1. Principles of Neck Exploration and Aerodigestive Tract Injuries Niqui Kiffin, MD Operative Skills Conference 04 August 2009

2. Introduction  Only 5-10% of traumas actually involve the neck Penetrating most common Penetrating most common  Numerous vital structures are concentrated in a very small anatomic area Vascular Vascular Aerodigestive Aerodigestive Vertebral Vertebral Nerve Injury Nerve Injury  Generally, unprotected by bone or dense muscular covering

3. Contents  Anatomy “Zones” “Zones” Platysma Platysma  Initial Evaluation  Injury Management  Exposure Options  Aero-Digestive Injury Trachea Trachea Esophagus Esophagus

4. Anatomy  Borders Lower margin of the mandible Lower margin of the mandible Superior nuchal line of the occipital bone Superior nuchal line of the occipital bone Suprasternal notch Suprasternal notch Upper border of the clavicle Upper border of the clavicle

5. Anatomy  Triangles Anterior Anterior Posterior belly of the digastric musclePosterior belly of the digastric muscle Anterior margin of the SCMAnterior margin of the SCM Sternohyoid muscleSternohyoid muscle Divide these structures with the inferior belly of the omohyoid muscleDivide these structures with the inferior belly of the omohyoid muscle Carotid Triangle Carotid Triangle Muscular Triangle Muscular Triangle

6. Anatomy  Posterior Anterior border of the trapezius muscle Anterior border of the trapezius muscle Posterior border of the SCM Posterior border of the SCM Superior border of the clavicle Superior border of the clavicle Divide with the posterior belly of the omohyoid muscle Divide with the posterior belly of the omohyoid muscle Occipital TriangleOccipital Triangle Omoclavicular TriangleOmoclavicular Triangle

7. Anatomy  Posterior Triangle Wounds Rarely involve the esophagus, airway or major vascular structure Rarely involve the esophagus, airway or major vascular structure However, be aware that any penetrating wound that appears to enter in one triangle may traverse into another compartment of the neck and cause a lot of damage. However, be aware that any penetrating wound that appears to enter in one triangle may traverse into another compartment of the neck and cause a lot of damage.

8. “Zones” of the Neck  Anterior Triangle Wounds Zone I Zone I “Base of the neck”“Base of the neck” Sternal notchSternal notch Lower border of the cricoid cartilageLower border of the cricoid cartilage Highest mortality rate due to risk of major vascular and intrathoracic injuryHighest mortality rate due to risk of major vascular and intrathoracic injury

9. “Zones” of the Neck Zone II Zone II Central/largest portionCentral/largest portion Extends from the cricoid cartilage to the angle of the mandibleExtends from the cricoid cartilage to the angle of the mandible Most commonMost common Lower mortality rate because injuries are usually apparent and exposure is easily accomplishedLower mortality rate because injuries are usually apparent and exposure is easily accomplished

10. “Zones” of the Neck  Zone III Above the angle of the mandible Above the angle of the mandible High risk of injury to the distal carotid artery, pharynx, and salivary glands High risk of injury to the distal carotid artery, pharynx, and salivary glands Exposure can be exceedingly difficult Exposure can be exceedingly difficult

11. “Zones’ of the Neck  Zone I Thoracic outlet vasculature, vertebral and proximal carotid arteries, lung, trachea, esophagus, spinal cord, thoracic duct, and major cervical nerve trunks Thoracic outlet vasculature, vertebral and proximal carotid arteries, lung, trachea, esophagus, spinal cord, thoracic duct, and major cervical nerve trunks  Zone II Jugular veins, vertebral and common carotid arteries, and external and internal carotid arteries Jugular veins, vertebral and common carotid arteries, and external and internal carotid arteries  Zone III Pharynx, jugular veins, vertebral arteries and the distal internal carotid arteries Pharynx, jugular veins, vertebral arteries and the distal internal carotid arteries

12. Platysma  Platysma Thin, broad muscle that lies just beneath the skin and covers the entire anterior triangle and the anteroinferior aspect of the posterior triangle. Thin, broad muscle that lies just beneath the skin and covers the entire anterior triangle and the anteroinferior aspect of the posterior triangle. Wounds that do not penetrate the platysma are considered superficial and do not require additional work-up Wounds that do not penetrate the platysma are considered superficial and do not require additional work-up

13. Initial Evaluation  Secure an adequate airway Preferably translaryngeal ETT Preferably translaryngeal ETT May require fiberoptic bronchoscopyMay require fiberoptic bronchoscopy Cricothyroidotomy Cricothyroidotomy Emergent tracheostomy via neck wound Emergent tracheostomy via neck wound Chest tubes as necessary Chest tubes as necessary PTX, hemothoraxPTX, hemothorax  Circulatory Assessment/Stabilization Significant hemorrhage Significant hemorrhage Direct pressureDirect pressure Immediate transfer to the operating roomImmediate transfer to the operating room No role for blind clamping or tourniquets in penetrating neck traumaNo role for blind clamping or tourniquets in penetrating neck trauma

14. Initial Evaluation  History/Physical If patient is hemodynamically stable and able to participate If patient is hemodynamically stable and able to participate

15. Injury Management  Depends on the status of the patient, the “zone” of injury, and the presence/absence of “hard” or “soft findings” of vascular or aero-digestive injury.  In the past, all Zone II injuries were surgically explored, however now with access to endoscopy, fluoroscopy, CT and angiography; it is not always necessary.

16. “Soft Findings”  Dysphagia  Voice Change  Hemoptysis  Hematemesis  Widened Mediastinum

17. “Hard Findings”  Airway compromise  Shock/active bleeding  Pulsatile hematomas  Extensive subcutaneous emphysema

18. Management  If “hard findings” present: Immediate operative exploration Immediate operative exploration  If “soft findings” present: CT/CT Angio CT/CT Angio Bronchoscopy Bronchoscopy Esophageal Swallow +/- Endoscopy Esophageal Swallow +/- Endoscopy If these studies positive for injury, pt deserves an operative exploration If these studies positive for injury, pt deserves an operative exploration

19. Exposure Options  Zone I Supraclavicular incision Supraclavicular incision Distal subclavian arteryDistal subclavian artery Left Thoracotomy Left Thoracotomy Proximal left subclavian arteryProximal left subclavian artery Distal EsophagusDistal Esophagus Right Thoracotomy Right Thoracotomy Distal TracheaDistal Trachea Median Sternotomy Median Sternotomy Innominate artery/proximal right subclavian arteryInnominate artery/proximal right subclavian artery Removal of the head of the clavicle Removal of the head of the clavicle Subclavian arteriesSubclavian arteries

20. Exposure Options  Zone I (con’t) “Trapdoor” incision “Trapdoor” incision Subclavian arteriesSubclavian arteries Collar incision Collar incision EsophagusEsophagus Proximal TracheaProximal Trachea Midline Midline TracheaTrachea Sternocleidomastoid Sternocleidomastoid EsophagusEsophagus CarotidCarotid Jugular VeinsJugular Veins

21. Exposure Options  Zone III Sternocleidomastoid Incision +/- extension Sternocleidomastoid Incision +/- extension May require disarticulation or partial mandibular resection May require disarticulation or partial mandibular resection Limited craniotomy Limited craniotomy

22. Exposure Options  Zone II Sternocleidomastoid Incision Sternocleidomastoid Incision Collar Incision Collar Incision Provides access to both sides of the neckProvides access to both sides of the neck

24. Aero-Digestive Injuries  10% of penetrating neck injuries Esophagus Esophagus < 1% of all traumatic injuries< 1% of all traumatic injuries <0.1% are secondary to blunt trauma<0.1% are secondary to blunt trauma >80%>80% Secondary to penetrating neck trauma Secondary to penetrating neck trauma However, 0.5-7% of penetrating neck injuries are associated with esophageal involvement However, 0.5-7% of penetrating neck injuries are associated with esophageal involvement Trachea Trachea 3-8% - injure cervical trachea3-8% - injure cervical trachea Only 4% of all injuries related to the cervical trachea are from blunt traumaOnly 4% of all injuries related to the cervical trachea are from blunt trauma Both Both May be as much as 28%May be as much as 28%

26. Pathophysiology  Penetrating Knife – cervical trachea Knife – cervical trachea GSW – cervical or intrathoracic GSW – cervical or intrathoracic Intrathoracic – higher incidence when projectile crosses the mediastinum. Associated with injuries to great vessels, heart, and esophagusIntrathoracic – higher incidence when projectile crosses the mediastinum. Associated with injuries to great vessels, heart, and esophagus

27. Pathophysiology  Penetrating Stab Wounds Stab Wounds Gunshot Wounds Gunshot Wounds Shotgun WoundsShotgun Wounds

28. Pathophysiology  Blunt Direct Blows Direct Blows “clothesline”-type injury“clothesline”-type injury Crushes the cervical trachea against the vertebraeCrushes the cervical trachea against the vertebrae May be called a “dashboard” injuryMay be called a “dashboard” injury May also occur secondary to a high-riding shoulder harnessMay also occur secondary to a high-riding shoulder harness Rapid Hyperextension Rapid Hyperextension Produces a traction and distraction injuryProduces a traction and distraction injury Most commonly results in laryngotracheal separationMost commonly results in laryngotracheal separation Shear Stress Shear Stress Creates damage at fixed points (cricoid and carina)Creates damage at fixed points (cricoid and carina) Burst Injury Burst Injury Rapid AP compression of the thoraxRapid AP compression of the thorax Simultaneous expansion in the lateral thoracic diameterSimultaneous expansion in the lateral thoracic diameter Closure of the glottis (increased intratracheal pressure)Closure of the glottis (increased intratracheal pressure) Results in linear tears within the membranous portionResults in linear tears within the membranous portion

29. Pathophysiology  Iatrogenic Tracheostomy/Intubation Tracheostomy/Intubation Improper stilette useImproper stilette use Erroneous choice of tube sizeErroneous choice of tube size Over-inflation of balloonOver-inflation of balloon Ill-positioned tracheostomy tubeIll-positioned tracheostomy tube

30. Presentation  SQ emphysema  PTX Persistent Persistent Continuous air leak Continuous air leak  Pneumomediastinum  Hemoptysis  Dyspnea  Dysphonia  Difficulty with mechanical ventilation

31. Presentation  Fallen Lung of Kumpe Lung falling away from the hilum (laterally and posteriorly), in contrast to simple PTX which collapses towards the hilum Lung falling away from the hilum (laterally and posteriorly), in contrast to simple PTX which collapses towards the hilum  Abnormal migration of ETT  Overdistention of the ETT outside the confines of the normal tracheal diameter

32. Management

33. Nonoperative Management  When? Small TBI Small TBI < 1/3 circumference < 1/3 circumference Well-opposed edges Well-opposed edges No tissue loss No tissue loss No associated injuries No associated injuries No need for PPV No need for PPV  Controversial……

34. Nonoperative Management  Retrospective Study  33 TBI  60% conservative/40% operative  5 deaths (none attributed to treatment choice)  Selection Criteria Absence of major symptoms, no progressive SQ or mediastinal emphysema, no severe dyspnea requiring intubation, no difficulty with mechanical ventilation, no PTX with persistent air leak, no open tracheal injuries or mediastinitis Absence of major symptoms, no progressive SQ or mediastinal emphysema, no severe dyspnea requiring intubation, no difficulty with mechanical ventilation, no PTX with persistent air leak, no open tracheal injuries or mediastinitis Independent of injury length, location, diagnostic delay or pathogenesis Independent of injury length, location, diagnostic delay or pathogenesis J of Trauma, Vol 61 (6), 2006

35. Nonoperative Management  What? Humidified air Humidified air Voice rest Voice rest Frequent suctioning Frequent suctioning Prophylactic abx Prophylactic abx PPI PPI Close observation Close observation Bronchoscopy follow-up Bronchoscopy follow-up Intubation distal to lesion Intubation distal to lesion If already intubated…If already intubated…

36. Operative Management  Airway Management Single lumen ETT (long) May be passed distal to injury Proximal Injuries May be passed into contralateral bronchus Distal Injuries Double lumen ETT Allow for one lung ventilation Larger size Cardiopulmonary Bypass High Frequency Jet Ventilation Low airway pressures ECMO

37. Operative Management  Exposure Cervical Injuries Cervical Injuries Transverse Collar IncisionTransverse Collar Incision May be extended up or down into median sternotomy if necessary May be extended up or down into median sternotomy if necessary SCM IncisionSCM Incision Intrathoracic Injuries Intrathoracic Injuries Right posterolateral thoracotomy (avoids heart and aorta)Right posterolateral thoracotomy (avoids heart and aorta) Intrathoracic trachea Intrathoracic trachea Right mainstem bronchus Right mainstem bronchus Proximal left mainstem bronchus Proximal left mainstem bronchus Left posterolateral thoracotomyLeft posterolateral thoracotomy Distal left mainstem bronchus (>3cm from carina) Distal left mainstem bronchus (>3cm from carina)

38. Operative Management  Prophylactic Abx  Debridement  Repair Primary Primary InterruptedInterrupted Absorbable SuturesAbsorbable Sutures Some studies have shown effective repair with non- absorbable sutures as well Some studies have shown effective repair with non- absorbable sutures as well Knots external to tracheaKnots external to trachea

39. Operative Management Resection Resection 4-5 cm of trachea can be mobilized to obtain length after resection4-5 cm of trachea can be mobilized to obtain length after resection Additional length can be obtained by cervical flexion Additional length can be obtained by cervical flexion Dissection should be carried out anteriorly and posteriorly to avoid lateral pedicles (devascularize the trachea)Dissection should be carried out anteriorly and posteriorly to avoid lateral pedicles (devascularize the trachea) End to end anastomosisEnd to end anastomosis Interrupted sutures Interrupted sutures Assure mucosa to mucosa approximation Assure mucosa to mucosa approximation Suture line should be buttressed with pleural flap, intercostal muscle flap, or pericardial flap Suture line should be buttressed with pleural flap, intercostal muscle flap, or pericardial flap

40. Operative Management  Intercostal Muscle Flap If considered, should be preserved on entrance into the thoracic cavity If considered, should be preserved on entrance into the thoracic cavity An incision is made directly over the rib and the periosteum stripped off An incision is made directly over the rib and the periosteum stripped off Incision is carried on through the posterior layer of the periosteum to enter the pleural space Incision is carried on through the posterior layer of the periosteum to enter the pleural space The muscle is then divided from the ribs above and below while sparing the blood supply and used as a flap to buttress your repair The muscle is then divided from the ribs above and below while sparing the blood supply and used as a flap to buttress your repair

41. Operative Management  Cervical Injuries Tracheostomy +/- Tracheostomy +/- Avoid placing your tracheostomy through the injuryAvoid placing your tracheostomy through the injury End tracheostomy is performed only for extensive devitalization and contaminationEnd tracheostomy is performed only for extensive devitalization and contamination Repair +/- Repair +/- Simple anterior injuries may require repair onlySimple anterior injuries may require repair only

43. Outcomes  Suture Granulomas Can usually be alleviated with laser or bronchoscopic intervention Can usually be alleviated with laser or bronchoscopic intervention  Stenosis May present later with “asthma” May present later with “asthma” Can be improved with serial dilatation and stents (rubber and metal) Can be improved with serial dilatation and stents (rubber and metal) May require additional resection May require additional resection 3-6 months after initial repair3-6 months after initial repair  Occlusion May require additional resection, possible pulmonary resection May require additional resection, possible pulmonary resection  Fistulas Tracheal/Innominate artery Tracheal/Innominate artery Tracheoesophageal Tracheoesophageal

44. Post-Operative Management  Extubate immediately if possible If pt remains intubated, keep endotracheal balloon distal to suture line or proximal if injury is near the carina. If pt remains intubated, keep endotracheal balloon distal to suture line or proximal if injury is near the carina. Keep airway pressures low. Keep airway pressures low.  Aggressive pulmonary toilet  Repeated bronchoscopy as needed to evaluate repair

45. Highlights  Initial priority is airway stabilization May require fiberoptic bronchoscopy May require fiberoptic bronchoscopy  Penetrating injury predominantly affects the cervical trachea  Blunt injury affects the distal trachea and carina  Suspect the diagnosis in any patient with a significant air leak, SQ emphysema, and/or PTX despite chest tube placement  Collar incision – upper half of the trachea  Right 4 th ICS posterolateral thoracotomy – distal trachea  Operative repair involves debridement of devitalized tissue, but in most cases simple reconstruction with absorbable interrupted sutures will suffice.

47. Pharynx and Esophagus  Esophageal injuries 5% of patients with penetrating neck wounds 5% of patients with penetrating neck wounds Blunt - < 10% of all esophageal perforations Blunt - < 10% of all esophageal perforations If suspected, it must be ruled out… If suspected, it must be ruled out… Direct visualization (OR)Direct visualization (OR) Esophagraphy – sensitivity 50-90%Esophagraphy – sensitivity 50-90% Endoscopy – sensitivity 29-100%Endoscopy – sensitivity 29-100% Combined – accuracy of almost 100%Combined – accuracy of almost 100% It must be suspected in any patient with a penetrating neck wound, a hyperextended neck or a blast injury It must be suspected in any patient with a penetrating neck wound, a hyperextended neck or a blast injury If diagnosis delayed, mortality increases exponentially….based on length of time from diagnosis to treatment. If diagnosis delayed, mortality increases exponentially….based on length of time from diagnosis to treatment.

48. Clinical Presentation  May be suggested by mechanism of injury  Dx can be suggested or obscured by the presence of associated injuries  Hoarseness  Hemoptysis  Subcutaneous air  Anterior tracheal deviation  Extra-esophageal NGT  Late Presentation Fever Fever Erythema Erythema Abscess Abscess Mediastinitis Mediastinitis Sepsis Sepsis

49. Diagnosis  Gastrograffin Swallow If negative, should be followed by barium If negative, should be followed by barium Confirms leakConfirms leak Gives location (right or left)Gives location (right or left) False negative 10%False negative 10%  Esophagoscopy Can miss 15-40% of injuries Can miss 15-40% of injuries  CT Scan May show track of penetrating trauma, contrast/air around the mediastinum, pleural effusions, or as a follow-up May show track of penetrating trauma, contrast/air around the mediastinum, pleural effusions, or as a follow-up  Esophagram + Esophagoscopy Sensitivity - Nearly 100% Sensitivity - Nearly 100%

50. Operative Repair  Collar Incision Particularly useful if bilateral injuries present Particularly useful if bilateral injuries present  Sternocleidomastoid Incision “Carotid” incision “Carotid” incision  Right posterolateral thoracotomy Upper 2/3 of the thoracic esophagus Upper 2/3 of the thoracic esophagus  Left posterolateral thoracotomy Distal thoracic esophagus Distal thoracic esophagus

51. Management  Control leak  Adequate drainage  Esophageal debridement  Primary repair Single vs. double layer closure Single vs. double layer closure Absorbable suture internally, may use nonabsorbable for external layer Absorbable suture internally, may use nonabsorbable for external layer Interrupted vs. running repair Interrupted vs. running repair  Buttress repair SCM SCM Intercostal muscle Intercostal muscle Pleural flap Pleural flap Pericardial flap Pericardial flap  Nutritional Support  Early use of Abx

52. Operative Management  If in doubt…..operate on the side of the wound or the leak.  Most injuries can be repaired primarily, If not possible, (large defects, extensive tissue damage, or delayed diagnosis) may consider: If not possible, (large defects, extensive tissue damage, or delayed diagnosis) may consider: Tissue flaps,Tissue flaps, T-tube drainage,T-tube drainage, End-to-end anastomosis, orEnd-to-end anastomosis, or Diversion with cervical esophagostomyDiversion with cervical esophagostomy EsophagectomyEsophagectomy

53. Complications  Leaks after repair may heal spontaneously if drained adequately and antibiotic support provided. Thoracic leaks may require radiographically placed drains Thoracic leaks may require radiographically placed drains Consider stents for mid-esophageal leaks Consider stents for mid-esophageal leaks Unstable or septic patients require re-operation Unstable or septic patients require re-operation  Post-operative stenosis can usually be managed with repeated endoscopic dilatation  Fistula Tracheoesophageal Tracheoesophageal New onset cough or pneumoniaNew onset cough or pneumonia Repeated aspirationRepeated aspiration Usually avoided if repair is buttressed adequatelyUsually avoided if repair is buttressed adequately Requires operative repairRequires operative repair

54. Highlights  Signs and symptoms are nonspecific Must have a high degree of suspicion Must have a high degree of suspicion  Most injuries require a simple repair  All repairs should be buttressed by local tissue  Outcome is critically affected by delay in diagnosis

56. References…  Trauma David V. Feliciano, Kenneth L. Mattox, Ernest E. Moore CH 23 Management of Acute Neck Injuries CH 27 Esophagus, Trachea and Bronchus  ACS Surgery: Principles and Practice CH 7 Trauma and Thermal Injury Sect 4 Injuries to the Neck