1. 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

3. Airway
Vascular system
Nervous system
Esophagus/Hypopharynx
Bone

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

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

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

7. Esophagus / hypopharynx
Subcutaneous emphysema
Dysphagia
Odynophagia
Hematemesis
Hemoptysis
Tachycardia
Fever

10. 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 :

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

12. 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

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

16. 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)

17. 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

18. 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)

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

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

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

22. 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 : %

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

24. Mandatory Versus Elective Exploration
1-Lifethreatening
2-Not lifethreatening

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

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

27. 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)

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

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

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

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

41. Penterating Neck Injury
Is immediately life-threatening
Is not

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

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

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

45. 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.

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

47. Airway
a-Intubation
b-cricothyroidectomy
c-tracheostomy

48. Direct transcervical tracheal intubation
Oral cavity
Pharynx
larynx

49. X-ray
Anterior
Lateral
Chest x-ray

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

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

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

53. Extensive esophageal injury
Lateral cervical esophagostomy
Later definitive repair

54. Direct laryngoscopy
Bronchoscopy
Rigid esophagoscopy anesthesia
(spine fracture)

55. Air in the soft tissue
Hemoptysis
Hematemesis
Others

56. 24 hours (3 times)
48-72 hours

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

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

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