Clinical Practice Guideline: Penetrating Zone II Neck Trauma...Table 1 Penetrating Zone II Neck Trauma Evidentiary Table No. First Author Year Reference Class Conclusions 1 Bumpous

Clinical Practice Guideline: Penetrating Zone II NeckTraumaSamuel A. Tisherman, MD, Faran Bokhari, MD, Bryan Collier, DO, John Cumming, MD, James Ebert, MD,Michele Holevar, MD, Stanley Kurek, DO, Stuart Leon, MD, and Peter Rhee, MD

Key Words: Trauma, Neck, Carotid artery, Trachea, Esophagus.

J Trauma. 2008;64:1392–1405.

STATEMENT OF THE PROBLEM

Penetrating wounds of the neck are common in the ci-vilian trauma population. Risk of significant injury tovital structures in the neck is dependent on the pene-

trating object. For gunshot wounds, approximately 50%(higher with high velocity weapons) of victims have signifi-cant injuries, whereas this risk may be only 10% to 20% withstab wounds.

The management of injuries to the neck that penetrate theplatysma is dependent on the anatomic level of injury. The neckhas been divided into threes zones. Zone I, including thethoracic inlet, up to the level of the cricothyroid membrane, istreated as an upper thoracic injury. Zone III, above the angle ofthe mandible, is treated as a head injury. Zone II, betweenzones I and III, is the area of controversy. Because of thedensity of vital structures in this zone, multiple injuries arecommon1 and can affect length of stay.2 Mortality, particu-larly for major vascular injuries may reach 50%.3 Delayedcomplications such as pseudoaneurysms or arteriovenous fis-tulae can affect long-term outcomes.4 Appropriate and timely

management of these injuries is critical. For the patients withhard signs of significant injury, including active hemorrhage,expanding hematoma, bruit, pulse deficit, subcutaneous em-physema, hoarseness, stridor, respiratory distress, or hemipa-resis, immediate operative management may be indicated.Controversy arises over management of the patient withoutsignificant symptoms. The management of these patients hasbeen evolving from an era of mandatory exploration to an eraof more selective management. Mandatory exploration, whileseemingly safe and conservative, led to many nontherapeuticoperations. This fact, along with advances in technology,such as high resolution computed tomography (CT), mayeliminate the need to explore the neck to determine whetherthere are injuries. Also during the time that technology hadbeen advancing, many reports have documented the safety ofselective management of neck injuries that penetrate theplatysma. This experience has demonstrated that physicalexamination may be reliable and that not all injuries to vitalstructures in the neck need surgical intervention for repair.This guideline was therefore initiated to examine the specificroles of mandatory exploration versus selective managementbased on physical examination and current imaging technol-ogies for penetrating neck trauma.

Goals of the GuidelineThis guideline is designed to answer the following ques-

tions regarding the management of penetrating injuries tozone II of the neck that penetrate the platysma.1. Is mandatory operative management or selective operative

management appropriate?2. Can duplex ultrasonography (US) or CT angiography rule

out an arterial injury in patients with no hard signs ofvascular injury on physical examination, thereby makingarteriography unnecessary?

3. Are both contrast studies (barium or gastrograffin swal-low) and esophagoscopy needed to safely rule out esoph-ageal injury?

Submitted for publication July 19, 2007.Accepted for publication December 18, 2007.Copyright © 2008 by Lippincott Williams & WilkinsFrom the Departments of Surgery and Critical Care Medicine (S.A.T.),

University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Trauma(F.B.), Stroger Hospital of Cook County, Chicago, Illinois; Department ofSurgery (B.C.), Vanderbilt University, Nashville, Tennessee; Department ofEmergency Medicine (J.E.), Elmhurst Memorial Healthcare, Elmhurst , Illi-nois; Department of Surgery (M.H.), Mount Sinai Hospital, Chicago, Illinois;Department of Surgery (J.C.), Stamford Hospital, Stamford, Connecticut;Department of Surgery (S.K.), University of Tennessee Medical Center atKnoxville, Knoxville, Tennessee; Department of Surgery (S.L.), MedicalUniversity of Southern Carolina, Charleston, South Carolina; and Depart-ment of Surgery (P.R.), University of Arizona, University Medical Center,Tucson, Arizona.

Address for reprints: Samuel A. Tisherman, MD, Department of Crit-ical Care Medicine, 638 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA15261; email: [email protected].

DOI: 10.1097/TA.0b013e3181692116

The Journal of TRAUMA� Injury, Infection, and Critical Care

1392 May 2008

4. Is physical examination sensitive enough to rule out inju-ries to vascular structures or the aerodigestive tract?

PROCESSThe process used by this committee was developed by

the Practice Management Guidelines Committee of the East-ern Association for the Surgery of Trauma (www.east.org).The committee agreed on the questions to be considered.Literature for review included the following terms: human,trauma patients, penetrating, and neck; specific structureswere also searched (larynx, trachea, esophagus, carotid ar-tery, and jugular vein). Medline and EMBASE were searchedfrom 1966 to 2007.

Articles were distributed among committee members forformal review. Each article was entered into a review datasheet that summarized the main conclusions of the study andidentified any deficiencies in the study. Furthermore, review-ers classified each reference by the methodology establishedby the Agency for Health Care Policy and Research of theUnited States Department of Health and Human Services asfollows: Class I—prospective, randomized, double-blindedstudy; Class II—prospective, randomized, nonblinded trial;or Class III—retrospective series, meta-analysis.

An evidentiary table (Table 1) was constructed using the112 references that were identified: Class I, 1 reference; ClassII, 30 references; and Class III, 81 references. Recommenda-tions were made on the basis of the studies included in thistable. Level I recommendations, usually based on Class Idata, were meant to be convincingly justifiable on scientificevidence alone. Level II recommendations, usually supportedby Class I and II data, were to be reasonably justifiable byavailable scientific evidence and strongly supported by expertopinion. Level III recommendations, usually based on ClassII and III data, were to be made when adequate scientificevidence is lacking, but the recommendation is widely sup-ported by available data and expert opinion.

RECOMMENDATIONSSelective Workup—Operation Versus SelectiveNonoperative ManagementRecommendations

Level I: Selective operative management and mandatoryexploration of penetrating injuries to zone II of theneck have equivalent diagnostic accuracy. Therefore,selective management is recommended to minimizeunnecessary operations.

Level II: High resolution CT angiography offers appropri-ate diagnostic accuracy with minimal risk, making thisthe initial diagnostic study of choice when available.

Level III: No recommendations.

Scientific FoundationNonoperative management of penetrating neck wounds

was common in the early 20th century. Based on a review ofcivilian experience, Fogelman and Stewart5 recognized in

1956 that mandatory exploration led to less mortality than astrategy of observation. The rationale was that a significantnumber of seemingly asymptomatic patients with penetratingneck injuries actually have injuries.6 In addition, negativeneck explorations have little morbidity, though the financialcost is noteworthy; in 1981, Merion et al.7 estimated the costof a negative exploration at $1,930. Although an explorationunder local anesthesia is appealing in terms of limitingrecovery time and costs, Almskog et al.8 found that neckexplorations under local anesthesia, compared with generalanesthesia, resulted in more hematomas and missed inju-ries. Consequently, mandatory exploration under generalanesthesia for injuries that penetrate the platysma seemedreasonable.9,10

Mandatory exploration gained in popularity as studiesshowed that clinical symptoms were not present in 0% to23% of the cases. However, mandatory exploration was neg-ative 53% to 60% of the time and did not identify anyinjuries. In addition, some of the clinically silent injuries werevenous and pharyngoesophageal injuries, which did not re-quire operative therapy.11–13

Slowly, uncontrolled studies began to suggest that pa-tients without clear signs of vascular or visceral injury couldbe observed,14–34 though observation for up to 48 hours maybe necessary,35 depending on the use of ancillary tests. Jurk-ovich et al.36 compared the results of mandatory exploration(the preference of the attending surgeon) in 47 patients witha selective approach in 53 patients using 43 angiograms and14 endoscopies. In the mandatory exploration group, thenegative exploration rate was 53%. In the selective approachgroup, 12 injuries were found but only five patients benefitedfrom the work up. Some studies specifically recommendedthat to manage penetrating neck injuries, a well-staffed teach-ing hospital with a trauma service and immediate availabilityof radiologic and endoscopic evaluations is needed.37 How-ever, it has been shown that selective management can besafe in community hospitals with experienced surgeons.38

Evidence of chest injury does not seem to be an indication forneck exploration.39

Debate on the issue of selective management continuedas Meyer et al.40 questioned this new approach of selectiveexploration for penetrating neck injuries. In a series of 113patients, they obtained arteriograms, laryngotracheoscopy,esophagoscopy, and esophagography in each patient before amandatory exploration. Forty-eight injuries were identified in35 explorations. Of concern was the fact that five patients hadsix major injuries that were not identified by the preoperativetesting. Thus they believed that a mandatory explorationapproach was indicated.

More recent studies have consistently shown that theselective approach is a safe option. In a series of 128 asymp-tomatic patients who were observed by Biffl et al.,41 basedprimarily on physical examination, only one patient had amissed injury (from an ice pick). Only 15% of these patientsrequired adjuvant tests. Sriussadaporn et al.42 also success-

Penetrating Neck Trauma CPG

Volume 64 • Number 5 1393

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onin

this

typ

eof

inju

ry.

31K

lyac

hkin

ML

1997

Am

Sur

g63

:189

–94

IIITh

ed

ata

sup

por

tth

eap

plic

atio

nof

the

sele

ctiv

em

anag

emen

tal

gorit

hmfo

rzo

neII

neck

wou

nds.

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oper

ativ

ean

cilla

ryd

iagn

ostic

test

sw

ould

have

furt

her

red

uced

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nega

tive

exp

lora

tion

rate

.32

Her

sman

G20

01In

tS

urg

86:8

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ore

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and

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yex

plo

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ctiv

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emen

t.N

oco

nclu

sion

sca

nb

ed

raw

nfr

omth

eir

dat

a.33

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ely

CH

1975

JTr

aum

a15

:895

–900

IIIC

aref

ully

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cted

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ient

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nb

eob

serv

edfo

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olut

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ltant

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uenc

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atio

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ound

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inju

ries

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min

imiz

edin

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sele

ctiv

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plo

ratio

ngr

oup

.35

Str

oud

WH

1980

Am

JS

urg

140:

323–

6III

Man

dat

ory

exp

lora

tion

isno

tne

cess

ary,

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ifno

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ical

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curs

.O

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ion

for

48h

isre

com

men

ded

.36

Jurk

ovic

hG

J19

85J

Trau

ma

25:8

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Inth

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ical

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ined

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the

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fely

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rved

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jurie

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aggr

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eval

uate

db

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terio

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fluor

oeso

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sw

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hy.

Aer

odig

estiv

etr

act

stud

ies

ofin

jurie

sto

this

neck

zone

are

usel

ess.

37O

rdog

GJ

1985

JTr

aum

a25

:238

–46

IIIA

sub

stan

tialn

umb

erof

pat

ient

sw

ithp

enet

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ctiv

ely

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aged

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end

ing

onth

esy

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ther

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time

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wee

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ance

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eho

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lis

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ter

than

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ient

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able

and

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phy

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obvi

ous

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jury

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eval

uate

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iagn

ostic

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iolo

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and

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osco

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ifica

ntin

jury

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und

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serv

atio

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ithre

pea

ted

phy

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lexa

ms

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24h

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lab

ility

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can

den

dos

cop

icm

odal

ities

mus

tb

ead

here

dto

.38

Cab

asar

esH

V19

82A

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urg

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whe

nap

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te,

can

spar

ep

atie

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unne

cess

ary

and

cost

lyte

stin

g.39

Gol

db

erg

PA

1991

Inju

ry22

:7–8

IIC

onco

mita

ntp

enet

ratin

gch

est

inju

ryis

not

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dic

atio

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rex

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Con

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40M

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JP19

87A

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Sur

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2:59

2–7

IIIP

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tially

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41B

ifflW

L19

97A

mJ

Sur

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4:67

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IIS

elec

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agem

ent

issa

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dd

oes

not

man

dat

ed

iagn

ostic

test

ing.

42S

riuss

adap

orn

S20

01In

tS

urg

86:9

0–3

IIIS

elec

tive

man

agem

ent

bas

edon

clin

ical

find

ings

issa

fe.

43N

ason

RW

2001

Can

JS

urg

44:1

22–6

IIIS

elec

tive

man

agem

ent

may

be

app

rop

riate

,b

utth

ecr

iteria

for

obse

rvat

ion

are

uncl

ear.

44N

arro

dJA

1984

JE

mer

gM

ed2:

17–2

2III

Man

dat

ory

exp

lora

tion

ofp

enet

ratin

gan

terio

rne

ckw

ound

sis

unne

cess

ary

and

use

ofa

sele

ctiv

eap

pro

ach

toth

eir

eval

uatio

nis

bot

hsa

fean

dco

st-e

ffec

tive.

Ob

serv

atio

nd

oes

not

man

dat

eex

tens

ive

anci

llary

dia

gnos

ticte

stin

gfo

rle

velI

Ian

dIII

inju

ries.

For

leve

lIin

jurie

s,ar

terio

grap

hyis

per

form

edan

dif

the

wou

ndap

pro

ache

sth

em

edia

stin

um,

esop

hage

alco

ntra

stst

udie

san

den

dos

cop

icev

alua

tion

are

per

form

edin

sele

cted

pat

ient

s.In

this

stud

y,th

ese

nsiti

vity

ofes

opha

gosc

opy

and

esop

hage

alco

ntra

stst

udie

sw

asle

ssth

an70

%;

ther

efor

e,in

jurie

sw

ithab

norm

also

fttis

sue

air

und

ergo

man

dat

ory

exp

lora

tion

des

pite

the

risk

ofne

gativ

eex

plo

ratio

n.45

Nar

rod

JA19

84A

rch

Sur

g11

9:57

4–8

IIS

elec

tive

exp

lora

tion

for

pen

etra

ting

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inju

ries

issa

fean

dco

st-e

ffec

tive.

Ob

serv

atio

nd

oes

not

man

dat

eex

tens

ive

anci

llary

test

ing

for

leve

lII

and

IIIin

jurie

s.46

Vel

mah

osG

C19

94C

anJ

Sur

g37

:487

–91

IILa

rge

stud

yof

sele

ctiv

em

anag

emen

t,b

ut9%

mis

sed

inju

ries

seem

shi

gh.

47G

olue

keP

J19

84J

Trau

ma

24:1

010–

4I

Man

dat

ory

and

sele

ctiv

est

rate

gies

are

equi

vale

nt.

48A

tta

HM

1998

Am

Sur

g64

:222

–5III

Tran

scer

vica

linj

urie

sar

em

ore

leth

alth

anot

her

typ

esof

inju

ries

toth

ene

ck.

49H

irshb

erg

A19

94A

mJ

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7:30

9–12

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ansc

ervi

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enet

ratio

nm

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ea

pre

dic

tor

ofm

ajor

inju

ry,

sup

por

ting

anap

pro

ach

ofm

and

ator

yne

ckex

plo

ratio

n.50

Dem

etria

des

D19

96J

Trau

ma

40:7

58–6

0II

This

stud

yd

oes

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sup

por

tm

and

ator

yop

erat

ion

for

allt

rans

cerv

ical

guns

hot

wou

nds.

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refu

lclin

ical

exam

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ion

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bin

edw

ithth

eap

pro

pria

ted

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inve

stig

atio

nssh

ould

det

erm

ine

the

trea

tmen

tm

odal

ity.

Ab

out

80%

ofth

ese

pat

ient

sca

nsa

fely

be

man

aged

nono

per

ativ

ely.

51G

raci

asV

H20

01A

rch

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g13

6:12

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IIIC

Tin

stab

lese

lect

edp

atie

nts

with

pen

etra

ting

neck

trau

ma

seem

ssa

fe.

Inva

sive

stud

ies

can

ofte

nb

eel

imin

ated

whe

nC

Td

emon

stra

tes

traj

ecto

ries

rem

ote

from

vita

lstr

uctu

res.

Furt

her

pro

spec

tive

stud

yof

CT

scan

afte

rp

enet

ratin

gne

cktr

aum

ais

need

ed.

52M

azol

ewsk

iPJ

2001

JTr

aum

a51

:315

–9II

CT

isgo

odan

dca

nb

eus

edto

elim

inat

eth

ene

edfo

rm

and

ator

yex

plo

ratio

n.53

Mun

era

F20

04E

mer

gR

ad10

:303

–9III

CT

angi

ogra

phy

dec

reas

esth

ene

edfo

ran

giog

rap

hy.

54N

unez

DB

,Jr

2004

Rad

iogr

aphi

cs24

:108

7–98

IIITh

isis

mor

eof

are

view

ofth

ep

ossi

ble

inju

ries

that

can

be

dem

onst

rate

dw

ithC

Tan

giog

rap

hy.

They

poi

ntou

tth

atC

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ayal

sop

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able

info

rmat

ion

rega

rdin

gso

fttis

sues

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rod

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ine.

55In

aba

K20

06J

Trau

ma

61:1

44–1

49III

106

inju

ries.

15ne

eded

urge

ntop

erat

ion.

91p

atie

nts

und

erw

ent

CT

angi

o.10

0%se

nsiti

vity

and

93.5

%sp

ecifi

city

ind

etec

ting

allv

ascu

lar

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aero

dig

estiv

ein

jurie

ssu

stai

ned

.N

on-d

iagn

ostic

stud

ies

wer

ese

cond

ary

tore

tain

edm

issi

lefr

agm

ents

.56

Woo

K20

05A

mS

urg

71:7

54–7

58II

Ret

rosp

ectiv

est

udy

of13

0p

atie

nts.

Pat

ient

sw

houn

der

wen

tC

Tan

giog

ram

had

few

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plo

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ns(3

%vs

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few

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%vs

.32

%).

Use

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giog

rap

hyan

des

opha

gogr

aphy

also

dec

reas

edw

ithus

eof

CT

angi

ogra

phy

.57

Bel

lRB

2007

JO

ralM

axill

ofac

Sur

g65

:69

1–70

5II

Ret

rosp

ectiv

est

udy.

65p

atie

nts

und

erw

ent

CT

angi

ogra

phy

.Th

enu

mb

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neck

exp

lora

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dec

reas

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imin

ated

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tive

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exp

lora

tions

.58

Prg

omet

D19

96E

urA

rch

Oto

rhin

olar

yngo

l25

3:29

4–6

IIIW

ound

str

eate

dd

urin

gth

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st6

haf

ter

inju

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ould

be

clos

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ilyb

utw

ithob

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dra

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ycl

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eis

bet

ter

for

wou

nds

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mor

eth

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haf

ter

inju

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ses

with

larg

ertis

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def

ects

req

uirin

gla

rger

loca

lor

free

graf

tfla

ps

for

clos

ure.

59D

anic

D19

98M

ilM

ed16

3:11

7–9

IIIP

rimar

ycl

osur

eof

war

wou

nds

toth

ehe

adan

dne

ck(s

upp

orte

db

yan

tibio

ticth

erap

y)an

dre

cons

truc

tion

ofex

tens

ive

lary

ngot

rach

eali

njur

ies

with

the

med

iall

ayer

ofth

ece

rvic

ald

eep

fasc

iaw

ere

used

for

the

first

time

asw

arsu

rger

yp

roce

dur

es.

60C

oop

erA

1987

JP

edS

urg

22:2

4–7

IIIS

elec

tive

man

agem

ent

ofne

ckin

jurie

sse

ems

app

rop

riate

inch

ildre

n.


1396 May 2008

Tabl

e1

Pen

etra

ting

Zon

eII

Nec

kT

raum

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vide

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able

(con

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No.

Firs

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ear

Ref

eren

ceC

lass

Con

clus

ions

61H

allJ

R19

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Trau

ma

31:1

614–

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Non

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ativ

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atio

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pen

etra

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neck

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ries

issa

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choi

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activ

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atio

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nb

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iate

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.62

Thom

asA

N19

78J

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ard

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scS

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76:6

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help

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oid

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.63

O’D

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llV

A19

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elec

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man

agem

ent

bas

edon

angi

ogra

phy

issa

fean

def

fect

ive.

64S

mith

RF

1974

Arc

hS

urg

109:

198–

205

IIIN

ofir

mco

nclu

sion

sre

gard

ing

ind

icat

ions

for

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Dun

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ram

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66H

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IIIN

egat

ive

angi

ogra

mal

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ssa

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nop

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man

agem

ent.

67N

orth

CM

1986

Am

JR

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geno

l147

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ular

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rym

ore

freq

uent

lyth

anst

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ound

s.68

Har

tling

RP

1989

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iolo

gy17

2:79

–82

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ccul

tva

scul

artr

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ely

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atie

nts

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min

orp

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ings

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ngio

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ind

icat

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inju

ries

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ithm

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lfin

din

gs,

but

not

inth

ose

with

min

orp

hysi

cal

find

ings

.69

Riv

ers

SP

1988

JV

asc

Sur

g8:

112–

6III

Art

erio

grap

hyfo

rp

enet

ratin

gne

cktr

aum

ais

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llyun

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ssar

yfo

rob

serv

atio

nof

pat

ient

sin

stab

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onw

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tsu

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ates

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need

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ost

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san

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oid

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uenc

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ap

ossi

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e-ne

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udy.

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urg

204:

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Com

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lem

etho

dof

initi

alex

plo

ratio

nfo

rst

able

pat

ient

sw

ithp

enet

ratin

gne

ckw

ound

s.71

Scl

afan

iSJ

1991

JTr

aum

a31

:557

–62

IIIP

hysi

cale

xam

inat

ion

isin

suff

icie

nt.

Ang

iogr

aphy

orex

plo

ratio

nis

ind

icat

edif

pla

tysm

ais

viol

ated

.72

Men

awat

SS

1992

JV

asc

Sur

g16

:397

–400

IIILo

catio

nan

dp

hysi

cale

xam

inat

ion

can

rule

out

am

ajor

arte

riali

njur

yne

cess

itatin

gop

erat

ion.

73N

emze

kW

R19

96A

mJ

Neu

rora

d17

:161

–7III

Pre

vert

ebra

lsof

ttis

sue

swel

ling

and

bul

let

frag

men

tatio

nin

pro

xim

ityto

ave

ssel

are

non-

spec

ific

find

ings

and

are

pre

sent

inm

any

pat

ient

sw

ithne

gativ

ean

gio.

No

com

men

ton

com

put

edto

mog

rap

hy.

74Ja

rvik

JG19

95A

mJ

Neu

rora

dio

l16:

647–

54II

Clin

ical

exam

isgo

odan

dno

td

oing

angi

ogra

ms

save

s3.

08m

illio

nd

olla

rsp

erce

ntra

lner

vous

syst

emev

ent

pre

vent

ed.

75D

emet

riad

esD

1995

Arc

hS

urg

130:

971–

5II

Dop

ple

ran

dp

hysi

cale

xam

have

100%

sens

itivi

tyfo

rcl

inic

ally

imp

orta

ntle

sion

sin

the

vasc

ulat

ure

ofth

ene

ck.

76D

emet

riad

esD

1997

Wor

ldJ

Sur

g21

:41–

7II

Phy

sica

lexa

min

atio

nis

suff

icie

ntto

iden

tify

pat

ient

sw

hore

qui

rear

teria

lor

esop

hage

alev

alua

tion.

Dup

lex

isa

reas

onab

leal

tern

ativ

eto

angi

ogra

phy

.77

Byn

oeR

P19

91J

Vas

cS

urg

14:3

46–5

2II

Ulta

soun

dis

accu

rate

and

cost

-eff

ectiv

e.78

Mon

talv

oB

M19

96A

mJ

Neu

rora

dio

l17:

943–

51II

Col

orD

opp

ler

sono

grap

hyis

asac

cura

teas

angi

ogra

phy

insc

reen

ing

clin

ical

lyst

able

pat

ient

sw

ithzo

neII

orII

inju

ries

and

nosi

gns

ofac

tive

ble

edin

g.79

Gin

zbur

gE

1996

Arc

hS

urg

131:

691–

3II

Dup

lex

ultr

asou

ndis

are

liab

lem

etho

dfo

rid

entif

ying

vasc

ular

trau

ma

inth

est

able

pat

ient

.A

bno

rmal

ultr

asou

ndre

sults

shou

ldw

arra

ntsu

bse

que

ntan

giog

rap

hy.

80C

orr

P19

99S

Afr

Med

J89

:644

–6II

Dup

lex

isa

reas

onab

lesc

reen

ing

test

for

pen

etra

ting

arte

riali

njur

ies.

81M

uner

aF

2000

Rad

iolo

gy21

6:35

6–62

IITh

ese

nsiti

vity

and

spec

ifici

tyof

helic

alC

Tan

giog

rap

hyar

ehi

ghfo

rd

etec

tion

ofm

ajor

caro

tidan

dve

rteb

rala

rter

iali

njur

ies

resu

lting

from

pen

etra

ting

trau

ma.

The

entir

ene

ckm

ust

be

incl

uded

inth

eex

amin

atio

n.



Tabl

e1

Pen

etra

ting

Zon

eII

Nec

kT

raum

aE

vide

ntia

ryT

able

(con

tinu

ed)

No.

Firs

tA

utho

rY

ear

Ref

eren

ceC

lass

Con

clus

ions

82M

uner

aF

2002

Rad

iolo

gy22

4:36

6–72

IIIH

elic

alC

Tan

giog

rap

hyca

nb

ere

liab

lyus

edto

eval

uate

pen

etra

ting

neck

trau

ma

inth

est

able

pat

ient

.P

atie

nts

with

bru

itsor

thril

lat

adm

issi

onm

ayb

eb

ette

rm

anag

edb

yco

nven

tiona

lang

iogr

aphy

bec

ause

ofth

elik

elih

ood

ofen

dov

ascu

lar

ther

apy.

Hel

ical

CT

angi

ogra

phy

islim

ited

by

artif

act

due

tom

etal

whi

chm

ayob

scur

ear

teria

lseg

men

ts;

ther

efor

e,th

ese

pat

ient

ssh

ould

und

ergo

conv

entio

nal

angi

ogra

phy

.S

ubtle

lesi

ons

such

asin

timal

flap

sm

ayb

em

isse

db

yhe

lical

CT

angi

ogra

phy

ther

efor

eun

der

estim

atin

gth

eto

taln

umb

erof

inju

ries.

83O

fer

A20

01E

urJ

Vas

cE

ndov

asc

Sur

g21

:401

–7III

CT

angi

ogra

phy

was

100%

accu

rate

for

caro

tidar

tery

inju

ries

in12

pat

ient

sw

ithp

enet

ratin

gtr

aum

aan

d4

with

blu

nttr

aum

a.O

neb

lunt

and

1p

enet

ratin

gin

jury

det

ecte

d.

84S

ple

ner

CW

1976

Arc

hS

urg

111:

663–

7III

Ear

lysi

gns

wer

esu

btle

.S

mal

lam

ount

sof

med

iast

inal

and

cerv

ical

air

tend

edto

be

over

look

edor

erro

neou

sly

attr

ibut

edto

othe

rca

uses

,su

chas

asso

ciat

edp

neum

otho

rax.

Onc

esu

spec

ted

,th

ep

ossi

bili

tyof

esop

hage

ald

isru

ptio

nw

asno

tal

way

sp

ursu

edw

ithop

timum

vigo

r.85

Ase

nsio

JA19

97J

Trau

ma

43:3

19–2

4III

Eso

pha

geal

inju

ries

carr

ya

high

mor

bid

ityan

dm

orta

lity.

Thou

ghth

esa

mp

lesi

zeis

smal

l,th

ere

doe

sap

pea

rto

be

anin

crea

sed

mor

bid

ityas

soci

ated

with

the

dia

gnos

ticw

orku

pan

dits

inhe

rent

del

ayin

oper

ativ

ere

pai

rof

thes

ein

jurie

s.Fo

rce

nter

sp

ract

icin

gse

lect

ive

man

agem

ent,

rap

idd

iagn

osis

and

def

initi

vere

pai

rsh

ould

be

mad

ea

high

prio

rity.

86A

sens

ioJA

2001

JTr

aum

a50

:289

–96

IIP

reop

erat

ive

eval

uatio

nfo

res

opha

geal

inju

ries

shou

ldb

eca

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dou

tex

ped

itiou

sly

toav

oid

del

ays

that

are

det

rimen

talt

oth

ep

atie

nt.

87H

atzi

theo

filou

C19

93B

rJ

Sur

g80

:114

7–9

IIID

iagn

ose

and

rep

air

esop

hage

alin

jurie

sea

rly(�

24h)

.88

Sym

bas

PN

1980

Ann

Sur

g19

1:70

3–7

IIIP

erfo

rmE

GD

inp

atie

nts

with

mis

sile

traj

ecto

ryne

arth

ees

opha

gus

irres

pec

tive

ofp

hysi

cals

igns

ofes

opha

geal

inju

ry.

Rep

air

alli

njur

ies

with

plic

atio

nin

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ition

top

rimar

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r.89

Che

adle

J19

82S

urg

Gyn

ecol

Ob

stet

155:

380–

4III

Rep

air

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hage

alin

jurie

s.

90S

ham

aD

M19

84B

rJ

Sur

g71

:534

–6III

Trac

heal

wou

nds

are

usua

llyre

cogn

ized

early

but

cerv

ical

esop

hage

alin

jurie

sar

eno

t.E

arly

reco

gniti

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refe

rral

are

asso

ciat

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wm

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idity

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Late

reco

gniti

on&

refe

rral

carr

ya

high

mor

bid

ityan

dm

orta

lity

rate

.91

Pop

ovsk

yJ

1984

JTr

aum

a24

:337

–9III

Due

toex

tens

ive

tissu

ed

amag

ein

GS

Ws,

prim

ary

rep

airs

ofth

orac

ices

opha

geal

per

fora

tions

have

ahi

ghin

cid

ence

offa

ilure

.D

efun

ctio

naliz

atio

nof

the

esop

hagu

sth

roug

hlig

atio

nof

the

dis

tale

sop

hagu

s,ga

stro

stom

y,an

dce

rvic

ales

opha

gost

omy

pro

vid

esa

safe

rm

etho

d.

Use

ofa

dou

ble

stra

ndof

abso

rbab

leD

exon

tolig

ate

the

dis

tale

sop

hagu

sm

akes

ase

cond

thor

acot

omy

unne

cess

ary

for

ligat

ure

rem

oval

.R

outin

eus

eof

hyp

eral

imen

tatio

nav

oid

sth

ene

edfo

rfe

edin

gje

juno

stom

y.A

llp

atie

nts

with

cerv

ical

esop

hage

alle

sion

sar

ero

utin

ely

exp

lore

dth

roug

ha

pre

-ste

rnoc

leid

omas

toid

inci

sion

onth

esi

de

ofth

ein

jury

and

the

per

fora

tion

clos

edw

ith2

laye

rsof

nona

bso

rbab

lem

onof

ilam

ent

and

dra

ined

.92

Arm

stro

ngW

B19

94A

nnO

tolR

hino

lLar

yngo

l10

3:86

3–71

IIITr

eat

asp

hary

ngea

linj

urie

san

dre

pai

rp

rimar

ily.

Div

ersi

onle

ads

toco

mp

licat

ions

such

asst

rictu

res.

93S

tanl

eyR

B19

97J

Trau

ma

42:6

75–9

IIIIn

jurie

slo

cate

din

the

upp

erp

ortio

nof

the

hyp

opha

rynx

can

be

rout

inel

ym

anag

edw

ithou

tsu

rgic

alin

terv

entio

n.N

eck

exp

lora

tion

and

adeq

uate

dra

inag

eof

the

dee

pne

cksp

aces

are,

how

ever

,m

and

ator

yfo

ral

lpen

etra

ting

inju

ries

into

the

cerv

ical

esop

hagu

san

dm

ost

inju

ries

into

the

low

erp

ortio

nof

the

hyp

opha

rynx

.94

Mad

iba

TE20

03A

nnR

Col

lSur

gE

ngl8

5:16

2–6

IIIN

on-o

per

ativ

em

anag

emen

tof

pen

etra

ting

inju

ries

toth

ece

rvic

ales

opha

gus

issa

fean

def

fect

ive.

95M

inar

dG

1992

Am

Sur

g58

:181

–7III

Lary

ngot

rach

ealt

raum

aus

ually

pre

sent

sw

ithsy

mp

tom

san

d/o

rsi

gns,

but

they

may

be

min

imal

and

nons

pec

ific.

Em

erge

ncy

trac

heos

tom

ysh

ould

not

be

del

ayed

ifve

ntila

tion

isco

mp

rom

ised

.C

onco

mita

ntes

opha

geal

inju

ries

are

freq

uent

and

pre

dis

pos

eth

ep

atie

ntto

pos

top

erat

ive

com

plic

atio

ns.

Airw

ayco

mp

rom

ise

freq

uent

lyco

rrel

ates

with

seve

rity

ofin

jury

and

risk

for

com

plic

atio

ns.


1398 May 2008

Tabl

e1

Pen

etra

ting

Zon

eII

Nec

kT

raum

aE

vide

ntia

ryT

able

(con

tinu

ed)

No.

Firs

tA

utho

rY

ear

Ref

eren

ceC

lass

Con

clus

ions

96G

rew

alH

1995

Hea

dN

eck

17:4

94–5

02III

End

otra

chea

lint

ubat

ion

can

be

acco

mp

lishe

dsa

fely

inse

lect

edp

atie

nts

with

pen

etra

ting

lary

ngot

rach

eal

inju

ries.

Dig

estiv

etr

act

inju

ries

can

ofte

nb

ecl

inic

ally

occu

lt&

early

eval

uatio

nof

the

esop

hagu

sis

vita

l.In

pat

ient

sw

ithm

inor

inju

ries,

trac

heos

tom

yd

oes

not

app

ear

tob

em

and

ator

y.97

Wei

gelt

JA19

87A

mJ

Sur

g15

4:61

9–22

IIIFo

rse

lect

ive

man

agem

ent,

arte

riogr

aphy

,es

opha

gogr

aphy

and

rigid

esop

hago

scop

y(if

esop

hagr

amis

equi

voca

l)ar

ene

cess

ary

toru

leou

tin

jurie

sth

atre

qui

reex

plo

ratio

n.98

Woo

dJ

1989

JTr

aum

a29

:602

–5III

Uns

tab

lep

atie

nts

req

uire

imm

edia

teex

plo

ratio

n.S

tab

lep

atie

nts

with

equi

voca

lphy

sica

lfin

din

gsca

nb

em

anag

edac

cord

ing

tore

sults

ofes

opha

geal

exam

inat

ion

and

angi

ogra

phy

.P

atie

nts

with

low

pro

bab

ility

ofin

jury

due

tolo

catio

nan

dcl

inic

alp

rese

ntat

ion

can

be

obse

rved

.R

egar

dle

ssof

met

hod

ofm

anag

emen

t,th

ose

with

ap

ossi

bili

tyof

esop

hage

alin

jury

shou

ldun

der

goes

opha

gram

and

/or

esop

hago

scop

y.99

Nga

kane

H19

90B

rJ

Sur

g77

:908

–10

IIITr

ache

alin

jury

inth

eab

senc

eof

life-

thre

aten

ing

airw

aypr

oble

ms

can

betr

eate

dsu

cces

sful

lyw

itha

cons

erva

tive

appr

oach

.Pat

ient

sw

ithm

inim

alsy

mpt

oms

ofvi

scer

alin

jury

follo

win

gpe

netr

atin

gce

rvic

altr

aum

am

aybe

sele

cted

for

furt

her

eval

uatio

nba

sed

onth

esi

mpl

ew

ater

swal

low

ing

test

.Ase

vere

pain

resp

onse

onsw

allo

win

gsh

ould

elic

ita

cont

rast

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low

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ient

sw

itha

norm

alst

udy

and

thos

ew

ithm

inim

alle

akag

eof

cont

rast

mat

eria

lcan

bem

anag

edno

n-op

erat

ivel

yha

ving

are

peat

exam

onda

y5.

100

Srin

ivas

anR

2000

Am

JG

astr

oent

erol

95:1

725–

9III

End

osco

py

isa

safe

and

relia

ble

met

hod

for

eval

uatin

gth

ees

opha

gus

for

pen

etra

ting

trau

ma.

101

McC

orm

ick

TM19

79J

Trau

ma

19:3

84–7

IIP

hysi

cale

xam

inta

ion

isun

relia

ble

inru

ling

inor

out

vasc

ular

trau

ma,

alth

ough

nosu

bcat

egor

izat

ion

ofne

ckan

dex

trem

ityin

jurie

sw

asdo

ne,n

orw

asth

ere

ade

scrip

tion

ofho

wse

rious

the

mis

sed

inju

ries

wer

e.10

2M

etzd

orff

MT

1984

Am

JS

urg

147:

646–

9III

Clin

ical

find

ings

are

are

liab

lein

dic

ator

ofsi

gnifi

cant

trau

ma.

103

Ap

ffel

stae

dt

JP19

94W

orld

JS

urg

18:9

17–9

IIIP

hysi

cale

xam

inat

ion

doe

sno

the

lpd

eter

min

ew

hich

pat

ient

sha

velif

e-th

reat

enin

gin

jurie

s.M

and

ator

yex

plo

ratio

nis

reco

mm

end

ed.

104

Dem

etria

des

D19

93B

rJ

Sur

g80

:153

4–6

IIP

hysi

cale

xam

inat

ion

isre

liab

lein

det

ectin

gsi

gnifi

cant

inju

ries

inp

enet

ratin

gne

cktr

aum

a.10

5G

erst

PH

1990

Am

Sur

g56

:553

–5II

Sel

ectiv

em

anag

emen

t,w

hen

guid

edb

yre

pea

ted

,ca

refu

lexa

min

atio

ns,

issa

fean

dav

oid

sun

nece

ssar

yop

erat

ions

.10

6B

eits

chP

1994

Arc

hS

urg

129:

577–

81III

Nei

ther

man

dat

ory

neck

exp

lora

tion

nor

man

dat

ory

arte

riogr

aphy

isne

cess

ary.

Phy

sica

lexa

min

atio

nsh

ould

be

used

toas

sess

for

pos

sib

ility

ofin

jury

inp

enet

ratin

gne

cktr

aum

a.10

7A

tteb

erry

LR19

94J

Am

Col

lSur

g17

9:65

7–62

IIV

ascu

lar

inju

ryca

nb

eex

clud

edb

yp

hysi

cale

xam

.10

8S

ekha

ran

J20

00J

Vas

cS

urg

32:4

83–9

IIP

atie

nts

with

Zon

eII

pen

etra

ting

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wou

nds

can

be

safe

lyan

dac

cura

tely

eval

uate

db

yp

hysi

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fully observed 17 asymptomatic patients. Only 2 of 40 pa-tients who underwent exploration did not need the operation,though they seemed to have deep wounds. In asymptomaticpatients, Nason et al.43 found that 67% underwent negativeexplorations. All zone II vascular injuries were symptomatic.Narrod and Moore44,45 reviewed their 10-year experiencewith penetrating neck trauma. In the first 6 years, mandatoryexploration led to a 56% rate of negative explorations. In thenext 4 years, a selective management strategy was used.Forty-one of 48 patients who underwent exploration hadsignificant injuries,45 whereas 29 asymptomatic patients wereobserved without any missed injuries. Few ancillary studieswere performed in this group. In a large, retrospective studyfrom Johannesburg, South Africa, Velmahos et al.46 com-pared results with patients who underwent immediate surgicalexploration versus constant monitoring. In the explorationgroup, 3% of the explorations were unnecessary; mortalitywas 4.2%. In the monitoring group, 9% had missed injuries;mortality was 4%. Criteria for observation versus explorationwere not clear making the interpretation of the 9% missedinjury rate difficult. The only randomized trial comparingmandatory neck exploration with a selective approach basedon physical examination and radiographs was performed byGolueke et al.47 in 160 patients. There was no difference inhospital stay, morbidity, or mortality.

Management of transcervical gunshot wounds deservesseparate consideration because of the high likelihood of ma-jor injury.48 Hirshberg et al.49 explored 41 patients withtranscervical gunshot wounds. Twenty-eight had more thanone zone of the neck involved. Although seven patients didnot have major injuries, 34 patients had 52 major injuries tocervical structures mainly involving vessels and the upperairway. Sixteen presented with life-threatening problems.They recommended mandatory exploration. In contrast, Dem-etriades et al.50 found that a selective approach based on physicalexamination, angiography, esophagoscopy, and esophagographywas safe.

Helical CT angiography is the newest technology to betested for identifying vascular injuries from penetrating necktrauma, particularly arterial injuries. Because it might also beuseful for identifying or ruling out other injuries (e.g., aerodi-gestive tract injury), this modality is particularly intriguing as a“one stop shop” to evaluate asymptomatic patients for selectiveoperative management. The speed and resolution of this mo-dality continues to improve. Gracias et al.51 have alreadyrecommended that if a CT demonstrates trajectories that areremote from vital structures, the need for additional invasivestudies can be eliminated.

In the setting of a mandatory exploration protocol,Mazolewski et al.52 found that CT angiography, comparedwith operative findings, was 100% sensitive and 91% specificin 14 patients. Both Munera et al.53 and Nunez et al.54 pointedout the utility of CT angiography for identifying nonvascularsoft tissue injuries, and the vascular injuries. Inaba et al.55

reviewed their experience with 106 patients who had pene-

trating injuries to the neck. Fifteen required urgent operation.The remainder underwent CT angiogram. Two tracheal injuriesand two carotid artery injuries were identified. No injuries re-quiring intervention were missed. Use of CT angiography cansafely decrease the number of neck explorations and, moreimportantly, the number of negative neck explorations.56,57 Inaddition, CT angiography can decrease, though not eliminate,the need for formal angiography and esophagography in somepatients.56

Management of neck wounds in the military setting maybe different from that in the civilian world. Prgomet et al.58

found that injuries that did not penetrate the platysma did notcause significant injuries. Forty-nine of 84 patients who un-derwent immediate exploration had injuries to vital struc-tures. They also found that it was safe to close the woundprimarily if it was seen within 6 hours of injury. In theirexperience, even extensive laryngotracheal injuries could berepaired safely.59

There is little data on selective management of penetrat-ing neck injuries in children. Small studies60,61 suggest that aselective management strategy is safe.

Diagnosis of Arterial InjuryRecommendations

Level I: No recommendations.Level II: CT angiography or duplex US can be used in

lieu of arteriography to rule out an arterial injury inpenetrating injuries to zone II of the neck.

Level III: CT of the neck (even without CT angiography)can be used to rule out a significant vascular injury ifit demonstrates that the trajectory of the penetratingobject is remote from vital structures. With injuries inproximity to vascular structures, minor vascular inju-ries such as intimal flaps may be missed.

Scientific FoundationIn the era of mandatory neck exploration for penetrating

trauma, there seemed to be little need for angiography,though some9 suggested that the angiogram could assist inoperative planning and thereby minimize morbidity or rule outthe need for exploration.62,63 Physical examination, however,seemed unreliable for ruling out arterial injury.64 Delayedpseudoaneuryms and neurologic events have been described inoriginally asymptomatic patients, prompting some to advo-cate angiography in all such patients.65 A negative arterio-gram in a stable patient can rule out an arterial injury.66 Northet al.67 reviewed the records of 139 stable patients withpenetrating neck trauma. Patients who had at least soft signsof vascular injury (absent pulse, bruit, hematoma, or alteredneurologic status) had a 30% incidence of vascular injury byangiography, whereas only 2 of 78 asymptomatic patients hadinjuries (one minor and one that did not affect management).Gunshot wounds were more likely than stab wounds to causevascular injury. Similarly, Hartling et al.68 found, using an-giography, that 43 patients with stab wounds to the neck and


1400 May 2008

minimal symptoms had no significant injuries. Even in the 18patients with physical findings consistent with a vascularinjury, only two had significant injuries. Similarly, Rivers etal.69 questioned the value of angiography. Of 63 angiogramsin 61 patients, only 6 were abnormal. Three were thought tobe spurious on subsequent review, two were clinically insig-nificant, and one required surgery. No significant arterialinjuries were identified by arteriography in the absence ofsuggestive physical findings. No major arterial injuries thatwere missed preoperatively were discovered during explora-tion. Angiograms did not alter the course of management.Noyes et al.70 examined the accuracy of a selective manage-ment strategy. Arteriography and laryngoscopy/bronchos-copy were 100% accurate.

In contrast, Sclafani et al.71 found that 10 of 26 patientswho had positive angiograms for penetrating vascular injuryto the neck had undergone the angiogram solely because ofproximity. Physical examination had a sensitivity of 61% andspecificity of 80%. They also found no differences in theirresults based on mechanism of injury. They suggested thatproximity should not be abandoned as an indication for an-giography in these patients.

Menawat et al.72 performed angiography for proximityor soft signs of vascular injury. Fifteen injuries were found on45 angiograms. Forty-two patients without any signs of injurywere successfully observed without angiography or opera-tion. Overall, only one patient had a significant injury thatwas not predicted by physical examination.

In contrast, Nemzek et al.73 found that proximity, basedon the addition of plain films or CT of the neck showingprevertebral soft-tissue swelling, missile fragmentation, ormissiles adjacent to major vessels can be useful, but arenonspecific radiographic signs.

To examine the cost effectiveness of angiography, Jarviket al.74 studied 111 patients with penetrating neck trauma.Forty-five of the 48 patients with vascular injuries had ab-normal clinical findings. Management in the other three pa-tients was not altered by the angiogram. They calculated thecost of screening angiography in asymptomatic patients to beapproximately $3.08 million per central nervous systemevent.

Demetriades et al.75 prospectively compared physicalexamination and duplex US imaging with angiography in 82stable patients with penetrating neck injuries. Only 11 pa-tients had vascular injuries by angiography; and only two ofthese injuries needed to be repaired. The serious injuries weredetected or suspected on physical examination, but six lesionsthat did not require treatment were missed (sensitivity 100%for serious injuries, but 45% for all injuries). By duplex USimaging, 10 of 11 injuries, including all serious ones, wereidentified, for an overall sensitivity of 91% (100% for clini-cally important lesions) and specificity of 99%. Further stud-ies by Demetriades et al.76 included 223 patients. Of the 160asymptomatic patients, 11 had injuries that did not requiretreatment. Overall, duplex US was 92% sensitive (100% for

findings that required an operation) and 100% specific fordefining an injury. Similarly, Bynoe et al.77 found that duplexUS was 95% sensitive and 99% specific for vascular injuriesafter both neck and extremity trauma. The only missed inju-ries were two shotgun pellet injuries that did not need repair.

In a prospective, double-blind study, Montalvo et al.78

found that US identified all 10 significant injuries in 52patients with penetrating neck trauma. Duplex US did notidentify reversible carotid narrowing in one patient and didnot visualize two vertebral arteries. Another report by thesame group79 found in 55 patients that duplex US had 100%sensitivity and 85% specificity.

Corr et al.80 reported that duplex US picked up twointimal flaps that were not identified on angiography.

Munera et al.81 prospectively studied 60 patients, whohad 10 vascular injuries. There was one missed injury byCT angiography because the study actually did not includethe entire neck. They later82 suggested that patients withbruits or thrills at admission may be better treated byundergoing conventional angiography because of the po-tential for endovascular therapy. Helical CT angiographyis limited by artifact due to metal, which may obscurearterial segments; therefore, these patients should undergoconventional angiography.

Ofer et al.83 reviewed their experience with CT angiog-raphy in 16 patients (12 with penetrating trauma and fourwith blunt) and found no missed injuries, although only onepatient with penetrating trauma had a carotid injury (con-firmed at operation).

Diagnosis of Esophageal InjuryRecommendations

Level I: No recommendations.Level II: Either contrast esophagography or esophagos-

copy can be used to rule out an esophageal perforationthat requires operative repair. Diagnostic workupshould be expeditious because morbidity increases ifrepair is delayed by more than 24 hours.

Level III: No recommendations.

Scientific FoundationThe problem with penetrating injuries to the esophagus is

that there are frequently no findings on physical examination.Esophagography can miss the injury.84 This is of grave concernsince late referral and management can lead to significant mor-bidity and mortality.85–87 Early diagnosis and management, oftenwith primary repair, lead to good outcomes.88–90 Even gun-shot wounds can be closed primarily91; more complex repairsmay lead to strictures.92 Location of the injury can affectoutcome as injuries above the arytenoid cartilages can bemanaged without intervention, whereas more inferior injuriesrequire neck drainage to prevent a deep tissue infection.93

Madiba et al.94 also found that patients with small injuriesand contained perforation on contrast studies could be ob-served without operation unless there was another indication



for exploration. All 26 patients with injuries had odynopha-gia. Of 17 patients managed nonoperatively, only one devel-oped local sepsis. Six patients had associated tracheal injuries.In addition, patients with tracheal injuries have worse out-comes if they have concomitant esophageal injuries.95,96

Noyes et al.70 found that esophagograms were 90% ac-curate and esophagoscopy was 86% accurate. Weigelt et al.97

used a strategy of esophagography followed by rigid esopha-goscopy if the esophagogram were equivocal to identifyesophageal injuries in patients who had no or minimal symp-toms after penetrating neck trauma. All 10 injuries in 118patients were identified. Wood et al.98 found that esophagog-raphy alone was 100% sensitive and 96% specific in 225patients. Ngakane et al.99 reviewed 109 patients with pene-trating neck trauma. All patients with gunshot wounds un-derwent esophagography, whereas patients with stab woundswere only studied if they had pain with swallowing. Twenty-nine studies were performed and four injuries were identified.All were observed without intervention. Repeat contrast stud-ies demonstrated resolution of the injury.

In 23 patients with esophageal injuries, Armstrong etal.92 found that esophagography only identified 62% of theinjuries whereas rigid esophagoscopy detected all injuries.Srinivasan et al.100 found reasonable accuracy with flexibleendoscopy. In 55 patients, flexible endoscopy identified theonly two injuries, but suggested an injury in four patients,resulting in four negative explorations, for an overall sensi-tivity of 100% and specificity of 92%.

Value of the Physical ExaminationRecommendations

Level I: No recommendations.Level II: No recommendations.Level III: Careful physical examination using protocols

for serial examinations, including auscultation of thecarotid arteries, is �95% sensitive for detecting arte-rial and aerodigestive tract injuries that require repair.Given the potential morbidity of missed injuries, cli-nicians should have a low threshold for obtainingimaging studies.

Scientific FoundationEarly reports suggested that the physical examination is

unreliable to rule out a vascular injury. McCormick andBurch101 found physical examination of neck and extremityinjuries yielded a 20% false negative rate and a 42% falsepositive rate. Metzdorff and Lowe102 found an overall 80%accuracy of physical examination. Apffelstaedt and Muller103

found that clinical signs were absent in 30% of patients withpositive neck explorations and in 58% of patients with neg-ative neck explorations, supporting their approach of manda-tory exploration.

More recently, Demetriades et al.104 studied 335 patientswith penetrating neck injuries. Sixty patients underwent ex-ploration for positive physical examination findings or a

positive workup, whereas 269 asymptomatic patients wereobserved. Only two of the latter patients later required elec-tive procedures. In a subsequent article, this group demon-strated that physical examination did not miss any majorvascular or esophageal injuries that required intervention;though minor injuries were identified by angiography (1 of 8required intervention) and esophagography. Using a selectiveapproach based on careful and repeated physical examina-tions, Gerst et al.105 observed 58 asymptomatic patients with-out sequelae. Of the 52 patients who underwent promptexploration based on physical examination, 17% did not havesignificant injuries. Similarly, Beitsch et al.106 found thatonly 1 of 71 asymptomatic patients had a vascular injurydetected by angiography. Thus, in this patient populationphysical examination ruled out 99% of vascular injuries andthe yield for angiography was 1.4%. Atteberry et al.107 foundthat if patients did not have physical examination findings ofarterial injury (active bleeding, expanding hematoma or he-matoma larger than 10 cm, a bruit or thrill, or a neurologicdeficit), no vascular injuries were present based on angiog-raphy, duplex ultrasound, or clinical follow-up. They ob-served patients for at least 23 hours.

Conversely, Sekharan et al.108 found that only 2 of 30patients who underwent exploration for hard signs of vascularinjury did not have a significant injury. Twenty-three of 114asymptomatic patients underwent angiography for proximityor involvement of another zone. Only one of these patientsneeded an operation. All 91 other patients with negativephysical examinations were safely observed without imaging.Azuaje et al.109 found that 68% of patients with positivephysical examination had a positive angiogram. Of the 89 pa-tients with negative physical examinations, only three had pos-itive angiograms, but none needed operations. Overall, physicalexaminations had sensitivity of 93% and a negative predictivevalue of 97%. Both sensitivity and negative predictive value forinjuries requiring operation were 100%.

A recent study by Mohammed et al.110 suggests cautionin relying on physical examination alone to rule out vascularinjuries secondary to gunshot wounds of the neck. Of 59patients with gunshot wounds to any zone of the neck, 13 hadpositive physical findings suggesting a vascular injury,whereas 10 patients with negative physical findings werefound to have injuries by angiography, giving physical ex-amination a negative predictive value of 67%. The signifi-cance of these findings is difficult to determine, because theyincluded all zones of the neck and did not define the severityof the injuries that were identified.

Subcutaneous emphysema or crepitance are physicalfindings suggestive of aerodigestive tract injuries that mayrequire operative intervention. Goudy et al.111 reviewed thecases of 19 patients with emphysema or crepitance. Twenty-onepercent had dysphagia, and 63% had stridor or hoarseness.Most underwent direct laryngoscopy and esophagoscopy. Pa-tients without demonstrable injuries or small tears were suc-cessfully observed without exploration.


1402 May 2008

The best study, though small, that attempted to determinewhether imaging adds to physical examination in the evalu-ation of patients with penetrating neck injuries was that byGonzalez et al.112 Forty-two patients, who did not have ob-vious need for operation at admission, underwent soft tissuedynamic CT of the neck and esophagography before mandatoryexploration. All tracheal and carotid injuries were identifiedby physical examination. Two of four esophageal injuries(both from stab wounds) were missed by both CT andesophagography. CT was better than physical examinationfor identifying venous injuries, but most of these did notrequire intervention.

FUTURE DIRECTIONSSelective management of penetrating injuries to zone II

of the neck has become common for asymptomatic patients.The roles of physical examination, arteriography, duplex US,CT angiography, esophagography, and esophogoscopy re-main unclear. At the moment, the single imaging modalitythat holds the greatest potential for ruling out vascular, tra-cheal, and esophageal injuries is CT angiography. Additionaltrials are needed to confirm this hypothesis. As the resolutionof CT images improves, accuracy will surely increase. Rapiddefinitive imaging studies may allow early discharge of pa-tients with neck injuries.

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Clinical Practice Guideline: Penetrating Zone II Neck Trauma...Table 1 Penetrating Zone II Neck Trauma Evidentiary Table No. First Author Year Reference Class Conclusions 1 Bumpous