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Background
Tracheal injury is an uncommon presentation, and as many patients unfortunately die before arriving at the hospital, the true epidemiology is not known. Tracheal trauma consists of penetrating, blunt, and iatrogenic mechanisms. Often, injuries to nearby structures such as the esophagus, vasculature, and nerves occur. There are also cases of delayed tracheal injury, which may not be immediately clinically obvious but can be disastrous if not identified early. While bronchoscopy is the gold standard for diagnosis, there are signs of tracheal trauma that appear on CT and even x-ray. Additionally, multiplanar reconstruction allows for virtual bronchoscopies that are comparable to conventional bronchoscopy. Treatment can be conservative or surgical. We outline an approach to suspected tracheal injury in the setting of trauma. The focus will be on using imaging to change clinical outcomes through early identification, especially when the clinical presentation is nonspecific.

Educational Goals / Teaching Points
First, the early and accurate detection of tracheal trauma is crucial to reduce the significant morbidity and mortality associated with these injuries. Second, a low threshold of suspicion for tracheal injury facilitates timely decision-making and intervention in the setting of trauma. Third, injuries to neighboring structures, such as the esophagus, are often concomitant to tracheal injury following blunt and penetrating neck trauma.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
To begin, an overview of relevant neck anatomy will be presented, including the protective role of the cartilaginous rings. Next, the epidemiology of tracheal trauma will be discussed. Additionally, we will explain the etiology and pathophysiology in tracheal trauma, including blunt, penetrating, and iatrogenic mechanisms. We will discuss the different anatomical sites of injury, from the cervical trachea to the thoracic. Red flags in the clinical presentation that predict impending deterioration will be mentioned. We will also provide an approach to diagnosis in cases of suspected tracheal trauma, such as the role of x-ray, CT, fluoroscopy, and bronchoscopy and the pearls and pitfalls of diagnosis. Cases demonstrating findings such as subcutaneous emphysema, paratracheal air, pneumomediastinum and pneumothorax, and concomitant fractures will be shown. Indications for nonoperative versus surgical management will be stated. The short- and long-term complications of tracheal injuries and tips to identify concomitant injuries, such as esophageal trauma, will be provided.

Conclusion
Tracheal injury is uncommon but associated with high morbidity and mortality. Signs can appear on various radiological imaging modalities. Concomitant injury to neighboring structures such as the esophagus and cervical vasculature may be present. Keeping a low threshold of suspicion for tracheal injury can avoid deterioration and poor clinical outcomes.