Injuries to the Neck Jason Davis, MD

Blunt Neck Trauma Blunt arterial injuries Blunt airway injuries Usually managed non-operatively Operative tx similar to penetrating injuries (rare) Almost always diagnosed by angiography Blunt airway injuries Managed similar to penetrating injuries Occasionally surgical emergencies

Penetrating Neck Trauma Categorized into 6 groups Airway compromise Isolated laryngotracheal injuries Carotid artery injuries Jugular vein injuries Esophogeal injuries Pharyngeal injuries Helps in choosing incision, operative priorities

Airway Compromise Establish airway first Orotracheal intubation Cricothyrotomy (emergent) Tracheotomy (less emergent) Nasotracheal not advised in most trauma settings

Airway Compromise Establish airway first Cricothyrotomy (emergent) Landmarks: Thyroid & Cricoid cartilages Stabilize thyroid cartilage (notched superiorly) Transverse incision at Cricothyroid membrane Vertical incision in emergencies w/ unknown injury Extend through subcutaneous tissue, cricothyroid Avoid injury to posterior tracheal wall Twist 11-blade scalpel 900 to enlarge Insert No. 4 – 6 (largest for most adults) airway Convert to tracheotomy 48 – 72hrs

Cricothyrotomy

Airway Compromise Establish airway first Tracheotomy (less emergent) Incision 1 – 2 fingerbreadths inferior to cricothyroid Skin incision to anterior border of SCM bilaterally May use wound. Mediasternotomy for distal injuries. Conversion Cricothyrotomy to Tracheotomy Believed less likely to stricture or cause tension Literature does not support such a difference 7

Penetrating Neck Trauma Traditional cervical neck divisions Zone 1: Zone 2: Zone 3: 8

Penetrating Neck Trauma Traditional cervical neck divisions Zone 1: thoracic inlet to cricoid cartilage superiorly Zone 2: cricoid cartilate to angle of mandible Zone 3: angle of mandible and base of skull Zone 2 – mandatory exploration if injury violates platysma Zones 1, 3 - imaging studies, endoscopy to assess injuries Consider injury depth, pt stability 9

Neck Exploration Most common for unknown injuries associated w/ penetrating neck trauma Anterior sternocleidomastoid incision offers rapid access to most vital neck structures Carotid sheath, pharynx, cervical esophagus Particularly important for bleeding, neuro deficits May be lengthened for proximal/distal exposure Include anter chest in prep for poss prox control Greasy feel may indicate salivary amylase 10

Isolated Laryngotracheal Injuries Most commonly not recognized pre-op, though laryngoscopy / bronchoscopy can be useful in the context of a suspicious history Initial focus on establish airway, min debridement Repair small trachea injury w/ 3.0 - 4.0 absorbable Post-op monitor for mediastinitis +cxr for pneumo-mediastinum, leaks or missed pharyngoesoph injury Reconstruction / definitive repair semi-elective 11

Neck Exploration *Curved posteriorly at mandible

Neck Exploration

Carotid Artery Injuries Dissection comparable to CEA Prox/distal control, protect nerves Proximal exposure occasionally may require subluxation of mandible and division of stylohyoid lig, styloglossus/pharyngeus muscles at styloid process May occlude more distal injuries w/ 4-5F fogarty Repair vs ligation as per hemodynamic stability, complexity of injuries, and back-bleeding

Pharyngoesoph Injuries Repair w/ 3.0 – 4.0 absorbable suture, 1-2 layers and drain (closed/penrose) x1 wk Several doses post-op antibiotics (oral flora) UGI & feeding before drains removed

Injuries at Base of Neck Median sternotomy for inominate or R subclavian injuries Left thoracotomy for L subclavian

Injuries at Base of Neck Median sternotomy for inominate or R subclavian injuries Left thoracotomy for L subclavian

Vertebral Artery Injuries Most vertebral artery injuries dx w/ angiography and may be embolized

Blunt Cervical Injuries Most often hyperextension w/ MVC Blunt injury to cervical arteries ~rare Angio or CTA dx if  cervical bruit <50yo, evidence of cerebral infarct on CT, basilar skull fx involving carotid canal, neurologic sx not explained by CT, or as per mechanism Anticoag typically for dissection/aneurysm