Neck Neck TraumaTrauma

prepared by: Dr. Hiwa As’adprepared by: Dr. Hiwa As’ad

IntroductionIntroduction

Incidence: 1:30,000 ER VisitsIncidence: 1:30,000 ER Visits It should be suspected in all injuries It should be suspected in all injuries

affecting the face and chest.affecting the face and chest. Outcome determined by initial Outcome determined by initial

managementmanagement

Anatomy and Physiology of Anatomy and Physiology of LarynxLarynx

Well protected (mandible, sternum, neck flex)Well protected (mandible, sternum, neck flex) Functions: Airway, tracheobronchial Functions: Airway, tracheobronchial

protection, voiceprotection, voice Support: Hyoid, thyroid, cricoidSupport: Hyoid, thyroid, cricoid Innervation: RLN, SLNInnervation: RLN, SLN Supraglottis: soft tissueSupraglottis: soft tissue Glottis: relies on external support, crico-Glottis: relies on external support, crico-

arytenoid mobility and neuromuscular inputarytenoid mobility and neuromuscular input Subglottis: cricoid, narrowest in infantsSubglottis: cricoid, narrowest in infants

Anatomy and Physiology of Anatomy and Physiology of LarynxLarynx

Mechanism of InjuryMechanism of Injury

Blunt Blunt Motor vehicle accident, strangulation, Motor vehicle accident, strangulation,

clothesline, sports related.clothesline, sports related. Significant internal damage, minimal Significant internal damage, minimal

external signs.external signs. Penetrating Penetrating

Gun shot : damage related to velocityGun shot : damage related to velocity Knife: easy to underestimate damageKnife: easy to underestimate damage

Blunt Trauma: Mechanisms of Blunt Trauma: Mechanisms of InjuryInjury

Compression Compression over spineover spine

Static lateral Static lateral forceforce

L-T separationL-T separation

Compression Over SpineCompression Over Spine

Static Lateral ForceStatic Lateral Force

Penetrating traumaPenetrating trauma

Types of Weapons Types of Weapons Low velocity – knives, glassLow velocity – knives, glass High velocity – handguns, shotguns, High velocity – handguns, shotguns,

shrapnelshrapnel

Penetrating traumaPenetrating trauma

Penetrating traumaPenetrating trauma

AnatomyAnatomy

Initial EvaluationInitial Evaluation

Secure airway – local tracheotomySecure airway – local tracheotomy Intubation can worsen airwayIntubation can worsen airway Avoid cricothyroidotomyAvoid cricothyroidotomy Pediatric: tracheotomy over Pediatric: tracheotomy over

bronchoscopebronchoscope Clear C-spineClear C-spine

HistoryHistory

Change in voice – most reliableChange in voice – most reliable DysphagiaDysphagia OdynophagiaOdynophagia Difficulty breathing - more severe injuryDifficulty breathing - more severe injury Anterior neck painAnterior neck pain Inability to tolerate supine position – Inability to tolerate supine position –

probable airway compromise imminentprobable airway compromise imminent

Signs of Injury: VascularSigns of Injury: Vascular

Signs of Injury:Signs of Injury:

Physical examPhysical exam Stridor Stridor HoarsenessHoarseness Subcutaneous emphysemaSubcutaneous emphysema HemoptysisHemoptysis Laryngeal tenderness, ecchymosis, edemaLaryngeal tenderness, ecchymosis, edema Loss of thyroid cartilage prominenceLoss of thyroid cartilage prominence Associated injuries - vascular, cervical Associated injuries - vascular, cervical

spine, esophagealspine, esophageal

Physical ExamPhysical Exam

Flexible Fiberoptic Flexible Fiberoptic LaryngoscopyLaryngoscopy

Performed in emergency roomPerformed in emergency room Findings dictate next stepFindings dictate next step

CT scanCT scan TracheotomyTracheotomy EndoscopicEndoscopic Surgical ExplorationSurgical Exploration

Laryngoscopic ExamLaryngoscopic Exam

Radiographic ImagingRadiographic Imaging

C-spineC-spine CT if airway stable and mild CT if airway stable and mild

abnormality on flexible exam.abnormality on flexible exam. Good for intermediate cases with scope Good for intermediate cases with scope

limited by edema limited by edema Angiography and contrast Angiography and contrast

esophagrams consideredesophagrams considered

CT ScanCT ScanIndications:Indications: Significant Significant

mechanism of mechanism of injuryinjury

Rule out occult Rule out occult fracture/dislocationfracture/dislocation

Confirmation of Confirmation of suspectedsuspected fracturefracture

Determine extent Determine extent of fracture(s)of fracture(s)

CT ScanCT Scan

Laryngotracheal Injury ClassificationLaryngotracheal Injury Classification Group I: Minor hematoma, no fractureGroup I: Minor hematoma, no fracture Group II: Edema/hematoma, minor Group II: Edema/hematoma, minor

mucosal injury, no exposed cartilage, mucosal injury, no exposed cartilage, non displaced fracturenon displaced fracture

Group III: Massive edema, mucosal Group III: Massive edema, mucosal tears, exposed cartilage, cord tears, exposed cartilage, cord immobilityimmobility

Group IV: See group III, more than 2 Group IV: See group III, more than 2 fracture lines, massive trauma fracture lines, massive trauma laryngeal mucosalaryngeal mucosa

Group V: Complete laryngotracheal Group V: Complete laryngotracheal separation separation

Laryngeal TraumaLaryngeal TraumaAsymptomatic or minimal symptoms

F/L

CT scan

Mild EdemaSmall hematoma

Non-displaced linear fractureIntact mucosa

Small lacerations

Displaced fracture (by CT or exam)

Loss of mucosa or extensive lacerationBleeding

Exposed cartilage

Bed restCool mistAntibioticsSteroids

Anti-reflux

Tracheotomy

Panendoscopy

Explore

Laryngeal TraumaLaryngeal TraumaRespiratory distress, open wounds, bleeding

Tracheotomy

Panendoscopy

Explore

Indications for RepairIndications for Repair Comminuted Comminuted

fracturesfractures Displaced Displaced

fracturesfractures All fractures All fractures

involving the involving the median and median and paramedian paramedian thyroid alathyroid ala

Cricoid fractureCricoid fracture LT separationLT separation

Large mucosal Large mucosal lacerationslacerations

Laceration of AC Laceration of AC and free edge and free edge VCVC

Disruption CA Disruption CA jointjoint

VC immobility VC immobility Exposed Exposed

cartilagecartilage

Laryngeal exploration and Laryngeal exploration and repairrepair

Laryngeal exploration and Laryngeal exploration and repairrepair

Laryngeal exploration and Laryngeal exploration and repairrepair

Laryngeal exploration and Laryngeal exploration and repairrepair

Goals of Laryngeal Goals of Laryngeal explorationexploration Cover all cartilage to prevent Cover all cartilage to prevent

granulation tissue and fibrosisgranulation tissue and fibrosis Primary closure ideal,can undermine Primary closure ideal,can undermine

mucosa or use advancement flaps mucosa or use advancement flaps from epiglottis or pyriformsfrom epiglottis or pyriforms

Palpate arytenoids and reposition if Palpate arytenoids and reposition if necessarynecessary

Resuspend anterior commisure, ORIF Resuspend anterior commisure, ORIF of fracturesof fractures

Laryngeal Framework RepairLaryngeal Framework Repair

Laryngeal Framework RepairLaryngeal Framework Repair

Endolaryngeal stentingEndolaryngeal stenting

Necessary for disrupted Anterior Necessary for disrupted Anterior Commisure, multiple displaced Commisure, multiple displaced fractures, and/or multiple and severe fractures, and/or multiple and severe mucosal lacerationsmucosal lacerations

Provides support and prevents Provides support and prevents stenosis but can cause iatrogenic stenosis but can cause iatrogenic injury (remove between 2 to 3 injury (remove between 2 to 3 weeks)weeks)

4 point fixation allows safe recovery4 point fixation allows safe recovery

Endolaryngeal stentingEndolaryngeal stenting

Treatment GoalsTreatment Goals

Preservation of airwayPreservation of airway Prevention of aspirationPrevention of aspiration Restoration of normal voiceRestoration of normal voice

Management of Vascular Management of Vascular Injuries:Injuries:

Common carotid: repair preferred over Common carotid: repair preferred over ligation in almost all cases. Saphenous vein ligation in almost all cases. Saphenous vein graft may be used. Shunting is rarely graft may be used. Shunting is rarely necessary. Thrombectomy may be necessary. Thrombectomy may be necessary.necessary.

Internal carotid: Shunting is usually necessaryInternal carotid: Shunting is usually necessary Vertebral: Angiographic embolization or Vertebral: Angiographic embolization or

proximal ligation can be used if the proximal ligation can be used if the contralateral vertebral artery is intact.contralateral vertebral artery is intact.

Internal Jugular: Repair vs. ligation.Internal Jugular: Repair vs. ligation.

Esophageal Injury:Esophageal Injury:

Best detected by combination of esophagoscopy Best detected by combination of esophagoscopy and esophagogram in symptomatic patients.and esophagogram in symptomatic patients.

Injection of air or methylene blue in the mouth Injection of air or methylene blue in the mouth may aid in localizing injuries.may aid in localizing injuries.

Close wounds in watertight 2 layer fashion.Close wounds in watertight 2 layer fashion. Controlled fistula with T-tube or exteriorization Controlled fistula with T-tube or exteriorization

of low non-repairable woundsof low non-repairable wounds Small pharyngeal lesions above arytenoids can Small pharyngeal lesions above arytenoids can

be treated with NPO and observation 5-7 daysbe treated with NPO and observation 5-7 days All patients should be NPO for 5-7 days.All patients should be NPO for 5-7 days.

OutcomesOutcomes

AirwayAirway Poor – tracheostomy dependentPoor – tracheostomy dependent Fair – mild aspiration or exercise Fair – mild aspiration or exercise

intoleranceintolerance Good – preinjury statusGood – preinjury status

OutcomesOutcomes

VoiceVoice Poor: aphonia or whisperPoor: aphonia or whisper Fair: changed or hoarseFair: changed or hoarse Good – normal voiceGood – normal voice

OutcomesOutcomes

SwallowingSwallowing NormalNormal AbnormalAbnormal Subjective patient reportSubjective patient report

THANKSTHANKS