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34 S. Moeng, K. BoffardScandinavian Journal of Surgery 91: 3440, 2002

PENETRATING NECK INJURIES

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

INTRODUCTION

Management of penetrating neck injuries is compli-

cated by the anatomic high-density relationship be-tween vascular, upper respiratory, digestive and neu-rological structures. Up to 30 % of the injuries involvemultiple structures (1). Expeditious systematic as-sessment, decision-making and appropriate treat-ment is required to minimise catastrophic complica-tions.

Before World War II non-operative managementresulted in mortality rates as high as 16 %, whichprompted subsequent exploration of injuries pene-trating the platysma. It was further shown that mor-tality associated with mandatory exploration couldbe improved from 35 % to 6 % if patients were oper-ated on earlier (2). Numerous centres have chal-

lenged the principle of mandatory exploration in therecent years. Currently civilian mortality figures areexpected at 26 % and can be as high as 11 % (3).Most of these cases are associated with vascular in-juries (carotid arteries, subclavian vessels) and spi-nal injuries.

ANATOMY

Basic knowledge of the anatomy of the neck is es-sential in appreciating the complex nature of theseinjuries and serves as a landmark in the managementof these injuries. The platysma is a thin muscle that

originates from upper thorax extending into the neckand finally blending with muscles of the face. It iscovered by superficial fascia that lies just beneath the

skin. Injuries that penetrate this muscle define pene-trating neck injuries. The deep fascia underlies thismuscle and is divided into three portions (investing,

pretracheal and prevertebral layers). Investing fasciacovers the trapezius, omohyoid and sternocleidomas-toid muscles. The pretracheal fascia covers the thy-roid and cricoid cartilage extending and blendingwith mediastinal tissues. The prevertebral fascia cov-ers the vertebra and deep muscles close to it. Allthree fascial divisions contribute to form carotidsheath that covers the carotid vessels, internal jugu-lar and the vagus nerves. The recurrent laryngealnerve lies in the groove between trachea and theoesophagus.

The neck is divided into three anatomic zones. Thishelps in the categorisation and management of neckwounds. (See Fig. 1)

Zone I extends from the bottom of the cricoid car-tilage to the clavicles and thoracic outlet. Within thiszone lie the trachea, the great vessels, the oesopha-gus, the upper mediastinum, the lung apices and thethoracic duct. Mortality in this zone is the highest ofthe three zones.

Zone II includes the area between the cricoid car-tilage and the angle of the mandible. Enclosed with-in its region are the carotid and vertebral arteries,jugular veins, pharynx, larynx, oesophagus, and tra-chea.

Zone III involves the area above the angle of themandible up to the base of the skull, and includesthe distal extracranial carotid and vertebral arteries

as well as segments of the jugular veins.Injuries in Zone II are readily evaluated and easilyexposed operatively. Adequate exposure of Zone Ior Zone III injuries can be difficult, thus, the diag-nostic work-up may be more extensive than forZone II injuries. Trauma to the neck is not necessarilylimited to a specific zone.

The neck is also anatomically divided into the an-terior and the posterior triangles.

Most of injuries involve Zone II in many studies,yet mortality is the highest in Zone I (4). The mostcommon cause of death is exsanguination. Vascularinjuries account for up to 25 % of structural injurieswith carotid and internal jugular most frequently in-

Correspondence:K. D. Boffard, M.D.Department of SurgeryUniversity of the Witwatersrand Facultyof Health Sciences,7, York Road,Parktown,Johannesburg, 2193Republic of South AfricaEmail: [email protected]

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35Penetrating neck injuries

volved. The vertebral artery is less commonly in-volved due to its protected anatomic position. Therespiratory tract is involved in 10 % of the cases andproper airway management is essential to avoid res-piratory embarrassment. Though the oesophagus isless involved, missed injuries are associated withhigh morbidity and mortality. Neurological injuriesand other injuries should be borne in mind.

MECHANISM

Penetrating wounds can be broadly categorised intothose caused by missiles (gunshot wounds/ blastfragments/ pellets) and those by stabs and lacera-tions (knives/ axes/ swords/ tree branches).

The severity of injuries seen with missiles (e.g. bul-lets) is related to a number of factors, which includethe kinetic energy impacted by the missile on the tis-sues, the properties of the missile and the density ofthe tissues damaged.

Energy transferred to the tissues is related to the

Kinetic Energy (5) expressed as

KE = m (VenVex)2

Where KE is Kinetic energyM is the mass of the objectVenis the velocity on entryVexis the velocity on exit

High velocity (and therefore high energy) missilesas seen with military, rifle and short distance shot-gun wounds cause more damage than low velocitymissiles. The mass of the missile is proportional tothe energy transferred.

Missiles do not necessarily enter or even travel in

the tissues perpendicular to their long axis. This abil-ity to yaw and tumble increases the surface area thathas direct tissue contact thus increasing the damage.They also have the ability to form temporary cavita-tion in the tissues which relates to the amount ofenergy transmitted. By creating several waves of con-traction and expansion within the tissues they resultin damage of tissues remote from direct area of con-tact. This phenomenon is worst in tissues of greatestresistance. During initial debridement it is very easyto underestimate the degree of tissue damage awayfrom the path followed by the missile.

Some missiles are specially designed to cause moretissue damage by increasing the amount of energy

transferred to the tissues. They may do so by explod-ing on impact, fragmenting or even flattening on con-tact to cause rapid deceleration.

More damage is caused in the tissues that havegreater resistance mainly due to their absorption ofmost of the energy.

MANAGEMENT

Prompt initial assessment and institution of manage-ment should be carried out according to the ATLS

principles, prioritising the life-threatening conditionsfirst.

AIRWAY

Initial concern is to establish and maintain a patentairway, which may be compromised by direct airwayinjury, bleeding into the oral cavity, compressionfrom haematomas in the neck or even severe surgi-cal emphysema around the neck. Some patients mayhave impaired neurology from associated head in-

Fig. 1. Zones of the neck.

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36 S. Moeng, K. Boffard

jury or severe shock with impaired ability to main-

tain the airway. Sudden deterioration of initial air-way status may occur. The need for proper assess-ment and constant monitoring of the airway cannotbe overemphasised.

Different methods can be instituted (6) to achievethis depending on several factors, including the skillof the attending physician, availability of the re-sources and presenting features. Oxygen supplemen-tation, basic airway maintenance technique and mon-itoring should be instituted as soon as possible whilepreparing equipment for definitive airway. A highindex of suspicion for possible spinal injury shouldbe maintained and the neck immobilized until radi-ological or clinical clearance has been obtained.

Orotracheal intubation is recommended for pa-tients that are moribund, apnoeic or have associatedbleeding into the airway. Most emergency physiciansand departments are equipped for this technique butit may be challenging under emergency situations.Bleeding, collapsed airway and associated spinal in-jury complicate this technique and one should al-ways be ready to perform a surgical airway. The air-way cannot be clearly assessed below the cords withthis method. Therefore intubation may complicate analready existing injury below the cords. The use ofneuromuscular blocking agents should be avoided ifpossible because of the possible disaster that may fol-low collapse of the airway due to relaxation of mus-

cles which help to maintain some patency of the air-way especially when one fails to intubate successful-ly. The patient should not cough or strain during thisprocedure because of a potential risk of increasingbleeding in the presence of vascular injuries.

For this reason most people may use benzodi-azepines such as midazolam (with or without opi-oids) or anaesthetic inducing agents like etomidateor ketamine to facilitate intubation. Obviously a mor-ibund unstable patient might not even require anysedation or paralysis.

The need for a surgical airway should be antici-pated and instituted promptly should the need arise.Cricothyroidotomy in failed endotracheal intubation

or in cases associated with severe facial or laryngealfractures may be life saving. This procedure is tech-nically easier but may be challenging in the presenceof neck swelling due to extensive surgical emphyse-ma or haematoma. It is usually avoided in childrenand in patients with injuries below the cricothyroidmembrane. Tracheostomy may be done in the emer-gency department or in the operating theatre in lessurgent cases. Not all upper airway injuries requiretracheostomy for definitive management. Either anopen or percutaneous route may be chosen.

Awake fibreoptic intubation with the use of localspray anaesthesia, bronchoscopy and endotrachealtube can be attempted if facilities and expertise areavailable. This technique has become useful in therecent years though not necessarily universally avail-able. The advantage is that the airway can be visual-ised, with placement of the intubation tube beyondthe injury, and it can be confirmed that the balloonis distal to the injury to minimise further damage tothe airway and massive air leak. This can be achievedwith the patient awake and breathing spontaneo-

usly. Some centres use a visual monitor that allowsother members of the resuscitation team to assess theairway and plan appropriately. Rapid sequencefiberoptic induction has also been tried but it is morechallenging in emergency situations, especially thoseassociated with bleeding in the area.

Other methods include intubation via the injuryitself, especially in stabs where there is an obviousdirect airway injury in the midline. This is only usedtemporarily until a more definitive airway can be es-tablished.

Blind nasal intubation is discouraged since it mayconvert a partial airway injury into a complete oneand there is a possibility of creating a false tract.

BREATHING

After securing the airway, ventilation should also beassessed to ensure good oxygenation. Tension pneu-mothorax, haemothorax and pneumothorax shouldbe dealt with. Persistent pneumothoraces despite in-tercostal decompression should alert one to a possi-ble major airway injury that may require surgical re-pair.

CIRCULATION

Vascular assessment and management will include

assessing for haemodynamic stability, checking forsigns of injury (expanding haematoma, bruit, shock,severe bleeding, unequal upper limb pulses, hemi-plegia etc), and control of active bleeders either bydirect pressure or balloon tamponade (7). Avoidprobing neck wounds because this may dislodge aclot resulting in bleeding or air embolism. Vascularaccess should be established and fluid administeredaccordingly. At this stage one would have an idea ofthe patients stability, in order to decide whether fur-ther investigation was helpful, or whether urgentsurgery in the unstable patient was necessary.

The key is where possible to obtain vascular con-trol. Ideally this should be by direct pressure, or dig-

Fig. 2. Stab wound of the neck showing the use of a Foleys cathe-ter for haemostasis.

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ital pressure, however in difficult access situations,a Foley catheter can be used.

The patient should never be allowed to sit up be-cause of the danger of air embolism.

DISABILITY

Neurological assessment includes checking level ofconsciousness and Glasgow Coma Scale (GCS), pres-ence of hemiplegia, Horners Syndrome, spinal cordlesion, brachial plexus injuries and injury to cranialnerves (especially VII/IX/ X/ XI/ XII). Hoarsenessshould alert one to possible recurrent laryngeal nerveinjury and further assessment of mobility of the vo-cal cords.

OTHER INJURIES

The presence of surgical emphysema, haemoptysis,or odynophagia should also alert one to the possibil-ity of oesophageal injury that may require furtherinvestigation.

Further assessment for associated injuries shouldbe carried out appropriately.

INVESTIGATION

The choice of investigation will be influenced by thecondition of the patient. Stable patients can be inves-tigated fully according to the clinical findings, where-as instability may only allow for a few emergencyroom investigations or nothing at all before explora-tion in theatre. Investigation does not replace goodthorough clinical examination but complements the

findings.

BASIC INVESTIGATION

As a minimum, a chest X-ray and an X-ray of the cer-vical spine will allow assessment for haemothorax,pneumothorax, surgical emphysema, cervical spineinjury and to check for foreign bodies. These can beused to augment clinical findings and help in direct-ing further management. Markers should be appliedto the entrance and exit wounds if possible prior toradiological examination to obtain an idea about thetract. The mediastinum should be assessed for evi-dence of vascular injury. Blood for cross-matching

and other tests should be organised accordingly.

SPECIFIC INVESTIGATIONS

Angiogram is considered the gold standard for ar-terial injury investigation. It is an invasive investi-gation associated with some complications in about1 % of the cases and false positives and false nega-tives do occur in about 3 % of cases (8). These com-plications include bleeding at the arteriotomy site,spasm of the vessels (which may be of major concernif it involves the carotids), allergic reactions, intimaltears, embolisation of atheromatous plaques and sep-sis. Indications include evidence of vascular injury

on examination in a stable patient, close proximitygunshot wounds, transcervical wounds and hemi-plegia. Abnormal findings include extravasation ofcontrast, vascular cut-off, intimal tears, false aneu-rysm and A-V fistula.

An additional advantage of angiography in pa-tients with proximal injury is that a balloon can beleft in place by the radiologist, to control proximalbleeding.

Other than diagnostic value it has therapeutic uses.Vessels can be embolised during this procedure. Themost commonly embolised vessels in the neck are thevertebral arteries. Stenting to control bleeding or tem-porary balloon occlusion of vessels to determine pos-sible neurological effects of arterial ligation can beattempted during angiography.

Recently, Colour Flow Duplex imaging has beenshown to be safe and effective as a screening proce-dure with fewer side effects and at a less cost (9). Thisis a non-invasive procedure using a 510 MHztrans-ducer to analyse vessels in the neck both longitudi-nally and transversely. Carotids and vertebral ves-

sels have been assessed with this method. It has beenshown that smaller vascular injuries may be missede.g. small intimal tears. However, these small inju-ries can be managed conservatively. Unfortunatelythis modality is not always available and is operatordependant. It can also be used in follow-up of con-servatively managed injuries. Angiography is pre-ferred in Zone I and possibly Zone III injuries.

Oesophagography and/or oesophagoscopy may berequired in the investigation of oesophageal injuries.Either of the studies alone may detect 60 % of the in-juries but together they approximate 100 % (10). Wa-ter-soluble contrast is preferred to barium swallowas an initial test in oesophagography, but if this test

is negative and there is still a high index of suspi-cion, the latter may yield superior results. Better yieldcan be achieved with the patient in a lateral decubi-tus position. The problem arises with a patient whocannot swallow for the test (e.g. intubated or uncon-scious patients). A nasogastric tube may be intro-duced under direct visual guidance into the oesopha-gus and contrast given, but proximal oesophageal le-sions are not well visualised this way. Both rigid andflexible oesophagoscopy may be used. Flexibleoesophagoscopy is associated with false negative re-sults in proximal oesophageal injuries especiallywhen mucosal oedema is present, and in addition,mucosal folds in the cricopharyngeal area may hide

the pathology. Some feel that rigid oesophagoscopymay yield closer to 100 % accuracy for proximal le-sion but general anaesthesia is required and hyper-extension of the neck may not be possible in unsta-ble spinal injuries.

Laryngoscopy and bronchoscopy may be used toassess the airway injury. Confirming mucosal in-volvement, and associated possible full thickness in-jury will assist in decision-making regarding furthermanagement. Both flexible and rigid bronchoscopesare available. Vocal cords may be assessed for move-ment in relevant cases.

Other tests include magnetic resonance imaging(MRI) angiography and helical (spiral) CT angiogra-

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phy for vascular work-up, and CT scanning of thebrain or neck tissues.

MRI angiography is not always immediately avail-able in most cases requiring transfer to relevant cen-tres. Furthermore monitoring of patients with multi-ple injury or haemodynamic instability may be com-promised. This makes this investigation impracticalin most situations.

Helical (spiral) CT angiography has been shownto have high specificity and sensitivity in diagnos-ing vascular injuries. It is available in certain centresand with recent advances in technology is rapid.Other injuries can be assessed at the same time. Tooptimise sensitivity it is advised to scan from the topof the arch of the aorta to the base of the skull.

In cases of hemiplegia, coma or head injury CTscan of the brain may be essential. Infarcts may notbe evident initially. CT scan may also be useful inassessing spinal injuries and some laryngeal injuries.

DEFINITIVE CARE

UNSTABLE PATIENT

There is no argument about the need to operate onpatients that are unstable or who have evidence ofsevere injury to the aerodigestive or vascular system.The patient will be prepared for theatre urgently, assoon as the airway and circulation have been tem-porarily controlled. Further resuscitation and inves-tigation may be carried out in theatre. This group in-cludes patients with severe active bleeding, shock notresponding to resuscitation, expanding haematomas,pulsatile haematomas, or evidence of severe respira-

tory injury.

STABLE PATIENT

Controversy exists in patients that have no clinicalsigns of major injury or have soft signs. Most au-thors practice selective management (11) of these in-juries while some advocate mandatory exploration.

Selective management

Most have adopted policy of selective managementin view of a high rate of negative exploration andgood outcomes. Patients are assessed clinically and

by investigation and triaged further into operative orconservative (non-operative) management. In injuriesthat have penetrated the platysma, a bronchoscopy,laryngoscopy, oesophagoscopy and/or oesophago-grapy with Duplex Flow Doppler studies or angio-graophy will be performed to assess the patient fur-ther and manage accordingly. This is even more im-portant in patients who cannot be clinically moni-tored to assess for change in symptoms (for exampleundergoing other surgical procedures). Angiographywould be advised for Zone I and III injuries.

Recently an even more selective approach has beenadopted by some centres even for Zone I and ZoneIII injuries (12). Clinical examination for stable pa-

tients would include cervical and chest X-rays, andwould be carried thoroughly as described above. Ifhoarseness was present, or minor haemoptysis orsurgical emphysema then laryngoscopy and or bron-choscopy would be required. Pain on swallowingand emphysema around the neck should mandateoesophagoscopy and or oesophagography.

Minor evidence of vascular injury or injury in closeproximity to the vessel or sometimes even for trans-cervical will require vascular investigation. Initiallya Duplex Flow Ultrasound (when available) will beperformed if vascular injury is suspected. If the ul-trasound examination is equivocal or not availablethen angiography will be required.

Patients should be assessed regularly and then canbe discharged if no complications develop.

The major concern about this approach is possi-bility of missing injuries on examination.

Mandatory exploration

Those that favour mandatory exploration of all

wounds penetrating the platysma irrespective of thesigns and symptoms (13), argue that physical signsare unreliable and that morbidity from negative ex-ploration is preferable to complications related tomissed injuries. Studies have shown that up to 30 %of patients will have negative physical signs of inju-ry on presentation thus increasing the possibility ofmissing injuries, which increases the morbidity andmortality. The number of investigations required isminimised thus reducing cost. Morbidity from explo-ration is acceptable provided a thorough operationis done. They further feel that hospital stay is not sig-nificantly different from other methods.

Our own experience is that there is very little place

for mandatory exploration.

SPECIFIC SURGERY

Vascular injuries

General principles of good exposure, proximal anddistal control and initial direct pressure to controlbleeding are applicable.

Zone II injuries are explored by an incision alongthe anterior border of the sternocleidomastoid mus-cle. Zone I injuries may be approached by sternoto-my or thoracotomy depending on the vessels in-volved. Zone III injuries may be difficult to expose

and mandibular subluxation, vertical mandibular os-teotomy or even intracranial control may be neces-sary.

Trap-door incisions are often difficult and we arenot in favour of their use. Carotid arteries may in-volve internal, external or common carotid vessels.Common carotid injuries are associated with inter-nal jugular vein injuries and thus have higher mor-tality. Repair is recommended for major injuries butcare should be exercised in the presence of anaemicinfarcts because of fear of converting them intohaemorrhagic infarcts or the worsening of oedemaassociated with revascularisation. Presence of comahas poor outcome irrespective of the management

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(14) although the best results can be achieved withimmediate revascularisation.

Repairs vary from simple debridement and directanastomosis to the use of venous and synthetic graftsfor more extensive injuries. Shunts may be used incomplex injuries. External carotid injuries may beligated or treated conservatively.

Minor injuries like very small intimal flaps can bemanaged conservatively but regular follow up withDuplex ultrasound is essential if complications areto be minimised.

Most vertebral injuries can be managed non-oper-atively or by proximal and distal embolisation. Sur-gical approach to these arteries is a major challengeand is reserved for patients with failed embolisationor major bleeding.

Subclavian venous injury has a higher mortalitythan subclavian arterial injury, probably because ofpossible air embolism and inability of the vessel tocontract. Proximal injuries may require sternotomywith lateral extension. Access can also be gained bythoracotomy and transclavicular approaches. Veins

can be ligated but arteries should be repaired wherepossible. Ligation of arteries is associated with in-creased morbidity.

Upper airway injuries

Aggressive airway management is essential to mini-mize mortality.

Management of laryngeal injuries depends on theirseverity (15). In minor injuries (minor lacerations,minor mucosal disruption, airway compromise with-out laryngeal fracture) simple repair without trache-ostomy is sufficient. Repair of major injuries (largemucosal lacerations, displaced fractures of the larynx,

laryngeal instability, vocal cord injuries) may requirethyrotomy with reduction of displaced fractures,stenting or tracheostomy. Minor injuries with mobilecords have better voice results. Major injuries tendto have worse voice results if stenting is used in thepresence of mobile cords. Follow-up includes assess-ment for airway patency and voice quality.

Tracheal injuries can be assessed using broncho-scopy or during exploration. The posterior membra-nous wall should also be inspected in anterior inju-ries. Early diagnosis and primary repair leads to theleast complication and best long-term results.

Simple lacerations may be repaired without trache-ostomy. Larger defects once debrided and repaired

are best managed with tracheostomy and may re-quire muscle flaps especially if there is an associatedoesophageal injury.

Upper digestive tract

Hypopharyngeal and oesophageal injuries may beeasily missed. Leakage of saliva and bacteria, as wellas reflux of acid, pepsin and bile into the tissues re-sults in a severe necrotising inflammatory response.This response is more severe if there is a delay in ac-tive management (>1224 hours). Delayed repairs ofthe oesophagus are associated with increased mor-bidity and mortality.

Oesophageal perforations should be debrided,mobilised if necessary and repaired primarily. Ade-quate drainage is essential. A muscle flap may beused in large defects or when there is associated tra-cheal injury. Their use may not prevent oesophagealleaks but may prevent tracheo-oesophageal fistulaformation. Antibiotics should be started as early aspossible. Delayed oesophageal repairs may requiremore extensive procedures, including diversion.

There is a place for conservative management ofupper hypophyseal injuries (lesions above the levelof arytenoid cartilage). This area is wrapped by mid-dle and inferior constrictor muscles and has a lowintraluminal pressure allowing of injuries to sealspontaneously. Early intravenous antibiotics, restric-ted oral intake and frequent observation for septicmarkers can be sufficient for management of theselesions.

Lower hypophyseal injuries are managed as foroesophagus because they are more likely to leak andproduce deep neck sepsis if not repaired anddrained.

CONCLUSION

Management of penetrating neck injuries is contro-versial but there is a trend towards selective conserv-ative management. Rapid assessment and promptmanagement of life threatening conditions especi-ally airway and vascular control is essential in earlymanagement. Unstable patients should be surgicallyexplored as soon as possible. Thorough physical ex-amination and appropriate investigations followedby serial examination optimise care of stable patients.The incidence of missed injuries should be minimised

to avoid the high morbidity and mortality associatedwith them.

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11. Demetriades D, Asensio J, Velmahos G, Thal E: Complex prob-lems in penetrating neck trauma. Surg Clin North Am1996;76:661683

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Received: July 2, 2001

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