As a result, he hit his head on the edge of the front seat, which forced his neck back. Neck movements were unrestricted but the patient was extremely agitated because of conspicuous neck pain. In addition, his right cricoid bone was tender during palpation. Anteroposterior and lateral cervical radiographs obtained on admission showed normal cervical spine, and neck structures. A lateral cervical radiograph demonstrated a slight fracture line and displacement of the hyoid bone Fig.
A cervical computed tomography CT scan was performed because of persistent neck pain and it revealed a conspicuous fracture of the right greater horn of the hyoid bone with local swelling of adjacent soft tissue Fig.
Consequently, the patient was referred to the otorhinolaryngology department. Indirect transoral laryngoscopy showed symmetrical motion of the bilateral vocal cords with no edema or lacerations of the airway. In addition, he was treated with oral analgesics and a cold compress was applied to the neck. There was no subcutaneous emphysema or compromised airways during a physical examination. His vital signs remained stable and he was discharged after 24 h, with a recommendation to limit neck movement and consume a liquid or soft diet for a few days.
He was told to return to the otorhinolaryngology department for a follow-up exam. This index case focuses on managing a patient with an uncommon isolated fracture of the right greater horn of the hyoid bone sustained in a traffic accident.
The patient had no concomitant injuries. Blunt neck trauma is usually caused by a motor vehicle accident, strangulation, sport injury, or assault [ 9 ]. In the present case, direct blunt trauma in the form of a head-on collision with his seatbelt unfastened at the time of injury was delivered to the neck region of the body resulting in hyperextension of the cervical spine. The hyoid bone is a horseshoe-shaped, solitary bone localized at the level of the third and fourth cervical vertebrae in the front of the neck, which has a body and two greater and two lesser horns [ 5 ].
It is located below the protruding part of the mandible, just above the thyroid cartilage as a hanging styloid protrusion that supports movement of the tongue in front of the cervical spine.
These structures protect the hyoid bone from direct-impact injury [ 10 , 12 , 13 ]. Although it does not directly make a joint, the hyoid is a sensitive bone on which the cervical and tongue muscles are attached, and is very close to vital formations [ 13 ].
Hyoid bone fractures mostly occur in cases of hanging, manual strangulation, and drowning [ 1 , 14 ]. These fractures may occasionally be due to direct blunt trauma [ 15 ].
The rarity of a hyoid fracture is related to the omnidirectional movement ability of the hyoid bone between the mandible and cervical spine [ 8 ]. Protection of the hyoid by the surrounding bones decreases during hyperextension [ 7 ].
Even without direct trauma, a hyoid bone fracture can be caused by sudden cervical hyperextension [ 16 ]. In the present case, the fracture was due to direct blunt trauma due to hyperextension of the cervical spine. A physical examination, cervical radiographs, a CT scan, and direct laryngoscopy are valuable for diagnosing a hyoid bone fracture [ 5 ]. Anteroposterior and lateral cervical radiographs remain the gold standard to diagnose this injury [ 17 ]. However, a hyoid bone fracture may not be detected easily on a frontal cervical radiograph and may be relatively subtle on lateral cervical radiographs [ 12 ].
Thus, a cervical CT scan should be taken to confirm suspicion of a hyoid bone fracture [ 8 , 12 ]. The patient was alert and cooperative and his presenting symptoms were dysphonia, neck pain, odynophagia and dysphagia. He did not complain of shortness of breath, cough or gagging.
Examination of the neck did not reveal swelling or surgical emphysema. He underwent flexible nasolaryngoscopy which showed significant swelling of the left side of larynx left arytenoid, left aryepiglottic fold and left piriform recess.
The mobility of the left vocal fold was impaired however there were no signs of compromise of the supra-glottic airway nor injury of the hypo pharynx nor bleeding. A Computerized Tomography with contrast showed isolated fracture of the hyoid bone in the right para-median region Figure 1 and oedema of the left larynx Figure 2.
The patient was therefore admitted to ENT department where he was started on high-dose IV Steroids Beclometasone 4mg twice a day for three days to reduce pain and swelling. The dose of Steroids was then gradually reduced and after a week it was suspended. After three days we repeated a nasopharyngoscopy and we observed an improvement of the laryngeal haematoma and oedema as well as a reduction of dysphagia. The patient steadily improved and he was discharged a week later.
A follow up endoscopy was performed two weeks after discharge and demonstrated a complete healing of the laryngeal trauma. A recent review of literature has showed that this type of fractures are increasingly resulting from road traffic accidents, while in the past strangulation was reported to be the most frequent cause.
Fractures of the hyoid bone are infrequent because of the anatomic location of the bone. The U-shaped bone is well protected anteriorly and laterally by the protruded mandible and posteriorly by the cervical spine. The anatomic relationships of the hyoid bone make it extremely difficult for an isolated fracture to occur when patients are in a relaxed position.
As a result of its relationship to the surrounding structures, fractures of the hyoid bone are often associated with injuries to the mandible, cervical spine, larynx, and pharynx. These related injuries tend to be more medically urgent, and as a result, fractures of the hyoid might not be recognised immediately. The most common symptoms includes pain in the anterior neck, abnormalities related to swallowing such as dysphagia or odynophagia, and pain upon head rotation.
The most common finding on clinical examination is tenderness during palpation of the anterior neck, visible swelling of the neck, and inability to completely rotate the head. Several techniques have been reported to improve visualisation of the pyriform sinuses and post-cricoid areas.
These techniques includes: modified Valsalva manoeuvre, Trumpet manoeuvre and skin traction. Spielmann et al. Diagnosis is usually confirmed the use of CT scans. Cases are managed individually with decisions made on the basis of associated injuries, symptoms, and potential or actual complications. The age-dependency of hyoid fracture correlated with the degree of ossification or fusion of the hyoid synchondroses.
The shape of the hyoid bone was also found to differentiate fractured and unfractured hyoids. Fractured hyoids were longer in the anterior-posterior plane and were more steeply sloping when compared with unfractured hyoids.
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