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 patientُ 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