Penetrating Neck Injuries: S. Moeng, K. Boffard
Penetrating Neck Injuries: S. Moeng, K. Boffard
Penetrating Neck Injuries: S. Moeng, K. Boffard
S. Moeng, K. Boffard
Johannesburg Hospital Trauma Unit, and Department of Surgery, University of the Witwatersrand,
Johannesburg, South Africa.
Key words: Neck trauma; cervical trauma; penetrating trauma; vascular injuries; carotid trauma
MECHANISM
ital pressure, however in difficult access situations, on examination in a stable patient, close proximity
a Foley catheter can be used. gunshot wounds, transcervical wounds and hemi-
The patient should never be allowed to sit up be- plegia. Abnormal findings include extravasation of
cause of the danger of air embolism. contrast, vascular cut-off, intimal tears, false aneu-
rysm and A-V fistula.
DISABILITY An additional advantage of angiography in pa-
tients with proximal injury is that a balloon can be
Neurological assessment includes checking level of left in place by the radiologist, to control proximal
consciousness and Glasgow Coma Scale (GCS), pres- bleeding.
ence of hemiplegia, Horner’s Syndrome, spinal cord Other than diagnostic value it has therapeutic uses.
lesion, brachial plexus injuries and injury to cranial Vessels can be embolised during this procedure. The
nerves (especially VII / IX/ X / XI / XII). Hoarseness most commonly embolised vessels in the neck are the
should alert one to possible recurrent laryngeal nerve vertebral arteries. Stenting to control bleeding or tem-
injury and further assessment of mobility of the vo- porary balloon occlusion of vessels to determine pos-
cal cords. sible neurological effects of arterial ligation can be
attempted during angiography.
OTHER INJURIES Recently, Colour Flow Duplex imaging has been
shown to be safe and effective as a screening proce-
The presence of surgical emphysema, haemoptysis, dure with fewer side effects and at a less cost (9). This
or odynophagia should also alert one to the possibil- is a non-invasive procedure using a 5–10 MHz trans-
ity of oesophageal injury that may require further ducer to analyse vessels in the neck both longitudi-
investigation. nally and transversely. Carotids and vertebral ves-
Further assessment for associated injuries should sels have been assessed with this method. It has been
be carried out appropriately. shown that smaller vascular injuries may be missed
e.g. small intimal tears. However, these small inju-
ries can be managed conservatively. Unfortunately
this modality is not always available and is operator
INVESTIGATION dependant. It can also be used in follow-up of con-
servatively managed injuries. Angiography is pre-
The choice of investigation will be influenced by the ferred in Zone I and possibly Zone III injuries.
condition of the patient. Stable patients can be inves- Oesophagography and/or oesophagoscopy may be
tigated fully according to the clinical findings, where- required in the investigation of oesophageal injuries.
as instability may only allow for a few emergency Either of the studies alone may detect 60 % of the in-
room investigations or nothing at all before explora- juries but together they approximate 100 % (10). Wa-
tion in theatre. Investigation does not replace good ter-soluble contrast is preferred to barium swallow
thorough clinical examination but complements the as an initial test in oesophagography, but if this test
findings. is negative and there is still a high index of suspi-
cion, the latter may yield superior results. Better yield
BASIC INVESTIGATION can be achieved with the patient in a lateral decubi-
tus position. The problem arises with a patient who
As a minimum, a chest X-ray and an X-ray of the cer- cannot swallow for the test (e.g. intubated or uncon-
vical spine will allow assessment for haemothorax, scious patients). A nasogastric tube may be intro-
pneumothorax, surgical emphysema, cervical spine duced under direct visual guidance into the oesopha-
injury and to check for foreign bodies. These can be gus and contrast given, but proximal oesophageal le-
used to augment clinical findings and help in direct- sions are not well visualised this way. Both rigid and
ing further management. Markers should be applied flexible oesophagoscopy may be used. Flexible
to the entrance and exit wounds if possible prior to oesophagoscopy is associated with false negative re-
radiological examination to obtain an idea about the sults in proximal oesophageal injuries especially
tract. The mediastinum should be assessed for evi- when mucosal oedema is present, and in addition,
dence of vascular injury. Blood for cross-matching mucosal folds in the cricopharyngeal area may hide
and other tests should be organised accordingly. the pathology. Some feel that rigid oesophagoscopy
may yield closer to 100 % accuracy for proximal le-
SPECIFIC INVESTIGATIONS sion but general anaesthesia is required and hyper-
extension of the neck may not be possible in unsta-
Angiogram is considered the “gold standard” for ar- ble spinal injuries.
terial injury investigation. It is an invasive investi- Laryngoscopy and bronchoscopy may be used to
gation associated with some complications in about assess the airway injury. Confirming mucosal in-
1 % of the cases and false positives and false nega- volvement, and associated possible full thickness in-
tives do occur in about 3 % of cases (8). These com- jury will assist in decision-making regarding further
plications include bleeding at the arteriotomy site, management. Both flexible and rigid bronchoscopes
spasm of the vessels (which may be of major concern are available. Vocal cords may be assessed for move-
if it involves the carotids), allergic reactions, intimal ment in relevant cases.
tears, embolisation of atheromatous plaques and sep- Other tests include magnetic resonance imaging
sis. Indications include evidence of vascular injury (MRI) angiography and helical (spiral) CT angiogra-
38 S. Moeng, K. Boffard
phy for vascular work-up, and CT scanning of the tients would include cervical and chest X-rays, and
brain or neck tissues. would be carried thoroughly as described above. If
MRI angiography is not always immediately avail- hoarseness was present, or minor haemoptysis or
able in most cases requiring transfer to relevant cen- surgical emphysema then laryngoscopy and or bron-
tres. Furthermore monitoring of patients with multi- choscopy would be required. Pain on swallowing
ple injury or haemodynamic instability may be com- and emphysema around the neck should mandate
promised. This makes this investigation impractical oesophagoscopy and or oesophagography.
in most situations. Minor evidence of vascular injury or injury in close
Helical (spiral) CT angiography has been shown proximity to the vessel or sometimes even for trans-
to have high specificity and sensitivity in diagnos- cervical will require vascular investigation. Initially
ing vascular injuries. It is available in certain centres a Duplex Flow Ultrasound (when available) will be
and with recent advances in technology is rapid. performed if vascular injury is suspected. If the ul-
Other injuries can be assessed at the same time. To trasound examination is equivocal or not available
optimise sensitivity it is advised to scan from the top then angiography will be required.
of the arch of the aorta to the base of the skull. Patients should be assessed regularly and then can
In cases of hemiplegia, coma or head injury CT be discharged if no complications develop.
scan of the brain may be essential. Infarcts may not The major concern about this approach is possi-
be evident initially. CT scan may also be useful in bility of missing injuries on examination.
assessing spinal injuries and some laryngeal injuries.
Mandatory exploration
Those that favour mandatory exploration of all
DEFINITIVE CARE wounds penetrating the platysma irrespective of the
signs and symptoms (13), argue that physical signs
UNSTABLE PATIENT are unreliable and that morbidity from negative ex-
ploration is preferable to complications related to
There is no argument about the need to operate on missed injuries. Studies have shown that up to 30 %
patients that are unstable or who have evidence of of patients will have negative physical signs of inju-
severe injury to the aerodigestive or vascular system. ry on presentation thus increasing the possibility of
The patient will be prepared for theatre urgently, as missing injuries, which increases the morbidity and
soon as the airway and circulation have been tem- mortality. The number of investigations required is
porarily controlled. Further resuscitation and inves- minimised thus reducing cost. Morbidity from explo-
tigation may be carried out in theatre. This group in- ration is acceptable provided a thorough operation
cludes patients with severe active bleeding, shock not is done. They further feel that hospital stay is not sig-
responding to resuscitation, expanding haematomas, nificantly different from other methods.
pulsatile haematomas, or evidence of severe respira- Our own experience is that there is very little place
tory injury. for mandatory exploration.
(14) although the best results can be achieved with Oesophageal perforations should be debrided,
immediate revascularisation. mobilised if necessary and repaired primarily. Ade-
Repairs vary from simple debridement and direct quate drainage is essential. A muscle flap may be
anastomosis to the use of venous and synthetic grafts used in large defects or when there is associated tra-
for more extensive injuries. Shunts may be used in cheal injury. Their use may not prevent oesophageal
complex injuries. External carotid injuries may be leaks but may prevent tracheo-oesophageal fistula
ligated or treated conservatively. formation. Antibiotics should be started as early as
Minor injuries like very small intimal flaps can be possible. Delayed oesophageal repairs may require
managed conservatively but regular follow up with more extensive procedures, including diversion.
Duplex ultrasound is essential if complications are There is a place for conservative management of
to be minimised. upper hypophyseal injuries (lesions above the level
Most vertebral injuries can be managed non-oper- of arytenoid cartilage). This area is wrapped by mid-
atively or by proximal and distal embolisation. Sur- dle and inferior constrictor muscles and has a low
gical approach to these arteries is a major challenge intraluminal pressure allowing of injuries to seal
and is reserved for patients with failed embolisation spontaneously. Early intravenous antibiotics, restric-
or major bleeding. ted oral intake and frequent observation for septic
Subclavian venous injury has a higher mortality markers can be sufficient for management of these
than subclavian arterial injury, probably because of lesions.
possible air embolism and inability of the vessel to Lower hypophyseal injuries are managed as for
contract. Proximal injuries may require sternotomy oesophagus because they are more likely to leak and
with lateral extension. Access can also be gained by produce deep neck sepsis if not repaired and
thoracotomy and transclavicular approaches. Veins drained.
can be ligated but arteries should be repaired where
possible. Ligation of arteries is associated with in-
creased morbidity. CONCLUSION
11. Demetriades D, Asensio J, Velmahos G, Thal E: Complex prob- 14. Feliciano DV: A new look at penetrating carotid artery injuries.
lems in penetrating neck trauma. Surg Clin North Am Adv Trauma Crit Care. 1994;9:319–345
1996;76:661–683 15. Grewal H, Rao P, Mukerji S, Ivatury R: Management of pene-
12. Eddy VA, and the Zone I penetrating neck injury group: Is trating laryngotracheal injuries. Head and neck. 1995;17:494–
routine arteriography mandatory for penetrating injuries to 502
Zone I of the neck? J Trauma. 2000;48:208–214
13. Apffelstaedt J, Muller R: Results of mandatory exploration for
penetrating neck trauma. World J Surg 1994;18:917–920 Received: July 2, 2001