NECK TRAUMA

ENT
 Advanced Trauma Life Support
(ATLS)

1 2 3
Primary survey Secondary survey Tertiary survey
 CLASSIFICATION

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 ZONES OF THE
NECK
• Zone I: Sternal notch / clavicle to cricoid cartilage.

• Zone II: Cricoid cartilage to angle of mandible.

• Zone III: Angle of mandible to base of skull.

All three zones contain major vascular, and aerodigestive structures.

However injuries to zones I and III are both diagnostically and surgically
more challenging.
 MANDATORY VS SELECTIVE
EXPLORATION OF PENETRATING INJURIES
penetrating neck wounds that violated the platysma
controversy about mandatory exploration vs selective exploration for low-
velocity gunshot and sharp penetrating cervical wounds
The majority of trauma centres currently advocate some form of selective
conservative management for civilian injuries.
 Mandatory exploration
risk of missing an unsuspected vascular or
aerodigestive tract injury outweighs the
morbidity and expense of negative exploration.
the unreliability of clinical evaluation,
diagnostic studies do not have 100% sensitivity
to detect oesophageal and vascular injuries,
low morbidity associated with negative
exploration,
the significant morbidity and mortality
associated with delayed detection and repair of
oesophageal injury
Selective exploration
the high rate (36–89%) of negative
mandatory exploration,
good sensitivity and specificity of special
investigations such as angiography, doppler,
barium swallow, rigid oesophagoscopy, and
flexible laryngotracheobronchoscopy;
expense of prolonged hospitalization
following negative exploration;
many injuries (e.g. thyroid, pharyngeal
and certain venous injuries) that are
detected at mandatory exploration may be
treated conservatively; and that neck
exploration leaves an unsightly scar
 The hard signs The soft signs

• Severe active bleeding • shock responding to resuscitation,

• minor active bleeding,
• Shock not responding to fl haematoma,
•
uid resuscitation • dyspnoea,
• Expanding haematoma • subcutaneous emphysema,
• Large blowing wound • hoarseness,
• dysphagia
• Major haemoptysis • minor haematemesis
• subcutaneous emphysema,
• hoarseness,
• dysphagia
• minor haematemesis
 Modren practice
shift from mandatory exploration towards more selective, conservative
management based on clinical evaluation and specialized investigations.
Introduction of diagnostic tools such as flexible endoscopy, oesophagography,
high-resolution computed tomography (CT), and duplex doppler have
improved non-operative evaluation of aerodigestive and vascular injuries.
The realization that certain injuries may be treated non-operatively and the
management of selected arterial injuries by endovascular techniques have
further promoted the concept of selective exploration of the neck
so selective non-operative management of penetrating neck injuries is
effective and safe.
 Tracheal injury

Symptoms of tracheal injury include a blowing wound, surgical emphysema,

haemoptysis and hoarseness.
Chest X-ray may reveal surgical emphysema and pneumomediastinum. The
priority is to secure an airway.
Tracheobronchoscopy can be useful to assess the injury, but the diagnosis is
usually readily apparent on exploring the neck for associated injuries.
 Tracheostomy VS Endotracheal intubation.

The primary goal in the initial evaluation and management of a patient with a suspected
laryngotracheal injury, like any other presenting with a traumatic event, is to ensure the
airway is adequately assessed and protected
Options for acute management of the threatened airway include routine endotracheal
intubation, fibre-optic awake intubation and tracheostomy under local anaesthetic. In
emergent situations, cricothyroidotomy may be required
There is some controversy in the literature with regard to the best method to secure the
airway: tracheostomy under local anaesthetic Vs endotracheal intubation.
in experienced hands, there is adequate evidence in the literature to date supporting the
safety of endotracheal intubation for airway management in laryngeal trauma.
When experienced personnel are unavailable, an emergency tracheostomy under local
anaesthetic is recommended.
 Tracheal injury
Tracheotomy is appropriate in
the presence of laryngeal trauma to avoid further injury to the endolarynx,
when it is not possible to safely pass an endotracheal tube, or
with quadriplegia requiring ventilatory support.
The trachea can sometimes be intubated through a blowing wound in the neck.
marked surgical emphysema, a tracheotomy might expedite recovery.

Minor tracheal injuries in patients not otherwise requiring cervical exploration can be
managed expectantly.
Tracheal repair is effected with interrupted sutures.
When there is an associated oesophageal or vascular injury, then the repair can be
bolstered with a local muscle flap.
In selected cases a tracheotomy or an endotracheal tube may be used to protect the
tracheal repair.
 Emergency tracheostomy

This is ideally performed in a controlled environment as afforded by an operating theatre,

where appropriate instrumentation, lighting and anaesthetic, surgical and nursing support are
available.
However, in a struggling patient where this is not possible, an inhalational general
anaesthetic with the highest possible inspired oxygen concentration may be administered.
Muscle relaxants are contraindicated, as paralysis of spontaneous respiration and positive
pressure ventilation can aggravate air leak and surgical emphysema, lead to loss of airway
and result in respiratory arrest.
To avoid the area of laryngotracheal injury, the tracheostomy incision is ideally placed
distal to the site of injury, slightly lower than usual.
Where a traumatic tracheotomy exists, recommend the use of this wound to access the
trachea as a means to provide greatest preservation of healthy trachea for repair and
reconstruction.