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Trauma
The incidence of blunt trauma to the neck is reduced in US due to seat belt
The anterior neck is shielded by the anterior mandible and the clavicle .
When blunt trauma to the does occur , the laryngotracheal tree is the most
vulnerable to injury
Major vessels injury due to blunt trauma is an extermaly rare
phenomenon .
It must be considered if the patient has expanding hematoma carotid bruit
, or neurologic finding.
Emphysema , dysphagia , odynophagia
Perforation or tear of : pharynx hypopharynx esophagus
Penetrating trauma
Stab wound , Gun injury M/F : 5/1 Most injuries occur in the anterior neck Type of injury depend on the type of object
and the area of the neck that is injured .
Anatomic classification
The platysma , which extends from the facial muscles to the calvicle , remains the key anatomic land mark when dealing with
penetrating neck trauma
Neck Zones
Zone I
Is the area of the neck between the clavicle and the cricoid cartilage
It contains : proximal common carotid , vertebral artery , subclavian artery , upper mediastinal vasculature , lung apices , trachea , esophagus , thoracic duct
It is difficult to gain emergent proximal control of hemorrhage and it is difficult to expose intrathoracic
neurovascular structure
Zone II
Extending between cricoid cartilage and the angle of the mandible
Containing carotid bifurcation , vertebral artery , IJV , larynx , trachea , esophagus , vagus , RLN , spinal cord
Zone III
Is from the angle of the mandible to the base of the skull
contains distal ECA branches , vertebral artery , salivary glands , pharynx , spinal cord , CN VII , VIII , IX , X , XII
It is difficult to gain emergent distal control of hemorrhage and it is difficult to expose skull base
neurovascular structures
Evaluation
Airway assessment
Early airway intervention in the emergency room is paramount , especially in the face of an expanding hematoma
A quick survey of the patient ُ s airway status must be made .
A cricothyrotomy or vertical tracheotomy is the preferred of choice compared to oral or nasal intubation
Endotracheal intubation may be considered in select situation , but it may further
exacerbate bleeding , pharyngeal perforation , or laryngotracheal injury
One must assume a cervical spine injury until further testing can be done . This is
especially important whenever one is establishing a surgical airway.
Circulation
Any frank bleeding must be controlled with direct pressure only .
Any use of clamping instrument should be condemned .
Establishment large –bore IV access
Immediate surgical management
Life-threatening hemorrhage Hemodynamic instability Expanding hematoma
The operating room is the only place where a wound is explored or probed
or a foreign body is removed.
Secondary survey and definitive management can be dine in a system – by system fashion once the airway has been
addressed and the patient is hemodaynamically stable.
Respiratory tract injury
10% penetrating trauma Oropharynx …….lung apices Cyanosis Air per wound Subcutaneous emphysema Hemoptysis Dysphonia Hoarseness Decreased breath sound
An initial respiratory tract injury may appear stable but may rapidly decompensate ,
requiring emergent surgical airway intervention
Vascular Injury
Can be present in 25 % penetrating trauma Inspection , palpation & auscultation of the
H&N , upper extremity and thorax is important
Hypovolumic shock , frank brisk bleeding , expanding hematoma , decreased breath sound , decreased radial pulse , carotid bruit
Digestive tract injury
In 5% penetrating trauma Most frequent missed injury Dysphagia , odynophagia , hematemesis ,
crepitus , free air on imaging Early intervention to exteriorize the leak to
prevent mediastinitis
Nervous system
Complete or incomplete spinal cord transection should be considered : localizing & lateralizing deficit
CN , brachial plexus , phrenic nerve Hemiplagia due to carotid or vertebral
interruption
Soft tissue injury
Glandular or duct injury :
Saliva existing in the wound , associated facial or hypoglossal injury
Left sided trauma in zone III : thoracic duct injury
MANAGEMENT
Zone I
Symptomatic :
Arteriography with or without esophageal study
Asymptomatic :
Arteriography with or without esophageal study
ZONE II
Symptomatic :
To operating room if hemoptysis , dysphsgia , or nerve deficit is present
Asymptomatic :
Observe
Surgical exploration of zone II still remains an area of great controversy
ZONE III
Symptomatic :
Arteriography with or without mbolization
Asymptomatic :
With or without arteriography for possible occult vascular injury ( all patients admitted for overnight observation )
Diagnostic imaging
They will give important information and allow the surgeon to manage the patient in a more selective fashion
Arteriography in zone I , III Esophagography ( 90% sensitivity ) CT ( laryngotracheal complex ) Flexible laryngoscopy in awake patient and
stable patient
All attempts should be made to clear the cervical spine prior to any
operative manipulation
Awake tracheostomy → Rigid endoscopic evaluation
Parenteral antibiotic Tetanus toxoid booster
Occult vascular injury in zone III may often be managed with endovascular embolization but on rare occasion a lateral swing mandibulotomy may be required for surgical repair .
Zone II vascular injuries can be directly accessed via a transcervical
approach.
Vascular injury
Simple laceration of IJV & carotid → primary repair
Large damage → ligation or saphenous vein interposition
Zone I injury : sternotomy ot thoracotomy
All arterial vessels should be repaired , and venous injuries can be
ligated
Pharyngoesophageal injuries
Explored , debrided and closed primerily in one or two layer
Drained with either a closed suction or a Penrose drain
Direct insertion a NGT Late diagnosis (12h) drained wound
Laryngotracheal injury
Unstable patient : tracheostomy Stable patient : flexible laryngoscopy ± CT Inspection of carotid sheath , esophagus &
cartilaginous frame work Repair of endolarynx : laryngofissure Thyroid
cartilage fracture : reapproximate & suturing Tracheal laceration can be sutured or used for the
tracheostomy site