Head and Neck Trauma Hosseini M. M.D Head and Neck Surgeon   Head and Neck Trauma Hosseini M. M.D Head and Neck Surgeon Rasoul Akram Hospital Iran University

Airway Vascular system Nervous system Esophagus/Hypopharynx Bone

Signs and symptoms of penetrating neck trauma Airway Respiratory distress Stridor Cyanosis Hemoptysis Hoarseness Tracheal deviation Subcutaneous emphysema Sucking wound

Vascular system Hematoma Persistent bleeding Neurologic deficit Absent pulse Hypovolemic shock Bruit Thrill Change of sensorium

Nervous system Hemiplegia Quadriplegia Coma Cranial nerve deficit Change of sensorium Hoarseness

Esophagus / hypopharynx Subcutaneous emphysema Dysphagia Odynophagia Hematemesis Hemoptysis Tachycardia Fever

Zone I : 1-Close proximity to thorax (dangerous) 2-Protect by bony thorax and clavicle 3-Surgical exploration is difficult 4-Mortality 12% 5-Mandatory exploration is not recommended 6-Angiography 7-Right side : median sternotomy 8-Left side : left anterior thoracotomy Zone I :

Zone II : 1-The most involved zone (60% - 75%) 2-Mandetory versus selective

Zone III : 1- Protect by skeletal structures 2- Surgical exploration is difficult (need to divide or displace the mandible) 3-Cranial nerves injuries 4- Angiography and barium swallow (in stable patients and no lifethreating symptoms) 5-Frequent intraoral examination

- Temporal (frontal) Inability to raise the eyebrow - Zygoma (malar) Inability to close the eyelids - Buccal Inability to smile - Marginal mandibular Inability to frown

Facial nerve injuries 1-Maxillofacial trauma 2-Serious functional disabilities and aesthetic defects 3-Posterior half of parotid gland has deep laceration 4-Repaired five or main trunk (clean,sharp division)

Signs of immediate Lifethreatening Injuries 1-Massive bleeding 2-Expanding hematoma 3-Nonexpanding hematoma in the presence of hemodynamic instability 4-Hemomediastinum 5-Hemothorax 6-Hypovolemic shock

Diagnostic evaluation 1- Full examination of the unclothed body (entrance - exit ) 2- Full neurologic examination 3- Chest X - Ray ( Hemothorax pneumothorax-pneumomediastinum) 4- Cervical spine X- Ray 5- Flexible endoscopy – arteriography (24 hours available)

Angiography Indications : Wounds near vessel in zone I or zone III Contraindications : Expanding hematoma Profound shock Uncontrolled bleeding Accuracy : 98.5%

Barium swallow Indications : Hematemesis Contraindications : Intubated Drooling Dysphagia Vocal cord paralysis Contraindications : Intubated Saliva in wound Unstable pt. Accuracy : 90%

Direct laryngoscopy and broncoscopy Indications : Vocal cord paralysis Hoarseness Tenderness or crepitance over larynx Subcutaneous emphysema Hemoptysis Contraindications : None Accuracy : 100%

Esophagoscopy Indications Suspected but unconfirmed injury by Barium swallow Intubated Laryngeal or tracheal injury Vascular injury in zone II or zone III Contraindications : None Accuracy : 86%

The leading cause of death   From penetrating neck injuries is hemorrhago from vascular structures ( 50% )

Mandatory Versus Elective Exploration 1-Lifethreatening 2-Not lifethreatening

Stable patients: 1-Mandatory exploration for all penetrating neck wounds 2-Selective exploration with observation

Subcutaneous emphysema In the neck or face 1-Sinus 2- Hypopharynx 3- Laryngothracheal complex 4- Pulmonary parenchyma 5- Esophagus

Esophageal injuries 1-Blunt (rare) 2-16/288 (when penetrate platysma) 3-Air in mediastinum 4-Pain 5-Hematemesis 6-Hoarseness 7-Barium swallow 8-Endoscopy (rigid) 9-N.P.O (7-10 days)

Small injuries of Trachea      Primary repair     No tracheotomy Absorbable sutures (3-0 or 4-0)      Transversely sutures      Ring above and below      No drain

Large defects Anterior : Convert to tracheotomy Posterior &lateral : Close primary & tracheotomy Very large defect : Primary anastomosis(5-6 rings)

Initial management 1-Airway 2-Blood perfusion maintenance 3-Clarification and classification of the severity of wound

Parotid duct injuries - Opening opposite the second upper molar -  Orifice of Stensen s duct should be probed - Repair over catheter

Penterating Neck Injury Is immediately life-threatening Is not

Signs Of Immediate L. T. -Massive bleeding -Expanding hematoma -Nonexpanding hematoma in the presence of hemodynamic instability -Hemomediastinum -Hemothorax -Hemovolemic shock

Stable patient -Mandatory exploration for all pent.neck wounds -Selective exploration and observation -50-70% of pt. had negative exploration

-World war II mortality of penetrating neck wound 7-15% -End of vietnam war 3-6%

Transcervical injuries should be reported seperately from zone I , II , III injuries. Transcervical penetrating neck wounds when the projectile crosses the midline , have 100% vascular or aerodigestive injury.

Initial management 1-Airway establishment 2-blood perfusion maintenance 3-clarification & classification of severity of the wounds

Airway a-Intubation b-cricothyroidectomy c-tracheostomy

Direct transcervical tracheal intubation Oral cavity Pharynx larynx

X-ray Anterior Lateral Chest x-ray

Esophageal perforation Gastrografin swallow If g. is negative a barium swallow perform Flexible esophagoscopy 86% Contrast swallow 90% Rigid esophagoscopy Flexible+Rigid endoscopy

Air in the soft tissue:neck exploration NG tube(neck level)+methylene blue

Early esophageal perforation Debridment Two layer closure Wound irrigation Adequate drainage Muscle flap Appropriate AB

Extensive esophageal injury Lateral cervical esophagostomy Later definitive repair

Direct laryngoscopy Bronchoscopy Rigid esophagoscopy anesthesia (spine fracture)

Air in the soft tissue Hemoptysis Hematemesis Others

24 hours (3 times) 48-72 hours

Laryngotracheal injury Laryngeal laceration (stenosis+voice) repair early(24h) Significant glottic and supraglottic laceration+displaced cartilage surgical approximation

Endoscopy+CT a-Small laceration (observation) b-Large laceration (thyrotomy or open fracture reduction)+mucosal repair

Simple tracheal laceration repair without tracheostomy Severe tracheal injury 6-weeks tracheostomy (below or at the site of injury)