Abstract
Objective
Fractures of the hyoid bone are rare occurrences. They are mainly caused by strangulation/asphyxiation injuries, trauma to the neck, and motor vehicle accidents (MVAs). As a result of their rarity, proper treatment guidelines are not in place for dealing with these injuries. In this study, a systematic literature review was conducted with the goal of identifying optimal management for patients with fracture of the hyoid bone.
Data Sources
MEDLINE and PubMed databases.
Review Methods
The MEDLINE and PubMed databases were searched for patients diagnosed with hyoid bone fracture. Further cases were obtained from the bibliographies of relevant articles. Full-text articles were obtained. Patient presentation, method of diagnosis, treatment regimen, and outcomes are discussed.
Results
Forty-six cases were collected from 36 articles. No randomized controlled trials regarding treatment of hyoid fractures were found. The most common etiologies were MVA, assault, and neck trauma during athletic activities. Most common presenting symptoms included dysphagia, odynophagia, and pain upon neck rotation. Most frequent presenting signs included anterior neck tenderness and swelling. Five cases out of 46 had surgical repair of the fractured hyoid bone. In the remaining 41 cases, 26 were treated with conservative management, which included rest/observation, diet changes, and analgesia, while the other 15 cases required tracheotomy or surgical treatment for related injuries. All patients survived and had excellent outcomes with resolution of symptoms.
Conclusion
This review shows that direct surgical treatment of hyoid fractures was performed in only 10.9% of cases. Both conservative and surgical management yielded positive outcomes.
Keywords
Fractures of the hyoid bone ( Figure 1 ) are extremely rare occurrences, accounting for only 0.002% of all fractures. 1 In the past, strangulation was believed to be the leading cause of these fractures. 2 However, hyoid bone fractures are increasingly resulting from automobile 3 and other types of accidents. 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. 4 Adding to the protection of the hyoid from fracture is its mobility in all directions. Its main function is to serve as an attachment site for the suprahyoid and infrahyoid muscles. The anatomic relationships of the hyoid bone make it extremely difficult for an isolated fracture to occur when patients are in a relaxed position. However, if the neck is hyperextended, 4 the hyoid becomes more vulnerable to fracture, as it loses some of its anatomic protection. Furthermore, 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. 5 These related injuries tend to be more medically urgent, and as a result, fractures of the hyoid might not be recognized immediately.
Axial (A) and 3-dimensional (B) computed tomography scans of the maxillofacial bone depicting a hyoid bone fracture (arrows).
The symptoms and physical findings of hyoid bone fracture can significantly vary. Patients may present with pain that is exacerbated by coughing or swallowing, and crepitus or tenderness may be noted upon examination. 5 Some patients may experience suffocation upon protrusion of the tongue, dysphagia, odynophagia, or various degrees of dyspnea. 3 Other patients may present with dysphonia or subcutaneous emphysema. 5 Although hyoid bone fractures are rare, they can pose serious threats to patients when they do occur. Most of the literature on the topic has focused on case reports. However, there is no definite consensus on how patients with these fractures should be managed. 4 In this study, we aim to systematically review the existing literature on hyoid bone fractures, focusing primarily on treatments, to determine the most appropriate management for this rare but potentially life-threatening condition.
Materials and Methods
A systematic review of published literature on cases of hyoid bone fractures was performed. This study qualifies as nonhuman subject research as per the protocol set by the institutional review board (IRB) of the University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark, New Jersey, and was thus excluded from IRB approval. All articles written in the English literature reporting at least 1 case of a patient suffering from a hyoid bone fracture were eligible. The bibliographies of identified articles also were extensively reviewed and used as an additional data source. Exclusion criteria included all foreign language articles, postmortem studies, purely radiographic or anatomic studies, and veterinary articles.
Literature Search Strategy
The MEDLINE database was searched from 1948 to February 1, 2012. The search was performed using the following keywords: “hyoid bone” and “fracture, bone.” A PubMed search was also performed for all articles with the following words in the title, abstract, or keywords: “hyoid bone fracture,” “fracture of hyoid bone,” and “hyoid fracture.”
Eligibility Criteria
Once the searches were completed, study selection was performed by 3 authors in an unblinded standardized manner. A decision was made to have a majority vote in case of discrepancies. The publications gathered were grouped by title, and duplicates were excluded. The abstracts of these articles were then reviewed to determine whether they met the inclusion and exclusion criteria described above.
Results
In total, 171 articles were identified of which 135 were excluded. The only discrepancy occurred in an article on a patient with an ossified stylohyoid ligament fracture. 6 This case was excluded after a majority vote. Exclusion criteria included postmortem studies (52), foreign language articles (35), articles relating to a topic other than hyoid bone fractures (26), veterinary articles (7), radiographic studies (7), anatomic studies (2), medico-legal literature (1), and not enough information (5). In total, 36 articles detailing 46 cases were found to meet the inclusion criteria ( Figure 2 ). These articles included 29 case reports2,4,5,7-32 and 7 case series.1,3,33-37 A summary of the included cases is listed in Table S1 (available at otojournal.org).
Flow diagram of identified, excluded, and included studies.
Demographics
Average (SD) age in the cases was 32.6 years (14.2 years), with a range of 15 to 66 years. Patients were male in 42 cases (91.3%). The presenting etiology for the hyoid bone fracture was found to be motor vehicle accident (MVA) in 17 cases (37.0%), assault to the neck in 10 cases (21.7%), inadvertent neck trauma (typically while engaged in athletic activities) in 8 cases (17.4%), fall in 3 cases (6.5%), gunshot wound in 3 cases (6.5%), vomiting in 1 case (2.2%), iatrogenic (after cervical spine surgery) in 1 case (2.2%), and unknown in 3 cases (6.5%).
Presenting Symptoms and Physical Examination
The most common presenting symptoms included pain in the anterior neck (14 cases, 30.4%), odynophagia (12 cases, 26.1%), dysphagia (13 cases, 28.3%), hoarseness/odynophonia (7 cases, 15.2%), pain on head rotation (7 cases, 15.2%), and dyspnea (4 cases, 8.7%). The most common findings on physical examination included tenderness when palpating the anterior neck (18 cases, 39.1%), swelling of the throat (13 cases, 28.3%), and subcutaneous emphysema (5 cases, 10.9%).
Radiographic and Laryngoscopic Examination
Radiographic examination was utilized in 43 (93.5%) cases to diagnose hyoid bone fracture. A plain film x-ray was utilized for 29 patients (63.0%). In 14 cases (30.4%), a computed tomography (CT) scan was used to confirm the diagnosis. In 2 of these cases, a negative CT scan was followed up with a nasoendoscopic examination with Valsalva maneuver, which confirmed a fracture of the hyoid bone. In 3 cases (6.5%), radiographic examination was not performed because the patient was rushed to the operating room. Diagnosis of hyoid bone fracture in this case was confirmed with open exploration of the neck.
Twenty-five (54.3%) cases reported performing a laryngoscopic or pharyngoscopic examination. Ten of these 25 cases (30.5%) reported a normal examination. Edema of the larynx was found in 7 cases (28.0%). Bleeding lacerations and hematoma of the pharynx was found in 7 cases (28.0%). Fragments of the hyoid bone protruding into the vallecula were seen in 1 case. 17
Associated Injuries
Major associated injuries were found in 20 cases (43.4%). The most common associated injuries were mandibular fractures (8 patients, 17.4%), spine vertebral fracture (6 patients, 13.0%), and LeFort III fracture (2 patients. 4.3%).
Treatment: Conservative Management Versus Surgical Treatment
Conservative management was defined as observation, rest, liquid or semisolid diet, insertion of a nasogastric or orogastric tube, and medication including analgesics or antibiotics. Surgical treatment included tracheotomy, any type of operation for neck exploration or repair of associated facial fractures and pharyngeal lacerations, and surgery directly targeting the hyoid bone fracture.
Forty-one cases out of the 46 were managed without surgical repair of the hyoid bone fracture. This included 26 patients managed conservatively and 15 patients undergoing surgical treatment but not having the hyoid bone fracture directly repaired. Tracheostomy was used in 9 of these 15 cases. The reason for tracheostomy was upper airway compromise in all cases. Five patients underwent an operation to repair the hyoid bone (10.9%). In 4 of these 5 cases, a fragment of the hyoid bone was removed. One patient underwent an operation to repair the hyoid bone fracture with tension-band wiring. 21
Outcome/Follow-up
Seventeen patients (46.8%) had a follow-up visit to assess for resolution of symptoms. Resolution or improvement of symptoms was noted in all patients with follow-up. No follow-up imaging was performed on these patients to ascertain repair or healing of the fractured hyoid bone. An additional 12 patients (25.5%) were noted to have reduction or resolution of symptoms before discharge from the hospital.
Discussion
Hyoid bone fractures, albeit rare, can potentially lead to fatal complications. This is typically due to upper airway edema. It is important to recognize the presenting features of hyoid bone fractures and the treatments commonly employed in the literature. In this systematic review, we found that the most common etiology of hyoid bone fracture was MVAs. Other common causes included direct trauma to the neck either through assault or while participating in team sports. The latter would typically cause hyoid bone fractures in younger children whereby a ball or puck or an opposing teammate would inadvertently hit the patient’s neck.
Males accounted for 91.3% of all patients suffering from hyoid bone fractures. It is undetermined whether the hyoid bone itself is anatomically more prone to fracture in males or whether males are involved in activities that predispose them to hyoid bone fractures.
Presenting symptoms of patients with hyoid bone fractures can vary widely. Our analysis found the most common symptoms to be pain in the anterior neck, abnormalities related to swallowing such as dysphagia or odynophagia, and pain upon head rotation. The most common physical examination findings were tenderness during palpation of the anterior neck, visible swelling of the neck, and inability to completely rotate the head. Laryngoscopic examination revealed an abnormality in 15 of 46 cases. These abnormalities typically included pharyngeal lacerations, hematomas, edema, and visualized fragments of the hyoid bone protruding through the pharyngeal mucosa.
Diagnosis was typically confirmed by radiographic imaging. Although in earlier studies the lateral radiograph was the imaging modality of choice, in recent years the use of CT scans has supplanted plain X-rays in confirming the diagnosis. In all cases published before 1998, patients were diagnosed using plain radiographs. However, in the 19 cases since 1998, 14 patients (73.4%) were diagnosed with CT scans. In 2 cases, a negative CT scan was found to be incorrect after a follow-up nasal endoscopic examination confirmed a hyoid bone fracture. 35 This finding suggests that even with a negative CT scan, when patients are symptomatic or have significant findings on physical examination, otolaryngologists should maintain a high degree of suspicion to prevent a missed diagnosis of hyoid bone fracture. A laryngoscopic examination may be warranted in the symptomatic patient with a negative CT scan but a high degree of suspicion for a hyoid bone fracture.
Associated injuries are commonly found in patients (20 of 47 cases) with hyoid bone fractures and often require more urgent attention and focus. Patients suffering from MVAs were most likely to present with other significant injuries. The most common associated injuries included mandibular fracture or dislocation, cervical vertebral fractures, and Le Fort III fractures.
Surgical treatment was undertaken in 5 patients specifically targeting the hyoid bone fracture. In 4 patients, the goal of the surgery was to remove the completely separated fragment of the hyoid bone. In 1 case, the hyoid bone fracture was repaired utilizing tension band wiring. This patient did well after the procedure, with resolution of dysphagia. All procedures were successful in resolving symptoms.
Conservative treatment, which included observation for 24 to 72 hours, rest, liquid or semisolid diet, insertion of a nasogastric or orogastric tube, and medication including analgesics or antibiotics, was utilized in 26 patients. All patients had either dramatic decrease or complete resolution of their symptoms in the follow-up period. Twenty-one patients underwent surgical management, including 9 patients who underwent a tracheotomy. In these 9 patients, the tracheotomy was performed because of upper airway compromise. Surgical treatment was undertaken in an additional 6 patients to repair pharyngeal lacerations and fractures. In these patients, although the fractured hyoid bone was visualized, it was left alone. Patients treated both conservatively and surgically fared well. Based on these cases, surgery was typically undertaken only to remove hyoid bone fragments that had completely separated and possibly invaded the pharyngeal mucosa.
In this review, we found that the 41 patients treated without surgical repair of the fractured hyoid had complete resolution of their symptoms. Furthermore, surgical intervention inherently carries risks. Since a hyoid bone fracture in itself without associated upper airway edema is considered a benign entity, physicians should proceed cautiously in recommending surgery. Nonetheless, the follow-up noted in the literature in all the cases managed conservatively was very limited. Further long-term studies on these patients would be useful to ascertain whether conservative treatment indeed resolves all symptoms associated with the hyoid bone fracture.
Based on this review, we recommend conservative management as the preferred treatment approach of hyoid bone fractures. Physicians treating hyoid bone fractures should first ensure airway patency, followed by assessment of other significant injuries. If neither airway obstruction nor other significant injuries exists, patients can be managed with observation for 24 to 72 hours, rest, liquid or semisolid diet, insertion of a nasogastric or orogastric tube, and medication including analgesics or antibiotics. During conservative management, if a patient’s condition deteriorates or does not improve in a timely fashion, reevaluation is warranted, with possible surgical intervention for a worsening course. Surgical intervention for the repair of hyoid bone fractures should be considered in patients with obvious laryngopharyngeal lacerations with protruding bony fragments on laryngoscopic examination. Tracheostomy should be considered in patients presenting with significant airway obstruction.
Obvious shortcomings of this study include all the limitations inherent to a systematic review. This type of study is limited by the quality of the available articles in the literature. Given the rarity of this entity, this study was based on case reports and small case series related to hyoid bone fractures. No multi-institutional studies, prospective studies, or randomized controlled studies were found on the analyzed subject. Consequently, the overall quality of the analyzed data was judged to be poor. A prospective controlled study comparing conservative management with aggressive surgical treatment (including tracheotomy) would yield more information on the best course of strategy. However, prospective studies may be difficult to perform given the rarity of hyoid bone fractures.
Conclusion
Based on the available data, nonsurgical management of the fractured hyoid bone was used as the most common method of treatment. Tracheostomy was reserved for patients with impending airway obstruction. Direct surgical repair of the hyoid bone fracture was reported in a limited number of cases. Patients treated surgically or conservatively all experienced excellent outcomes.
Author Contributions
Disclosures
Footnotes
References
Supplementary Material
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