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Penetrating Neck Injuries
Penetrating Neck Injuries
28MAY
Background: Patients with penetrating neck trauma can present with a variety of injury patterns including hemorrhagic shock, airway
obstruction and neurologic injury. Serious injuries may not be clinically obvious making diagnosis and prompt treatment challenging.
Due to the large number of critical structures in the neck, a clear knowledge of the anatomy is necessary for proper evaluation and
management.
Epidemiology (Evans 2018)
Represent 1% of all trauma admissions in the US and have a 5% mortality rate
80% of morality secondary to cerebral infarction
~ 20% of mortality secondary to uncontrolled hemorrhage
Zones of the Neck and Anatomical Structures
The neck is classically divided into three zones
Zone I: Clavicles/sternum to the cricoid cartilage
Zone II: Cricoid cartilage to the angle of the mandible
Zone III: Superior to the angle of the mandible to skull area
Zones of the Neck (Rosen’s)
Neck Anatomy (Netter’s)
Posterior Triangle of the Neck Anatomy (anatomyqa.com)
Zone system can be used to think about what structures may be injured but caution should be used as a
penetrating injury can transverse zones
Historically the zones were divided by easy accessibility for surgical exploration (Zone II) vs those that would
likely need angiography to delineate vascular injury (Zones I, III)
Other important anatomic features
There is anatomic continuity in the fascial layers between the neck and the anterior mediastinum
The platysma muscle sits between the superficial and deep cervical fascia: Violation of the platysma increases the
likelihood of deep structure injury and should be explored in the operating room immediately.
Hard and Soft Signs of Major Aerodigestive or Neurovascular Injury
(Sperry 2013)
Specific Injuries
Pharyngoesophogeal Injuries
Signs/Symptoms
No pathognomic signs/symptoms
Soft signs: hematemesis, dysphagia, subcutaneous emphysema, hoarseness, cough
Diagnostics
Plain X-rays (Thoma 2008, Bryant 2007)
May suggest perforation but are not sensitive (cannot rule out injury)
Findings: pneumomediastinum, retropharyngeal air
Contrast esophogram with poor sensitivity for injury (Asensio 1997)
Gastrograffin and barium studies may be performed. Gastrograffin may be safer as it is water-
soluble and leakage is less likely to cause a chemical mediastinitis
Flexible endoscopy offers direct visualization and is consider to be the most sensitive for
ruling out injuries. It is often used in combination with contrast enhanced studies
Because esophageal injuries are difficult to diagnose and there is no ideal approach, observation with
reassessment is often necessary
Treatment
Broad-spectrum antibiotics (with coverage of anaerobes)
Nasogastric tube typically placed under endoscopic guidance to avoid further injury
Laryngotracheal Injuries
Signs/symptoms
Hard signs: Bubbling or air leakage from a neck wound, massive subcutaneous air
Soft signs: dyspnea, dysphonia, stridor, hemoptysis, subcutaneous emphysema, laryngeal
crepitus
Diagnostics
Plain X-rays: extraluminal air, foreign bodies, fracture of cartilaginous structures (i.e. larynx),
edema
CT scan
Need to obtain thin slices (1-mm) and multiplanar reconstructions
Do not rely solely on the cervical spine CT
Laryngoscopy and nasopharyngoscopy with flexible endoscopes are necessary for evaluating
internal injuries
Vascular Injuries
Signs/symptoms
Hard signs: active hemorrhage, expanding or pulsatile hematoma, hematemesis
Soft signs: Venous oozing, non-pulsatile, nonexpanding hematomas, minor hemoptysis
Diagnostics
CT Angiogram (CTA)
Most commonly used imaging modality for vascular trauma
Performance characteristics (Rosen’s 2010)
Sensitivity 90-100%
Specificity 99-100%
Should be obtained in all patients with soft signs of vascular trauma and selectively
in patients without hard or soft signs
Disposition
1. Patients with hard signs of aerodigestive or neurovascular injuries will require emergency surgery
2. Patients with soft signs of aerodigestive or neurovascular injuries will move on to further imaging and should be
admitted to a trauma surgery service (or transferred to one)
3. Patients with neither hard nor soft signs of aerodigestive or neurovascular injuries may have imaging or, may
simply be observed depending on local protocols
Take Home Points
1. Penetrating injuries to the neck can damage a host of structures. Understanding the zones of the neck and the
structures within them can help predict injuries
2. If the platysma is violated, it should be assumed that deeper structures have been injured until proven
otherwise..direct to OT if hard signs present.
3. Early airway management is crucial as injuries can lead to dynamic airway obstruction. Always be prepared for a
surgical airway
4. The presence of any hard signs of aerodigestive/neurovascular injuries (expanding/pulsatile hematoma, active
brisk bleeding, hemorrhagic shock, massive subcutaneous emphysema, air bubbling through the wound, neurologic deficit) or
violation of platysma+ hard signs, mandates an immediate OR trip. Do not delay the patient getting to the OR for
additional studies
5. Attempt to control vascular injuries with direct pressure and consider balloon tamponade with a foley
catheter