A 7-year-old boy presented with neck (fig 1A), chest and abdominal contusions following a frontal impact motor-vehicle accident. He had severe dyspnoea with cyanosis, recessions, hoarseness, deep stridor and haemoptysis. Diffuse crepitus and oedema with neck asymmetry were also noted. On impact, the patient was restrained by a three-point belt system, and the type of injury sustained was typical of the cervical seat-belt syndrome. Computerised tomography revealed extended soft-tissue and subcutaneuous cervico-thoracic emphysema (fig 1B) and pneumomediastinum. Magnetic resonance imaging showed soft-tissue oedema of the glottis and supraglottic area, contusions and haematoma (2.5×1×4 cm) at the level of cricoid cartilage (fig 2A) and blurring of the margins of the oesophagus and supraglottic area. After extubation, fibre-optic bronchoscopy revealed only an asymmetric right supraglottic post-traumatic wound at the arytenoid level (fig 2B) that did not influence the movement of the glottis, and the child was discharged home.

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Figure 1 (A) Neck ecchymoses and contusions. (B) Extended soft-tissue and subcutaneous cervico-thoracic emphysema (white arrows; black arrows indicate the endotracheal and nasogastric tube air).

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Figure 2 (A) Soft-tissue oedema and haematoma of the glottis and supraglottic area (white arrows; black arrows focus on the endotracheal tube air). (B) Asymmetric right supraglottic healing at the arytenoid level.

Although ruptures of the tracheo-bronchial tree from the tracheal origin to the division of the lobar bronchi resulted mainly from a crush, blunt trauma or rope strangulation, they can, rarely, result from seat-belt syndrome.¹ As children outgrow child safety seats, they frequently are placed in lap/shoulder-belt systems designed for an adult, which maximises the risk of adverse effects with this safety equipment.² The syndrome is differentiated from the “padded dash” syndrome in which, on impact, the victim is often unrestrained.³ In that case, the anterior aspect of the neck strikes the car dashboard, resulting in the larynx being crushed against the vertebral column.