Slide 1

NECK TRAUMADR SATINDER PAL SINGH

Background

Few emergencies pose as great a challenge as neck trauma. Because a multitude of organ systems (eg, airway, vascular, neurological, gastrointestinal) are compressed into a compact conduit, a single penetrating wound is capable of considerable harm. Airway occlusion and exsanguinating hemorrhage pose the most immediate risks to life. From the time when Ambroise Pare successfully treated a neck injury in 1552, debate has continued about the best approach for particular neck wounds

Neck trauma accounts for 5-10% of all serious traumatic injuries. Approximately 3500 people die every year from neck trauma secondary to hanging, suicide, and accidents.Initially missed cervical injuries secondary to neck trauma result in a mortality rate of greater than 15%. 10% of neck wounds lead to respiratory compromise. Loss of the airway patency may occur precipitously, resulting in mortality rates as high as 33%.Zone I injuries are associated with the highest morbidity and mortality rates.Sex-Trauma is more common among males than among females.Age-Most people who experience neck trauma are adolescents and young adults.

PATHOPHYSIOLOGY

A clear understanding of the anatomic relationships within the neck and the mechanisms of injury is critical to devising a rational diagnostic and therapeutic strategy.

ANATOMY

Think: vessels, airway, esophagus, spine, spinal cord, nerves, ducts Superficial fascia: covers the platysma just below the skinPlatysma: b/w the superficial and the deep fascia; violation increases risk of damage Deep Fascia Investing layer: surrounds neck and splits to encase the SCM and trapeziuz Pretracheal layer: adheres to cricoid and thyroid cartilage and travels behind the sternum to attach to the pericardium: PRETRACHEAL LAYER IS THE REASON THE NECK CONNECTS TO THE MEDIASTINUM Prevertebral: envelops the cervical and prevertebral muscles and extends to form the axillary sheath Carotid sheath Formed by components of all three layers

STRUCTURES AT RISK

With the neck protected by the spine posteriorly, the head superiorly, and the chest inferiorly, the anterior and lateral regions are most exposed to injury. The larynx and trachea are situated anteriorly and are therefore readily exposed to harm. The spinal cord lies posteriorly, cushioned by the vertebral bodies, muscles, and ligaments. The esophagus and the major blood vessels are between the airway and spine

Musculoskeletal structures at risk include the vertebral bodies; cervical muscles, tendons, and ligaments; clavicles; first and second ribs; and hyoid bone.Neural structures at risk include the spinal cord, phrenic nerve, brachial plexus, recurrent laryngeal nerve, cranial nerves (specifically IX-XII), and stellate ganglion.Vascular structures at risk include the carotid (common, internal, external) and vertebral arteries and the vertebral, brachiocephalic, and jugular (internal and external) veins.

Visceral structures at risk include the thoracic duct, esophagus and pharynx, and larynx and trachea.Glandular structures at risk include the thyroid, parathyroid, submandibular, and parotid glands.Associated structures at risk of intrathoracic injuries include the esophagus, tracheobronchial tree, lung, heart, and great vessels.

Zone ClassificationAnatomy classification is excellent for describing the static location of structuresInjury is not static, and an injury to the neck may enter the anterior triangle and then pass through the posterior triangle.A more useful classification of neck anatomy for trauma is the Zone classification developed by Roon and christensen

This classification system can guide the clinician in the diagnostic and therapeutic management Based on level of injury to the neck in a caudal to cranial orientationZone 1:Lower Border = ClaviclesUpper Border = Cricoid Cartilage

ANATOMIC ZONES

Zones of the Neck.Zone I: Thoracic inlet to Cricoid cartilageZone II: Cricoid cartilage to the Angle of mandibleZone III: Angle of the mandible to skull base

CLASSIFICATION

Zone I the base of the neck, is demarcated by the thoracic inlet inferiorly and the cricoid cartilage superiorly.Zone II encompasses the midportion of the neck and the region from the cricoid cartilage to the angle of the mandible.Zone III characterizes the superior aspect of the neck and is bounded by the angle of the mandible and the base of the skull.

Structures at greatest risk in this zone are the great vessels (subclavian vessels, brachiocephalic veins, common carotid arteries, aortic arch, and jugular veins, trachea, esophagus, lung apices, cervical spine, spinal cord, and cervical nerve roots. Signs of a significant injury in the zone I region may be hidden from inspection of the chest or the mediastinum

Zone IZone I StructuresVertebral arteriesProximal carotid arteriesMajor thoracic vesselsSuperior MediastinumLungs, tracheaEsophagus Spinal cordCervical nerve roots Signs of a significant injury in the zone I region may be hidden from inspection of the chest or the mediastinum

Zone IFrom the clavicles to the cricoidTracheaLungsProximal carotid and vertebral arteriesJugular veinsThoracic VesselsEsophagusSuperior MediastinumThoracic DuctSpinal Cord Brachial Plexus

Zone I

Ghana Emergency Medicine CollaborativeAdvanced Emergency Trauma CourseMysteriouskyn (Wikipedia)Zone 1

Trauma.org

Ghana Emergency Medicine CollaborativeAdvanced Emergency Trauma Course

Neck trauma. Zone I injury.

Zone IIFrom cricoid to angle of mandibleTracheaLarynxCarotid and vertebral aa.Jugular VeinEsophagusSpinal Cord

Important structures in this region include the carotid and vertebral arteries, jugular veins, pharynx, larynx, trachea, esophagus, and cervical spine and spinal cord. Zone II injuries are likely to be the most apparent on inspection and tend not to be occult. Additionally, most carotid artery injuries are associated with zone II injuries

Zone II

Medicine CollaborativeAdvanced Emergency Trauma CourseZone 2

Zone IIIAngle of mandible to base of skull

Distal carotid and vertebral arteriesPharynx Spinal cord

Diverse structures, such as the salivary and parotid glands, esophagus, trachea, vertebral bodies, carotid arteries, jugular veins, and major nerves (including cranial nerves IX-XII), traverse this zone. Injuries in zone III can prove difficult to access surgically.

Zone III

Ghana Emergency Medicine CollaborativeAdvanced Emergency Trauma CourseZone 3

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ZONECONTENTSCOMMENTSZONE ICommon carotidVertebral arterySubclavian arteryMediastinal major vesselsApices of lungsEsophagusTrachealThyroidThoracic ductSpinal cordThoracic outlet thus neck AND mediastinal structuresDifficult to apply pressure to vascularinjuries thus more difficult to examineDifficult to examine for subtle injuriesDifficult access to explore in OR thus more likely to image before ORZONE IICarotid and vertebral arteriesLarynx and trachealEsophagus and pharynx ,Jugular veinVagus and recurrentlaryngeal n. ,spinal cordEasier to apply pressure to bleedersEasier to locally explore in EDEasier to examine in EDEasier to explore in ORMORE likely to investigate/operate only if signs of significant injuryZONE IICarotid and vertebralsDistal jugular veinSalivary and parotid glandsCN 9,10,11,12 Spinal cordMore difficult to examineMore likely to explore in OR

Signs of laryngeal or tracheal injury

Voice alterationHemoptysisStridorDroolingSucking, hissing, or air frothing or bubbling through the neck woundSubcutaneous emphysema and/or crepitusHoarsenessDyspneaDistortion of the normal anatomic appearancePain on palpation or with coughing or swallowingPain with tongue movementCrepitus: Noteworthy in only one third of cases

Signs of esophageal and pharyngeal injuryDysphagiaBloody salivaSucking neck woundBloody nasogastric aspiratePain and tenderness in the neckResistance of neck with passive motion testingCrepitusBleeding from the mouth or nasogastric tube

Signs of carotid artery injuryDecreased level of consciousnessContralateral hemiparesisHemorrhageHematomaDyspnea secondary to compression of the tracheaThrillBruitPulse deficit

Signs of jugular vein injuryThese include hematoma, external hemorrhage, hypotension

Signs of spinal cord or brachial plexus injuryDiminished upper arm capacityQuadriplegiaPathologic reflexesBrown-Squard syndromePriapism and loss of the bulbocavernous reflexPoor rectal toneUrinary retention, fecal incontinence, and paralytic ileusHorner syndromeNeurogenic shockHypoxia and hypoventilation

Signs of cranial nerve injuryFacial nerve (cranial nerve VII): Drooping of the corner of the mouthGlossopharyngeal nerve (cranial nerve IX): Dysphagia (altered gag reflex)Vagus nerve (cranial nerve X, recurrent laryngeal): Hoarseness (weak voice)Spinal accessory nerve (cranial nerve XI): Inability to shrug a shoulder and to laterally rotate the chin to the opposite shoulderHypoglossal nerve (cranial nerve XII): Deviation of the tongue with protrusion

DIAGNOSTIC STRATEGIESTRIPLE SCOPE + AngiographyBronchoscopyEsophagoscopyLaryngoscopyOther: doppler, CTA, MRA

DiagnosisImaging studiesIn addition to cervical and chest radiography, the following supplementary tests may be useful:Computed tomography (CT) scanningMagnetic resonance imaging (MRI)Color flow Doppler ultrasonographyContrast studies of the esophagusInterventional angiographyEndoscopy--Laryngoscopy, bronchoscopy, pharyngoscopy, and esophagoscopy may be useful in the assessment of the aerodigestive tract. Rigid endoscopes are superior to flexible scopes.

General Indications for Angiography (assuming patient not unstable)Hematoma Vascular bruit/thrill Decreased pulse in upper extremity Signs of CVA General Indications for TRIPLE SCOPE Hematemesis Hemoptysis Chest tube air leak Subcutanoues or mediastinal air Oropharyngeal blood

Rosens signs of injury

SOFT signsHARD signs

Hemoptysis/hematemesis Oropharyngeal bleeding Dyspnea Dyphonia/dysphagia SubQ or mediastinal air Chest tube air leak Nonexpanding hematoma Focal neurologic signs

Expanding hematoma Severe active bleeding Shock unresponsive to fluids Decreased/absent radial pulses Vascular bruits/thrills Cerebral ischemia Airway obstruction

Goals of the GuidelineManagement of penetrating injuries to zone II of the neck that penetrate the platysma. 1. Is mandatory operative management or selective operativemanagement appropriate?2. Can duplex ultrasonography (US) or CT angiography ruleout 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 swallow)and esophagoscopy needed to safely rule out esophagealinjury?4. Is physical examination sensitive enough to rule out injuries to vascular structures or the aerodigestive tract?

Mandatory versus Elective ExplorationImmediately life threatening: massive bleeding, expanding hematoma, hemodynamic instability, hemomediastinum, hemothorax, and hypovolemic shock.Immediate surgical exploration Hemodynamically stable ,nonlife-threatening features can undergo thorough imaging investigations to determine the extent of injury.

Initial ManagementInitial Management is the same as all trauma casesA : airway with C-spine controlB : breathing and ventilationC : circulationD : disability and neurologic statusE : exposure and evaluation other injury

AirwaySecuring the airway should be considered if the patient is going to be leaving your supervised areaEndotracheal intubation using rapid sequence technique is the first choice Cricothyrodotomy is second line treatment when intubation is not successfulCare should be taken to when intubating to avoid an injured trachea

Patients with acute respiratory distress need a definitive and secure airwayIn neck trauma there is sometimes a debate as to when to interveneMultiple blind intubation attempts will risk enlarging a lacerated piriform sinus wound and extending it iatrogenically into the mediastinum.Blood and air from facial and neck injuries can distort the normal anatomic appearance and increase the difficulty of intubationTracheal tear may be exacerbated by extending the neck.

Breathing

All patients should receive high-flow oxygen Based on the zone and the proximity to the thoracic inlet, there could be simultaneous injury to the thoraxIf you notice any difficulty ventilating then suspect either upper airway injury or thoraxEvaluate for asymmetric breath soundsConsider tension pneumothorax if there is evidence of tracheal deviation

CirculationActive bleeding should be addressed immediately by direct point pressureDo not clamp bleeding vessels because you could cause further ischemiaAvoid placing IV access where the flow would head towards the injured area.Extravasation could create more distortion and compression

Disability

Examine and inspect for evidence of focal neurological deficitThis could suggest direct nerve injury, or spinal cord injury or vascular injury leading to ischemia

Zone 1 injuryBelow cricoid, dangerous areaProtect zone bony thorax and clavicleMotality rate 12 %Potential for injury to great vessel and mediastinumMandatory exploration : not recommendAngiography and esophageal evaluation: usually suggest> 1/3 no symptom at presentation

Zone 1 injuryEsophageal evaluation endoscopy , contrast esophagogramContrast mediumBarium- basedGastrografin ( meglumine diatrizoate)Combination tests should not miss an njuryCT scanDetermine the path of projectile

Zone 2 injuryLargest zone,most common site of trauma 60-75%Between angle of mandible & inf border of cricoid cartilageIsolate venous injury & pharyngoesophageal injury most common structure missed clinicallyAll pt. are admitted for observation and 24 hr re-evaluation50% of death hemorrhage from vascular structure

Indications for Immediate Surgery after Penetrating Neck TraumaShockPulsatile bleedingExpanding hematomaUnilateral extremity pulse deficitAudible bruit or palpable thrillAirway compromiseWound bubblingExtensive subcutaneous emphysemaStridorHoarsenessSigns of stroke/cerebral ischemia

Penetrating Injury Airway Control

Immediate Exploration Unstable Zone II (Hard Signs)

Zone II InjuryOperative management of GSW to carotid artery

Trauma.org

Zone 2 injurySymptomatic neck explorationAsymptomatic Directed evaluation and serial examArteriography,Laryngotraheoscopyflexible esophagoscopybarium swallowRequires adequate physician ,24 hr facility prepared for emergency testing and Surgery

Angiography: Zone1 & 3Routine preoperative arteriography in stable caseSurgical approach is more difficult than zone 2If wound involve both side of neck ( stable but symptomatic) four vessel angiography

Angiography: Zone1 & 3

1Arteriogram demonstrating common carotid artery injury with small hematoma2extravasation of the internal carotid artery near the base of the skull (arrow).3. A follow-up arteriogram of the internal carotid artery 1 week later shows enlargement of the pseudoaneurysm.

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Angiography: Zone2Easy accessible,low risk for explorationCertain indication for an angiogram in zone 2Stable pt. who has persistent hemorrhageNeurodeficit compatible with adjacent vascular structure damage eg. Horners syndrome , hoarsenessNeed explorationPositive arteriographyNegative arteriography but positive clinical signAsymptomatic in zone 2 Controversy,No sig difference btw. Clinical exam & angiographyCTA fast ,minimal invasive in hemostatic stable

CT ANGIOGRAPHYAdvantagesSuperior image qualityReadily available, quickLimited interuservariabilitySafeShows surrounding structureslaryngeal injuries and a stable patent airwayLimitationsPoor timing of contrast loadPatient movementMetallic artifactBody habitusNot therapeutic

Technique of vascular repairEnd to end or autogenous graft reccomended when stenosis is evident by arteriography Ligation of common or internal carotid a.reserved for irreparable injury and in pt, who are in a profound coma stateDelayed complication from unrepaired vascular injury Aneurysm formationDissecting aneurysmAV fistulas

Pharynx and esophageal injuryClinical sign and symptom neck explorationsubcutaneous emphysemaHematemesisHypopharyngeal blood>50%of Pt. asymptomatic at presentationCombination of esophagoscopy and contrast esophagographyMost sensitive for detected injuryDelayed explore & repair beyond 24 hrs after injury poorer outcome

Digestive tract evaluationPossible esophageal perforation gastrografin swallowBarium : extravasation & distort soft tissue plane and toxic

Digestive tract evaluationFlexible esophagoscopy Missed perforation : cricopharyngeus, hypopharynxNegative endoscopy but air leak in soft tissue mandatory neck exploreInfiltrate methylene blue : localize injury sizeCombination of flexible and rigid endoscopyExam entire cervial and upper esophagusNo perforation missed

Digestive tract evaluationSuspicious pharyngeal perforation NPO for several daysS&S : fever , tachycardia,widening of mediastinumRepeat endoscopy or neck explorationEsophageal injury in the early phaseTwo layer closure with wound irrigationDebridementAdequate drainage

Extensive esophageal injury lateral cervical esophagostomy

Penetrating of hypopharynxSuperior to the level of arytenoid cartilageIV ABONPO 5-7 daysPrimary closure not always necessaryInferior to the level of arytenoid cartilageDependent portionExploration with primary watertight closureUse absorbable suture with drainage of adjacent neck spaceNPO 5-7 daysTreat liked esophageal injury

TreatmentConservativeMedical therapyAdequate ventilation & oxygenationFluid resuscitationMonitor neurolodic statusPain controlABOTetanus prophylaxis

TreatmentSurgical approachZone 1Median sternotomyThoracotomyZone 2Collar incisionApron incisionZone 3Consult neuroSx

Blunt neck traumamotor vehicle accidents and sports result in laryngeal, vascular, and digestive injuryeasily underdiagnosed because their onset can be delayedoccult cervical spine injuryStrangulationBlows from fists or feetExcessive manipulation

Blunt Neck TraumaBlunt trauma to the neck is less frequent in occurrenceMechanism is often related to motor vehicle collisionsHyperextensionRotationHyper flexionDirect blows against a non mobile object (most commonly seatbelts)

Laryngotracheal InjurySigns and symptoms:Difficulty swallowing Pain with swallowingDifficulty breathing (feeling breathless)Hoarseness of voice (or change in voice)Subcutaneous emphysemaTracheal deviationHowever signs and symptoms may be absent even with a major injury

Common to all traumatic mechanisms is the direct transfer of severe forces to the larynx. These forces have the potential to produce many devastating injuries, includingmucosal tears, dislocations, and fractures. Edema, hematoma, cartilage necrosis, voice alteration, cord paralysis, aspiration, and airway loss may accompany these injuries. Common signs of laryngeal injury include stridor, subcutaneous emphysema, hemoptysis, hematoma, ecchymosis, laryngeal tenderness, vocal cord immobility, loss of anatomical landmarks, and bony crepitus.

Laryngotracheal Injury

Blunt trauma to neck with swelling and subcutaneous emphysema

Anterior neck bruise (see arrow) in a middle-aged woman involved in a motor vehicle accident.

CT scan (A) revealing a paramedian fracture (see arrow) from an acute blunt laryngeal trauma . This young man presented 1 week after being struck on the left side of the neck with a hockey stick. Note that the 3D reconstruction (B) provides valuable information as to the shape of the fracture and demonstrates that the anterior commissure has been displaced

Laryngeal injuries vary by anatomical locationSupraglottis: Traumatic forces commonly produce horizontal fractures of the thyroid alae and disruption of the hyoepiglottic ligament with subsequent superior and posterior displacement of the epiglottis. Repositioning of the epiglottis may result in the creation of a false lumen anterior to the epiglottis. This lumen may tunnel into the larynx or pass anterior to the thyroid cartilage and cause cervical emphysema.

Glottis: Traumatic force results in cruciate fractures of the thyroid cartilage near the attachment of the true vocal cords.Subglottis: Crushing forces to the cricoid cartilage cause injury to the cricothyroid joint and may result in bilateral vocal cord paralysis from recurrent laryngeal nerve damage.Hyoid bone: Found more commonly in women, hyoid fractures tend to occur in the central part of the hyoid bone because of the inherent strength of the cornua.

Cricoarytenoid joint: Traumatic forces that displace the thyroid alae medially or cause compression of the larynx against the cervical vertebrae often result in cricoarytenoid dislocation. This injury generally occurs unilaterally. Cricothyroid joint: Injury occurs when traumatic forces to the anterior portion of the neck cause the inferior cornu of the thyroid cartilage to be displaced posterior to the cricoid cartilage. This dislocation limits cricothyroid muscle function and therefore pitch control. Injury to the recurrent laryngeal nerve may also contribute tovocal cord paralysis

GroupSymptomsSign ManagementGroup 1Minor airway symptomsMinor hematomasSmall LacerationsNo detectable fracturesObservationHumidified airHead of bed elevationGroup 2Airway compromiseEdema/hematomaMinor mucosal disruptionNo cartilage exposurTracheostomyDirect laryngoscopyEsophagoscopy

Group 3Airway compromiseMassive edemaMucosal tearsExposed cartilageVocal cord immobilityTracheostomyDirect laryngoscopyEsophagoscopyExploration/repairNo stent necessaryGroup 4Airway compromiseMassive edemaMucosal tearsExposed cartilageVocal cord immobilityTracheostomyDirect laryngoscopyEsophagoscopyExploration/repairStent required

Laryngotracheal InjuryManagement:High index of suspicion is required to diagnose these types of injuries especially in the absence of classic symptomsSecuring an airway is the initial focus.Endotracheal intubation should be attempted by the most experienced personOther authors suggest immediate tracheostomy to avoid creating a false path or further injury to the unstable airwayCricothyrodotomy should be avoided as this may worsen the injury

Fractured thyroid cartilage closed with wires

Various methods for laryngeal cartilage stabilization

Intraoperative photo graphs of the patient from Figure 342 . The first photograph (A) was takenbefore rigid fixation using a plating system; the second photograph (B) was taken after the plate was inserted. Note that the plate is carefully bent to restore the proper anterior commissure angle and location

(A) Vocal granulation tissue funned as a result of endotracheal Intubation coalescing. If undivided this will become a mature scar tissue (B) and lead to ankylosis of cricoarytenoid joints.

Laceration repair

The anterior cartilaginous sutures are placed and then tied once all have been placed. Vicryl and Prolene sutures arealternated for this portion of the closure.

Sutures are placed submucosally around tracheal rings with the knot tied externally.

Complications

AcuteChronicAcuteAirway obstructionAphoniaDysphoniaOdynophagiaDysphagiaPostoperative complications (eg, hematoma, infection)

Voice compromise (21-25%)Chronic obstruction (15-17%)Vocal cord injuries (eg, paralysis, fixation)Fistula (tracheoesophageal, esophageal, or pharyngocutaneous)Cosmetic deformityChronic aspirationInability to decannulate

Subglottic stenosisis a difficult complication to treat effectively. Incomplete ring and weblike subglottic stenosis can be treated with laser excision or incision and dilation.More significant stenosis may require anterior or posterior cricoid splits with cartilage grafting.

McCaffrey system of laryngotracheal stenosis classlficatlon.

The most common problem in the immediate postoperative period is the development of granulation tissue and ulceration from exposed cartilage.The main concern with granulation tissue formation is the potential for the development of fibrosis and eventually stenosis. Many techniques have been used to slow the formation of granulation tissue, including systemic and intralesional administration of corticosteroids, long-term splinting, and low-dose radiation.Debulking granulation tissue through endoscopy is probably the most effective alternative treatment currently available.

Laryngeal trauma complications can manifest as inadequate voice and failure to decannulate. These can be prevented or treated in the following waysGranulation tissueCovering all exposed cartilage to preventAvoiding stents when possibleCareful excisionLaryngeal stenosisExcision with mucosal coverageStenting selected casesLaryngotracheoplastyTracheal resection with reanastomosis

Vocal fold immobilityObservationVocal fold injectionThyroplasty-type vocal fold medializationArytenoidectomy and vocal fold lateralization for bilateral paralysis