspace{-1em}



  
  \date{May 27, 2024}


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\selectlanguage{english}
\begin{abstract}
Laryngeal injury is a life-threatening risk in contact sports.
Exercise-induced laryngeal obstruction (EILO) can occur as a result of
trauma. Athletes can return to monitored training within weeks of
laryngeal surgery. Due to the rarity and complexity of laryngeal trauma
in sport, effective management requires a multidisciplinary approach.%
\end{abstract}%



\sloppy


\textbf{Life Threatening Laryngeal Injury in Elite Rugby Union:}

\textbf{Prevention and management}

\textbf{KEY POINTS}

\begin{itemize}
\tightlist
\item
  Laryngeal injury is a life-threatening risk in contact sports carries
  and has severe morbidity.
\item
  Exercise-induced laryngeal obstruction (EILO) can occur as a result of
  trauma.
\item
  Athletes can return to monitored training within weeks of laryngeal
  surgery.
\item
  Due to the rarity and complexity of laryngeal trauma in sport,
  effective management requires a multidisciplinary approach for acute
  in-field management, hospital care, and the rehabilitation phase of
  recovery.
\item
  Future work should focus on improving understanding and then
  minimizing the risk factors underlying traumatic laryngeal injury in
  all sports.
\end{itemize}

\textbf{Keywords:} larynx, sport, breathing, fracture, trauma, rugby

\textbf{Key clinical message}

Laryngeal trauma is a life-threatening injury in contact sports. Due to
its potentially devastating consequences, the prevention, diagnosis, and
management of neck trauma both pitch side and at the hospital are
essential for athletes.

\textbf{INTRODUCTION}

Laryngeal trauma is a life-threatening injury resulting from above the
shoulder contact and can cause acute upper airway compromise with fatal
consequences. It accounts for between 1 per 14,000 to 30,000 accident
and emergency attendances(1). Due to its potentially devastating
consequences, the prevention, diagnosis and management of neck trauma
both pitch side and at the hospital are essential for athletes.

\textbf{MATERIAL \& METHODS}

In September 2017, a 28-year-old male international rugby player
sustained direct trauma to the left side of his neck during an English
Premiership match (Figure 1 and see
https://www.youtube.com/watch?v=TodNq3aGFzk).

He was immediately apnoeic for a few seconds, rapidly developing
respiratory compromise. He was given basic airway support with
supplementary oxygen and transferred to hospital.

Once stabilised, computer tomography (CT) imaging revealed a fracture of
the posterior cricoid cartilage into the left arytenoid (Figure 2).
Direct laryngoscopic revealed oedema and local haemorrhage (Figure 3A).
Using the Becker (modified Schaefer) classification of laryngeal trauma,
the injury was graded as a group 2(2). The fracture was managed
conservatively with intravenous steroids and clinical surveillance in a
high dependency unit, mandating a week-long stay in hospital.

\emph{Subsequent clinic management}

Specialist upper airway speech and language therapy (SLT) assessment one
week after injury revealed turbulence on inspiration, a weak, breathy
voice and swallowing impairment. Initial therapy focused on voice
conservation and postural adjustments to avoid further strain and
facilitate healing, use of core breathing patterns combined with
exercises to encourage vocal fold abduction.

Over eight therapy sessions, the intensity of laryngeal abduction and
forward resonance exercises was increased with improvements to both
voice and respiratory function. Biofeedback laryngoscopy was used to
improve laryngeal control for breathing.

\emph{Management of trauma-induced exercise-induced laryngeal
obstruction}

Despite intensive therapy, the patient remained breathless on exertion.
A diagnosis of exercise-induced laryngeal obstruction (EILO) secondary
to trauma was suspected. Continuous laryngoscopy during exercise (CLE)
test(3) was performed and revealed a prolapse of the left arytenoid,
which increased with exercise intensity.

He subsequently underwent a left arytenoidectomy five weeks after the
injury. Post-operative therapy was tailored to support a phased return
to fitness training. Attention was given to maintaining core breathing
patterns, in combination with effective laryngeal manoeuvres to maximise
glottal aperture, confirmed on laryngoscopy. He made his return to
training one month after surgery.

The CARE case report guidelines were used when writing this report.

\emph{Data availability statement}

The data that support the findings of this study are available on
request from the corresponding author. The data are not publicly
available due to privacy or ethical restrictions.

\textbf{RESULTS}

The SLT attended training sessions and monitored breathing symptoms as
exercise intensity increased. At eight weeks following laryngeal surgery
there was no compromise to breathing on exertion of up to 160bpm and
there was no discernible deficit in vocal function. He returned to
professional play in March 2018 (i.e. six months after the initial
injury).

\textbf{DISCUSSION}

Blunt laryngeal trauma can have immediately life threatening
consequences(4) which highlights the importance of sports clinicians
having a heightened awareness of this problem. Due to the rarity and
complexity of these cases, effective management requires a
multidisciplinary approach.

\textbf{Multidisciplinary approach to management}

\emph{On field management}

Ensuring that on-field medical staff have the appropriate competencies
in immediate care in sport is a key element of secondary injury
prevention programmes. English Premiership matches medical staff must
have completed a minimum of a yearly level three course in Immediate
Care in Rugby which includes advanced airway management with training in
needle cricothyroidotomy and the surgical airway. The medical staff at
English Premiership matches (who are level three trained) are
specifically trained in both the recognition and if required advanced
airway management in the prehospital setting.

\emph{In hospital -- conservative versus surgical}

The indication, timing, and nature of surgical intervention have been
largely dictated based on single centre case series. There is thus great
heterogeneity with the surgical approach(4,5). Bent et al(6) reviewed 77
patients with laryngeal trauma and concluded that conservative treatment
of Schaefer group 1 and 2 injuries was 100\% effective and surgical
repair within 48 hours for those requiring surgery improved outcomes.

Our patient was Becker group 2 with no indication for early surgical
intervention. The later development of trauma induced EILO necessitated
arytenoidectomy. EILO is a cause of exertional breathing
difficulties(7). The vast majority of cases are caused by supraglottic
closure of the laryngeal inlet(8). It is diagnosed using CLE(3), which
allows visualisation of the larynx during incremental bouts of exercise.
Treatment options vary greatly by centre and include specialist SLT for
laryngeal control, physiotherapy for breathing pattern work and
surgery(9). Due to the severity of the EILO and the lack of full symptom
resolution with conservative treatment, our patient was deemed to be a
candidate for surgery. We believe this to be the first case of trauma
induced EILO treated with arytenoidectomy.

\emph{Longer-term follow-up}

Successful longer-term management of this type of injury is dependent on
high quality MDT input. Following arytenoidectomy flow parameters
improved but were still attenuated to 66\% of predicted values. SLT
therefore provided tailored breathing techniques to maximise laryngeal
aperture during exercise. Deficits in voice and respiratory function may
only develop when exercise intensity increases so it is important that
specialist therapy is integrated with physical training sessions.

Our patient began training within six weeks of surgery and this speed of
return to sport is similar to the figures seen in a case series of
patients that had surgery for EILO(9).

\textbf{Considerations for safety in rugby}

Recent changes to tackle laws in rugby should act to reduce risk of
blunt laryngeal trauma. Specifically, in addition to enforcing current
rules, World Rugby trialled a new tackle height (the level of the
armpit), during the start of the 2018 Championship Cup season and
tacklers made contact with the ball carrier's head and neck 30\% less
often(10).

\textbf{CONCLUSION}

In conclusion, laryngeal trauma is a risk in contact sports such as
rugby and more extensive research is needed to evaluate its incidence
within the sport. The care of athletes who have sustained such an injury
is complex and it is mandatory to have a plan in place to manage the
acute in-field event but also the in hospital and multidisciplinary team
follow-up rehabilitation phase of recovery. Future work should focus on
improving understanding and then minimizing the risk factors underlying
traumatic laryngeal injury in all sports, to ensure that these
devastating injuries never occur in the field of play.

\textbf{Authorship}

BF: prepared this case report for scientific publication. SK: provided
details on the on the field management of rugby injuries. JS: provided
specialist speech and language therapy and contributed to the drafting
of the manuscript. GM: involved in the acquisition and reporting of the
imaging. GS: led the surgical care of the patient. JH: led in the
clinical care of the patient and contributed substantially to the
contents of the final version of this manuscript.

\textbf{Conflict of interest}

None declared.

\textbf{REFERENCES}

1. Gussack G, Jurkovich G, Luterman A. Laryngotracheal trauma: A
protocol approach to a rare injury. Laryngoscope. 1986;96(6):660--5.

2. Becker M, Leuchter I, Platon A, Becker CD, Dulguerov P, Varoquaux A.
Imaging of laryngeal trauma. Eur J Radiol {[}Internet{]}.
2014;83(1):142--54. Available from:
http://dx.doi.org/10.1016/j.ejrad.2013.10.021

3. Heimdal JH, Roksund OD, Halvorsen T, Skadberg BT, Olofsson J.
Continuous laryngoscopy exercise test: A method for visualizing
laryngeal dysfunction during exercise. Laryngoscope. 2006;116(1):52--7.

4. Mendis D, Anderson JA. Blunt laryngeal trauma secondary to sporting
injuries. J Laryngol Otol. 2017;131(8):728--35.

5. Jalisi S, Zoccoli M. Management of Laryngeal Fractures - A 10-Year
Experience. J Voice {[}Internet{]}. 2011;25(4):473--9. Available from:
http://dx.doi.org/10.1016/j.jvoice.2009.12.008

6. Bent JP, Silver JR, Porubsky ES. Acute laryngeal trauma: A review of
77 patients. Otolaryngol Neck Surg. 1993;109(3):441--9.

7. Nordang L, Norlander K, Walsted ES. Exercise Induced Laryngeal
Obstruction --- An Overview. Immunol Allergy Clin North Am.
2018;38(2):271--80.

8. Christiaan R, Magnus M, Drange O, Thomas R, Olofsson J, J\selectlanguage{ngerman}ørgen H, et
al. Exercise-induced laryngeal obstruction: natural history and effect
of surgical treatment. 2011;1485--92.

9. Famokunwa B, Sandhu G, Hull J. Surgical Intervention for
Exercise-Induced Laryngeal Obstruction: A UK Perspective. Laryngoscope.
2020;

10. Stokes KA, Locke D, Roberts S, Henderson L, Tucker R, Ryan D, et al.
Does reducing the height of the tackle through law change in elite men's
rugby union (The Championship, England) reduce the incidence of
concussion? A controlled study in 126 games. Br J Sports Med
{[}Internet{]}. 2019 Dec 19;bjsports-2019-101557. Available from:
http://bjsm.bmj.com/content/early/2019/12/18/bjsports-2019-101557.abstract

\textbf{FIGURE LEGENDS}

\textbf{Figure 1} Tackle sequence \textbf{(A)} Prior to the contact
being made \textbf{(B)} Initial contact of left shoulder into
neck\textbf{(B)} Shoulder rides up into face \textbf{(C)} Players fall
to ground. Link to video of injury -
https://www.youtube.com/watch?v=TodNq3aGFzk

\textbf{Figure 2 (A)} Axial CT demonstrating a fracture of the left
posterior cricoid cartilage (arrow). Note the arytenoid cartilage (*) is
interposed between the displaced cartilage fragments \textbf{(B)}Coronal
maximum intensity projection (MIP) reconstruction demonstrating the
widely separated fracture of the left posterior cricoid cartilage (block
arrow) resulting in disruption of the criocarytenoid joint. Note the
normal right cricoarytenoid joint (arrow)

\textbf{Figure 3.} Laryngoscopic appearances on (\textbf{A, B} ) day 6
revealing acute haemorrhage (arrow) and oedema similar to findings at
presentation, (\textbf{C} ) 6 weeks post arytenoidectomy (\textbf{D} ) 4
months post arytenoidectomy.\selectlanguage{english}
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\includegraphics[width=0.70\columnwidth]{figures/Figure-1-A-D/Figure-1-A-D}

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\includegraphics[width=0.70\columnwidth]{figures/Figure-2-A-B/Figure-2-A-B}

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\includegraphics[width=0.70\columnwidth]{figures/Figure-3-A-D/Figure-3-A-D}

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