COMPLEX PROBLEMS IN PENETRATING NECK TRAUMA

COMPLEX AND CHALLENGING PROBLEMS IN TRAUMA SURGERY

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COMPLEX PROBLEMS IN PENETRATING NECK TRAUMA Demetrios Demetriades, MD, PhD, FACS, Juan A. Asensio, MD, FACS, George Velmahos, MD, and Erwin Thal, MD, FACS

Penetrating injuries of the neck are considered difficult to assess and manage. This small body area contains a dense concentration of vital vascular, aerodigestive, and nervous system structures. Many of these structures are not accessible to physical examination, and the surgical exposure of some of them is a technical challenge. The initial aggressive operative management of earlier years has been largely replaced by a selective conservative approach, but a major controversy still exists. The role of physical examination and various diagnostic procedures in the initial assessment of penetrating neck injury has become the theme of hundreds of publications. The surgical techniques for the management of specific injuries are still much debated and need resolution. This article discuss’es some of the complex problems related to the initial evaluation of penetrating neck injuries, offers guidelines in the management of specific difficult injuries, and highlights the controversial areas where more research is still needed. MANDATORY OPERATION OR SELECTIVE CONSERVATISM

There is no argument regarding the need for an emergency operation on patients with obvious signs or symptoms of major vascular or aerodigestive tract injuries. However, controversy exists about the role of surgical exploration in patients with no clinical signs or with soft signs of significant injuries. Some surgeons believe that all injuries that have penetrated the platysma should be

From Los Angeles County/University of Southern California Medical Center, Los Angeles, California (DD, JAA, GV); and the Department of Surgery, University of Texas Southwestern Medical School, Dallas, Texas (ET)

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explored surgically, irrespective of signs or symptoms, whereas others support a selective conservative management. The proponents of routine operation suggest that physical examination is not reliable and that potentially dangerous injuries may be missed.3,Hh They also claim that no specialized diagnostic investigations are necessary, nontherapeutic operations are safe, and hospitalization and costs are not increased. Apffelstaedt and Muller? in a prospective study of 393 patients with stab wounds penetrating the platysma, found that clinical signs were absent in 30% of positive neck explorations and in 58% of negative explorations. Although 58% of their operations were negative, only five relatively minor complications occurred in this group, and the average hospital stay was 1.5 days. The authors concluded that mandatory exploration saves unnecessary diagnostic studies, is safe, and does not prolong hospital stay. Most authors have not adopted this policy because of the high rate of negative explorations, ranging from 30% to 89Yi3,3R, 52, Rh The most common practice is some form of selective conservative policy based on clinical examination and a variety of investigations. However, the criteria for selection of operative or nonoperative management and the indications and modalities of vascular assessment are a matter of controversy. A special controversy involves the approach to zone I1 injuries, that is, mandatory versus selective exploration. Asensio et a1,4 in an extensive review of the literature, concluded that neither approach is clearly superior. The mandatory approach was found to be safe and acceptable. A selective approach, which included angiography, in asymptomatic patients was also safe. ROUTINE ANGIOGRAPHY

Many authors believe that physical examination alone is not reliable in identifying arterial or esophageal injuries and recommend routine angiography for all proximity injuries.", 92 Such policy almost eliminates nontherapeutic operations. In a series of 176 hemodynamically stable patients undergoing routine angiography, there were no nontherapeutic operations.2oThe major drawbacks of such policy are the high costs and the invasive character of angiography. Also, it is argued that angiography does not alter the course of management, including the approach to neck explorations,s6although not all surgeons share this view. In a prospective study in our center, of 176 patients with penetrating injuries of the neck, routine angiography showed vascular injuries in 19%, but only 8% required treatment of the vascular lesions. All vascular injuries requiring treatment were symptomatic.20 SELECTIVE ANGIOGRAPHY

Many surgeons recommend routine angiography for all injuries in zones I and 111 irrespective of symptoms because these areas are difficult to assess clinically and surgical exploration is technically difficuk70 Such policy can reduce nontherapeutic operations but at a significant financial cost. In a prospective study, only 5% of 148 zone I and 13% of 92 zone I11 injuries required operation for vascular injuries.2" PHYSICAL EXAMINATION AS TRIAGE MODALITY

Some surgeons believe that physical examination is safe and reliable in detecting significant neck vascular injuries requiring treatment.z0,21, 35, Demetri-

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ades et a1,2O in a prospective study of 335 patients with penetrating neck injuries, evaluated vascular structures on the basis of a detailed written protocol and an algorithm. Angiography was performed on only seven patients (2%). Eighty percent (269 patients) were selected for nonoperative management. Only two of these patients required subsequent operations for vascular injuries diagnosed during the same hospitalization, and there were no complications in the rest of the conservatively treated group. Some vascular injuries not requiring treatment may have been missed. Early follow-up (mean 16 days) of 192 patients and late follow-up (mean 48 days) of 111 patients treated conservatively showed no complications. In another recent studyE at the Los Angeles County and University of Southern California Medical Center, 223 patients were prospectively evaluated according to a strict, written clinical protocol. Subsequently, 176 hemodynamically stable patients were subjected to routine four-vessel angiography. Of the 160 patients with no clinical signs of vascular injuries, none had serious vascular trauma requiring treatment (negative predictive value loo%), although angiography on 127 of these patients diagnosed 11 injuries not requiring treatment. Of 34 patients with "soft" signs, 8 had angiographic lesions but only 1 required operation. The investigators proposed a protocol for physical examination and an algorithm (Figs. 1 and 2). Had this protocol been followed, 14% of patients would have been operated on without any investigation, 50 color flow Doppler studies and two angiograms would have been performed, no significant injury requiring treatment would have been missed, and the cost savings would have been about $400,000. ANGIOGRAPHY VERSUS COLOR FLOW DOPPLER IMAGING

In recent years, color flow Doppler (CFD) has been successfully used in the evaluation of penetrating extremity injuries, as an alternative to angiography. However, its role in penetrating neck injuries has not been studied extensively. Fry et a133used duplex scanning and angiography concomitantly in 15 patients. The duplex scanning accurately diagnosed 1 vascular abnormality and excluded injuries in the remaining 14 patients. Subsequently, the authors successfully used dupJex scanning alone in another 85 patients, reserving angiography for cases in which the scan was positive. The study concluded that duplex scanning can safely replace arteriography and operative exploration in penetrating neck injuries. However, the study can be criticized because arteriography was not performed for correlation in all patients. In a larger study from our trauma center, 82 hemodynamically stable patients were examined according to a strict protocol and subsequently had angiography and CFD performed.26Physical examination detected or suspected all significant vascular injuries but missed six lesions not requiring treatment. CFD identified 10 of the 11 angiographically detected injuries. One intimal tear not requiring treatment was missed. When only injuries requiring treatment were included, the sensitivity and specificity of CFD were 100%. The study suggested that the combination of a careful physical examination and CFD imaging is a safe and cost-effective alternative to routine contrast angiography. GUNSHOT WOUNDS VERSUS STAB WOUNDS

Some authors anecdotally suggested that it would be rational to pursue mandatory operation for gunshot wounds (GSWs) and selective nonoperative

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Wound Tract:

A. Site of Iniurv:

0 Anterior neck triangle (anterior to SMS muscle) 0 Posterior neck triangle (posterior to SMS muscle) 0 Zone I (between clavicles and cricoid) 0 Zone I1 (between cricoid and angle of mandible of skull) 0 Zone HI (between angle of mandible and base of skull)

0 0 0 0

Towards midline Towards clavicle Away from midline or Can’t assess

B. Vascular Structures 1. Active bleeding: 0 None, 0 Minor, 0 Moderate, 0 Severe 2. Hypovolemia: 0 BP > 100, 0 BP 60-90. 0 BP <60 3. Hematoma: 0 None, 0 Small. 0 Moderate. 0 Large, 0 Expanding. 0 Pulsatile 4. Peripheral pulses (compare with contralateral): Distal carotid: 0 normal. 0 diminished, 0 absent Superficial temporal: 0 normal, 0 diminished, 0 absent Brachial or radial: 0 normal. 0 diminished, 0 absent 5. Bruit: 0 No. 0 Yes, (If so, where )

C. Larvnxltrachea. esophaqus 1. Hemoptysis (ask patient to cough) 0 yes. 0 no 2. Air bubbling through wound? 0 yes, 0 no (ask patient to cough) 3. Subcutaneous emphysema: 0 yes. 0 no 4. Hoarseness: 0 yes, 0 no 5 . Pain on swallowing sputum: 0 yes, 0 no 6. Hernaternesis: 0 yes, 0 no

D. Nervous system

I . GCS: 0 eye response, 0 verbal response, 0 motor response Total GCS2. Localizing signs: Pupils: Limbs: Cranial nerves: Facial n.: 0 normal, 0 abnormal Glossopharyngeal n.: (check midline portion of soft palate) 0 nornal, 0 abnormal Recurrent laryngeal n. (hoarseness, effective cough): 0 norpal. 0 abnormal Accessory n. (lift the shoulder): 0 normal, 0 abnormal Hypoglossal n. ( check midline position of tongue): 0 abnormal, [3 abnormal Spinal cord: 0 normal, 0 abnormal (specify) Homers syndrome (myosis.ptosis): 0 yes. 0 no Brachial plexus: median n. (fist): 0 normal, 0 abnormal radial n. (wrist extension): 0 n o d , 0 abnormal ulnar n. (abductiodadduction of fingers): 0 normal, 0 abnormal musculocutaneous n. (flexion of forearm): 0 normal. 0 abnormal axillary n. (abduction of arm): 0 normal, 0 abnormal Figure 1. Clinical examination chart.

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Clinical Examination According to Protocol

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Obvious significant injuries?

I Yes

4

Operation

Severe active bleeding Shock not responding to fluids Absent radial pulse Air bubbling through wound

I

No

Bruit? z i a s t i n u m ? Yes

No

Angiogram

Hematoma? Diminished peripheral pulse? Shock responding to fluids? Shotgun?

I-Iemoptysis? Hoarseness? Painful swallowing? Subcutaneous emphysema? Hematemesis? Proximity in obtunded patient?

t

t

A No

Yes

t Color Flow Doppler

(Angiogram if CFD not available)

A

No

\ .r/ Observation (Color Flow Doppler optional)

Yes

t

Esophagoscopy Endoscopy

Figure 2. Algorithm for evaluation of penetrating neck injuries.

management for stab w o ~ n d sThis . ~ ~concept is not supported by the 1iteratureJO In a prospective study of 97 GSWs and 89 knife wounds to the neck, we found that GSWs were associated with a higher incidence of clinical signs suggestive of vascular injuries than were knife wounds (35% versus 19y0).GSWs were more likely to cause vascular, aerodigestive tract, spinal cord, and nerve injuries than were knife wounds. Therapeutic operation was required in 16.5% of GSWs and 10.1% of knife wounds. Routine operations for GSWs would have been associated with a high rate of unnecessary operation^.^^ TRANSCERVICAL GUNSHOT WOUNDS

Transcervical GSWs are more likely to involve vital structures than GSWs that do not cross the midline (73% versus 31?'0).~~ For this reason, routine exploration of such injuries has been Hirshberg et a1,46in a retrospective study of 41 patients, performed exploration in 36. Thirty of them (83%)were positive for injury to cervical structures. The authors concluded that transcervical penetration could serve as an excellent clinical predictor of visceral injury and recommended mandatory operation for all such injuries. The only other study in the English literature on transcervical GSWs reached a different conclusion. Demetriades et al,27in a prospective study of 33 patients, confirmed the high incidence of injuries to the neck structures. Overall, 73% of patients suffered one or more injuries to vital organs in the neck. However, only 7 patients (21%) had a therapeutic operation. The authors advocated against man-

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datory operation and suggested that a careful clinical examination combined with the appropriate diagnostic tests can safely select the appropriate treatment and that about 80% of all transcervical GSWs can be managed nonoperati~ely.~’ In summary, we suggest that the initial assessment of penetrating neck injuries should be tailored from center to center, depending on the available experience and facilities. A policy of mandatory exploration might be appropriate for small centers without angiographic or vascular laboratory facilities, treating only a small number of such injuries. A selective nonoperative policy can safely be applied in larger centers with experience in penetrating trauma. A meticulous physical examination according to a written protocol is critical. Asymptomatic patients may be observed clinically with or without CFD imaging. Patients with soft signs of vascular trauma should be assessed by means of CFD imaging or angiography, depending on the facilities of the center. In patients with a bruit, an angiogram is preferred over CFD because of the possibility of therapeutic embolization. Similarly, a widened mediastinum is better assessed by angiography. The algorithm in Figure 2 is currently in use at our center, following a prospective study of 223 patients. Had this protocol been applied prospectively in this series, 14% of the patients would have been subjected to an emergency operation because of ”hard” clinical signs. In the remaining group, only 50 CFD, 2 angiograms, and 56 esophagograms would have been performed and no significant injuries requiring treatment would have been missed. The total cost would have been $30,500, compared with $444,500 for routine angiography and esophagography. MANAGEMENTINTHEEMERGENCYDEPARTMENT

The initial assessment and management should be performed according to Advanced Trauma Life Support (ATLS) protocols. Approximately 10% of patients with penetrating neck injuries present with airway compromise.66Fiberoptic nasotracheal intubation should be attempted first in stable patients. In the presence of significant respiratory distress, an orotracheal intubation under direct view or a cricothyroidotomy should be performed. Muscle relaxation should be avoided, except for carefully selected patients. Intravenous lines should be avoided on the same side of injury because of the possibility of venous injury. Any external bleeding is controlled by direct pressure. The patient should be put in the Trendelenburg position to prevent air embolism, a common cause of death in major venous injuries. Local physical examination should be performed according to a written protocol (Fig. 1).The presence of a bleeding wound in the neck should not distract from other potentially dangerous wounds in other anatomic areas. If bleeding cannot be controlled by direct pressure, balloon tamponade may be a t t e m ~ t e d A . ~ Foley ~ catheter is inserted into the wound toward the estimated source of bleeding. The balloon is then inflated with saline until the bleeding stops or moderate resistance is felt (Fig. 3). For supraclavicular wounds with pleural violation and bleeding in the thoracic cavity, a combination of two Foley catheters may be necessary. The first catheter is inserted into the pleural cavity past the lesion, the balloon is inflated, and the catheter is pulled back firmly and held in place’ with an artery clip. This maneuver compresses the injured subclavian vessels against the first rib or the clavicle and prevents bleeding in the chest. If external bleeding continues, a second balloon is inserted proximally in the wound tract. Blood through the lumen of the Foley catheter suggests distal bleeding, and repositioning or further inflation of the balloon or clamping of the catheter should be considered.

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Figure 3. Balloon tamponade for active bleeding from a neck wound.

Cardiac arrest before or after admission to the emergency department is an absolute indication for emergency room thoracotomy. Following bleeding control and aortic cross-clamping, the right ventricle should be aspirated for air embolism. This is a common complication and a cause of death in injuries to major veins. OPERATIVE MANAGEMENT Patients with penetrating neck injuries may pose anesthetic problems, especially in the presence of large hematomas or major laryngotracheal trauma. Even with a seemingly patent airway, rapid expansion of a hematoma may cause airway obstruction. Early intubation, even in the absence of respiratory distress, is recommended. Insertion of a nasogastric tube before airway establishment should be avoided because the agitation of the patient during insertion of the tube may precipitate bleeding. Fiberoptic endotracheal intubation by an experienced member of the trauma team is the safest approach to these cases. A cricothyroidotomy tray should be immediately available, and a surgeon should be ready to proceed to cricothyroidotomy if fiberoptic or orotracheal intubation fails. SPECIFIC INJURIES Carotid Injuries Carotid injuries are diagnosed in about 6% of all penetrating injuries of the neck and account for 22% of all cervical vascular injuriesz5The reported inhospital-mortalityranges from 10% to 20%. However, many patients never reach the hospital alive, and the overall mortality has been reported to be as high as 66Y0.2~Many factors influence the selection of survivors: the prehospital time, the site and size of carotid injury, the anatomy of the carotid system, the presence of neurologic deficits, and associated injuries. The overall mortality for common carotid injuries is significantly higher than for internal carotid injuries,

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most probably because of the high incidence (31%)of associated internal jugular vein injuries in common carotid injuries.22In a study by one of the authors, of 54 patients reaching the hospital alive, the most common clinical presentation was shock (8l%), followed by active bleeding (6O%), a hematoma (33%),neurologic deficits (20%), and a bruit (5%).” Surgical Exposure

In most cases the carotid sheath can be easily accessed through the standard sternocleidomastoid incision. For proximal injuries, addition of a median sternotomy may be necessary. The exposure of high internal carotid lesions at the base of the skull is one of the most difficult operations in trauma surgery. Anterior subluxation of the mandible improves exposure by about 2 cm. For very high exposures a vertical mandibular ramus osteotomy is the preferred approach because of its relative simplicity and safety. This part of the operation is usually performed by an oromaxillofacial or otolaryngologic surgeon. Horizontal or oblique osteotomies in a stair-step fashion have also been used, but they have not gained widespread popularity. For severe intraoperative bleeding near the base of the skull, insertion of a Fogarty balloon catheter across the carotid may be effective in controlling bleeding. Detachable endovascular balloons have been successfully used as a permanent solution. Repair or Ligation

In the absence of neurologic deficits, carotid repair should be performed whenever possible. If an interposition graft is required, the saphenous vein is the preferred option, although prosthetic grafts have been successfully used. For internal carotid artery injury, transposition of the external carotid is an excellent option. Ligation in neurologically intact patients may be the only choice for high internal carotid artery lesions, because repair is very difficult or impossible. The role of carotid repair in the presence of neurologic deficits has been a matter of controversy for many years. Some of the recommendations regarding the management of these patients have been extrapolated from experience with chronic carotid disease and may not be applicable to the young, healthy trauma population. Earlier reports warned against routine restoration of carotid blood flow in the presence of neurologic deficits because of the danger of converting an anemic infarction to a worse hemorrhagic 85 Subsequent studies disputed the concept of postrevascularization hemorrhagic i n f a r c t i ~ nand ~ ~ suggested that brain edema is the most commonly found abnormality. Demetriades et alZ2found three hemorrhagic infarctions after re-establishing blood flow among 70 patients who died as a direct result of carotid injury: one patient with preoperative coma, one with hemiplegia, and one with no preoperative neurologic deficits. The authors suggested that severe anemic infarction predisposed to postrevascularization hemorrhagic infarction because of softening of the brain tissue. Theoretically, if there is severe anemic infarction or brain edema, revascularization should be avoided (Figs. 4 and 5). However, no reliable means are available to assess expeditiously the degree of brain ischemia. A CT scan may show changes in only 50% of patients within the first 3 to 6 hours. More recent studies support re-establishment of carotid flow in most patients with neurologic deficits short of coma.28, 69, 73, Rh Established anemic infarction or no distal carotid patency should preclude restoration of blood flow.85 The presence of coma has a grave prognosis, irrespective of type of opera-

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Figure 4. Acute traumatic thrombosis of the left internal carotid artery at the base of the skull. The patient developed hemiparesis. The brain CT scan showed a left anemic infarction. The patient was managed nonoperatively and improved significantly over the next few weeks.

tive management.22~28~50 Based on the available data, the best chance of improve51,61,91 This ment of patients in coma seems to be immediate revasculari~ation.~~~ is particularly important for patients admitted in shock or under the influence of alcohol or illicit drugs, conditions making the preoperative neurologic assessment inaccurate. Postoperatively, treatment aimed at preventing or reducing brain edema may improve the outcome. However, most trauma experts avoid revascularization after more than 3 or 4 hours from the establishment of coma or if there is established anemic infarction or no back

Figure 5. Severe brain edema following traumatic occlusion of the internal carotid artery. Revascularizationmay not be advisable.

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Shunts During Carotid Artery Injury Repair

Small carotid injuries that can be repaired rapidly do not need shunts. However, in more complex injuries requiring graft repair, the role of shunting is controversial. The existing studies are small and nonrandomized, and the 34, recommendations made are rather 74 Based on the available data and the safety of modern shunts, it is reasonable to employ shunting for complex injuries requiring graft reconstruction, especially in the presence of preoperative neurologic deficits or severe hypotension. Occlusion of the Carotid Artery with No Symptoms

Asymptomatic thrombosis of the common or internal carotid artery may result in late local or neurologic complications. The angiographic finding of an arterial occlusion, especially in penetrating trauma, is often associated with arterial transection, which may lead to subsequent false aneurysm formation or ruptu~e.~’ Also, delayed neurologic complications due to propagation of the thrombosis or emboli may occur. It is rational that these injuries should be repaired whenever technically possible. However, in high internal carotid arteries near the base of the skull, the risks of the operation may outweigh the potential benefits, and these injuries are best left alone. The role of prophylactic embolization of the proximal stump is not clear, and there is no evidence that it prevents late complications. Minor Carotid Artery Injuries

The natural history of untreated, clinically occult, radiologically detected minor carotid injuries such as intimal tears or small false aneurysms is not known (Fig. 6). Some authors believe that “minor” peripheral arterial injuries have a good prognosis and recommend ~ b s e r v a t i o n However, .~~ others express concern about the potential dangers of late complications from the carotid system and advocate a more aggressive approach. Experimental work suggests that arterial injuries with benign characteristics on duplex ultrasonography may not require repair. Ultrasonic findings of experimental intramural hemorrhage

Figure 6. Small false aneurysm of the carotid bulb. The lesion was managed nonoperatively. Repeat angiogram 1 month later showed no change. Most authors would recommend early surgical repair.

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or obstructing intimal defects are suggestive of a high incidence of late complications, and repair is recommended.63These experimental findings have not been validated in clinical studies, and the existing practices are based on anecdotal experience. If a nonoperative approach is selected, ultrasonic monitoring of the lesion is essential. The role of antiplatelet agents is not proven, although many surgeons use low-dose aspirin. Subclavian Vessels

Subclavian vascular injuries are found in about 4% of all patients with penetrating neck trauma.5l Although the hospital mortality ranges from 5% to 30%, the overall mortality is much higher. In a study of 228 patients with subclavian vessel injuries, the overall mortality was 66%, with most victims never reaching the hospital alive. The operative mortality was 15.5%.21The overall mortality of venous injuries was significantly higher than that of arterial ones (82% versus 60%), although the operative mortality was similar (21% versus 18%). The worse prognosis of the venous injuries is probably due to the usually fatal complications of air embolism and the inability of veins to contract and control exsanguination. The balloon tamponade technique described earlier can be very useful in preventing exsanguination. Familiarity with the anatomy of the region is critical in the management of these difficult injuries. The standard clavicular incision, which starts at the sternoclavicular junction, extends over the medial half of the clavicle and then curves downward toward the deltopectoral groove, provides adequate exposure in most cases. The medial half of the clavicle is removed or the sternoclavicular joint is disarticulated and the clavicle retracted. Subperiosteal partial excision of the clavicle does not lead to deformity or dysfunction. Regeneration usually takes place in 6 to 8 weeks.6l Proximal injuries require further exposure, which can be achieved by adding a median sternotomy or a left thoracotomy. Most authors advocate a median sternotomy for right subclavian vessel exposure and a left thoracotomy with a "trap door" on the left side. However, other authors use a median sternotomy for all proximal injuries, irrespective of side (Fig. 7). The exposure is satisfactory, and the problems associated with a thoracotomy are avoided.2I Arterial injuries are best managed by simple repair or dkbridement and end-to-end anastomosis. For more extensive injuries an interposition graft may be required. The choice of graftautologous vein versus prosthetic material-is a controversial issue. Some authors believe that foreign material should be avoided because of the danger of sepsis, although other studies suggest that synthetic grafts are safe.3oMost surgeons currently use synthetic grafts. Ligation of the subclavian artery should be avoided whenever possible because of the danger of claudication or subclavian steal syndrome if the ligation is proximal to the vertebral artery. Ligation should be reserved for patients in critical condition. Subclavian veins should be repaired only if it can be done expeditiously and without producing stenosis. Ligation is well tolerated without serious late sequelae. Vertebral Artery Injuries

Vertebral artery (VA) injuries are being recognized with increased frequency because of the liberal use of diagnostic angiography. In a prospective study of 335 patients with penetrating neck injuries in which angiography was used on

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Figure 7. Injury to the proximal left subclavian artery exposed through a clavicular incision and a median sternotomy. Note the excellent exposure of the innominate vein and the aortic arch with its major branches, including the subclavian artery.

only 7 patients, the overall incidence of VA injuries was 1.2%, or 10% of all major vascular injuries in the neck.20In another retrospective study from Los Angeles, VA injury was diagnosed in 8 of 147 patients (5.4%) investigated by diagnostic angiography. The incidence is higher in patients with GSWs (8.8% versus 5.3% in knife woundsZ4).

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Figure 8. Gunshot injury with bilateral vertebral artery thrombosis. The patient had no brain ischemic symptoms. (from Demetriades D, Theodorou D, Asensio J, et al: Management options in vertebral artery injuries. Br J Surg 83:83-86,1996; with permission.)

The clinical presentation depends on the nature of the injury and, most importantly, on the presence of other associated injuries. About two thirds of the victims have major associated injuries to cervical structures, the most common being the spine. Isolated VA injuries are asymptomatic in about one third of the patients.23Only rarely does occlusion of a VA result in neurologic sequelae. In one reported case (Fig. 8) with bilateral VA thrombosis, there were no neurologic symptoms.u Management Options

With the advance of interventional radiology, angiographic embolization has become the procedure of choice in many patients. Proximal and distal embolization of the VA lesion is usually necessary in order to control active bleeding, false aneurysms, or arteriovenous fistula (Figs. 9 and 10). If antegrade distal embolization is not technically possible, a retrograde approach through the opposite VA may be feasible.53For high VA lesions not amenable to distal embolization, a suboccipital craniectomy may be necessary to gain distal control.

Figure 9. False aneurysm of the vertebral artery, before and after successful embolization.

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Figure 10. Vertebral artery false aneurysm and arteriovenous fistula, before and after successful ernbolization. (From Demetriades D, Theodorou D, Asensio J, et al: Management options in vertebral artery injuries. Br J Surg 83:83-86, 1996; with permission.)

The procedure should follow angiographic embolization of the proximal VA (Fig. 11). Some patients with VA injury may require emergency surgical control of severe active bleeding. The surgical approach to the VA in its bony canal from C1 to C6 is a major challenge, even for experienced trauma surgeons. An incision is made along the anterior border of the sternocleidomastoid muscle. The carotid sheath is retracted medially or laterally. The prevertebral space is exposed and the longus coli is swept medially off the bone with the help of an osteotome. The anterior rim of the vertebral foramen costotransverse bar is then removed with bone rongeurs (Fig. 12) to expose and ligate the VA.21The vertebral veins, which form a large plexus within the bony canal, may be the source of persisting bleeding, which can be controlled by packing with a hemostatic agent. Blind clipping or suturing of the VA through the intertransverse ligament may damage the anterior nerve root, which lies just behind the artery. Nonoperative management has a definite role in the management of occlusive or minimal VA injuries9,24, 38 In a recent series, 13 of 22 patients with VA injuries were successfully managed nonoperati~ely.2~ Some authors expressed concern that such lesions may progress to false aneurysms or arteriovenous fistulas if left untreated and recommend routine operation and ligation of the ~ e s s e l .However, ~' this practice has not gained popularity because of the complexity of the operation and the success of interventional radiology in treating any late complication.45In summary, most VA lesions can be safely managed nonoperatively or by angiographic embolization. Surgical intervention should be reserved for patients with severe active bleeding or when embolization fails. Parotid Injuries

Injuries to the parotid parenchyma are best managed by suturing with an absorbable material over a closed drain. Sialoceles or fistulas appearing at a

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B

Figure 11. A, High vertebral artery false aneurysm. Proximal embolization failed to control the lesion. Suboccipital craniectomy with distal ligation of the artery was required. 6,Suboccipital craniectomy for distal control of high vertebral artery injuries. (From Demetriades D, Theodorou D, Asensio J, et al: Management options in vertebral artery injuries. Br J Surg 83:83-86,1996; with permission.)

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carotid sheath

1

longus colli myIe

Figure 12. Surgical exposure of the vertebral artery in its bony canal. The carotid sheath is retracted and the longus colli muscle is swept medially off the bone. The anterior rim of the vertebral foramen is then removed with bone rougeurs and the vessel is exposed. (From Demetriades D, Theodorou D, Asensio J, et al: Management options in vertebral injuries. Br J Surg 83:83-86, 1996; with permission.)

later stage respond well to aspiration and compression, and surgical intervention is rarely required. However, parotid duct injuries may be missed on initial examination and may result in sialoceles or fistulas that are more resistant to conservative treatment than those originating from the parotid parenchyma." A trial of repeated aspirations and compression dressings of the sialocele may be successful in some cases. Often, there is breakdown of the overlying skin and formation of an external fistula, with significant induration and scarring. For persistent sialoceles or fistulas, total parenteral nutrition with or without anticholinergics usually results in healing of the lesion. An alternative to parenteral nutrition is internal fistulization of the lesion.lYThe procedure can be performed under local or light general anesthesia. A 0.5-cm incision is made on the scar over the sialocele. If a fistula is present, there is always a small underlying cavity and the incision is made over this cystic area. The cavity is opened and a fine forceps is pushed through the floor of the cavity, through the masseter muscle, and into the mouth. A size 6 catheter is then inserted with one end in the cyst and the other in the mouth. The catheter is secured on the mucosa of the mouth with two sutures. The skin incision is closed and a firm compression dressing is applied. A liquid diet is allowed for the first 2 days and thereafter usual diet. The catheter usually stops draining saliva within 7 to 10 days; it is removed 2 or 3 days later. The artificially created internal fistula closes within days of removing the catheter. The mechanism by which this technique works is not clear. It has been postulated that it promotes fibrosis and obliteration of the parotid duct. This is supported by the finding of parotid gland atrophy on scans performed a few months after the procedure.19

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Laryngotracheal Trauma Tracheal Injuries

More than 75% of injuries to the trachea are confined to the cervical region.% Diagnosis of tracheal injuries is usually easy owing to the anterior and relatively superficial position of the organ. Air-bubbling through the wound, dyspnea or stridor, hemoptysis, and subcutaneous emphysema are the most common signs and symptoms." Triple endoscopy (laryngoscopy, bronchoscopy, and esophagoscopy) is mandated for stable patients with suspected upper airway trauma. Injury to one organ should raise the clinical suspicion of injuries to the adjacent organs. The vast majority of tracheal injuries after GSWs and stab wounds to the neck can be managed through lateral or transverse neck incisions, with extension to a stemotomy or a thoracotomy if necessary. In a series of 17 patients Sulek et als2performed only one thoracotomy for tracheal repair. Small tracheal wounds with no tissue loss and with well-opposed edges-as documented by bronchoscopy-can be 0bserved.5~. 75 An endotracheal tube with the cuff inflated distal to the laceration for 48 hours may help sealing of the tracheal wound, although this is not a standard practice. However, primary repair is the preferred method of management in most cases. Interrupted sutures of 3-0 synthetic absorbable material seem to carry the least risk of granuloma formation. The usefulness of a prophylactic tracheostomy in simple repairs is debatable.z9,41 It has been suggested that direct repair without tracheostomy is adequate for small tracheal wounds with no loss of tissue which do not require extensive mobilization.83Tracheostomy increases the infection-related morbidity rates and should be used only for extensive tracheal injuries.29The risk of sepsis can be of particular concern, especially in the presence of associated vascular repairs with prosthetic material. In managing extensive tracheal wounds, it is essential to achieve a tensionfree and well-vascularized anastomosis. The blood supply to the trachea enters primarily from the lateral aspects so that mobilization should be performed by anterior and sometimes posterior dissection with preservation of the adjacent lateral If the total length of damaged or dkbrided trachea is less than 2 or 3 cm, reapproximation of the free edges is feasible with relative ease. However, for wider gaps, more complicated techniques may be required. Thyroid or suprahyoid release and flexion of the neck can provide up to 6 cm of further mobilization. Flexion of the neck is maintained for 1 week postoperatively by a strong suture from the chin to the presternal skin. Retention submucosal sut u r e can ~ ~ also ~ reduce the anastomotic tension when placed from the upper to the lower tracheal rings. In cases of extensive defects in which wound closure cannot be achieved, musculofascial flaps or synthetic material can be used?, 55 Tracheostomy alone as a method of managing tracheal wounds is reserved for the cases in which the patient's instability prohibits prolonged surgical explorations, and tracheal reconstruction is postponed for a later stage. Laryngeal Injuries

In recent years fiberoptic nasoendoscopy has replaced indirect laryngoscopy in diagnosing laryngeal injuries. Patients with minimal intralaryngeal injuries

and nondisplaced fractures are good candidates for nonsurgical treatment. The majority of the rest can be repaired primarily.87The sooner the repair is accomplished, the more easily the wound edges are brought together and the better

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the functional outcome in terms of voice Stents are rarely necessary, but they may be useful in complicated cases in order to stabilize the airway or to hold the mucosa in position.54In cases of thyroid cartilage injury, endoscopic reapproximation of the mucosa combined with open surgical repair of the cartilage is a good option. In more extensive fractures, silicone rubber stents or Portex endotracheal tubes molded to conform to the shape of the larynx might be necessary.6,ysIt is important to stress that even under the most ideal circumstances it is difficult to restore the delicate laryngeal anatomy. In order to ensure optimal functional results, consultation with an otolaryngologist should be immediately obtained. Pharyngoesophageal Trauma

Esophageal trauma is relatively uncommon.z3However, it is the most commonly missed injury in the neck, and delays in diagnosis may result in severe complication^.^^ Bladergroen et aP showed that primary closure within 24 hours resulted in 92% survival. After 24 hours survival decreased to 67% and was not significantly influenced by the type of treatment. Velmahos et aP9 studied 119 patients with traumatic perforations of the pharynx and the esophagus. No mortality directly related to the esophageal injury was detected in 108 patients operated on within 24 hours. In 11 patients there was a delay in diagnosis and treatment of more than 24 hours, and 4 of them (36%) died of uncontrollable sepsis. Odynophagia, hematemesis, and subcutaneous emphysema are the most characteristic findings.43Demetriades et a1,25 in a prospective study of 223 patients with penetrating neck injury, found that the absence of these symptoms reliably excluded esophageal trauma. None of 174 awake asymptomatic patients had esophageal injuries. The authors suggested that only symptomatic or nonalert patients be subjected to further investigations. However, other authors14,6s believe that history and physical examination are not always diagnostic and recommend aggressive investigation by means of esophagography and esophagoscopy. A lateral view of the neck is the most useful initial radiograph for detection of intraluminal air.36The mainstay of diagnosis is the contrast swallow and endoscopy. Weigelt et a192estimated the sensitivity of either barium swallow or rigid esophagoscopy to be 89%, but the combination of the two was 100% sensitive. Placing the patient at the lateral decubitus position during esophagography is emphasized by DeMeester.'* Management Primary repair in one or two layers is almost always feasible if the diagnosis is established in a timely manner.7 On the contrary, if the initial treatment is delayed, definitive procedures can only rarely be a c c ~ m p l i s h e dThis . ~ ~ time is not well defined but is considered to be 12 to 24 h o ~ r s . "The ~ management of late esophageal perforations can vary from drainage alone to es~phagectomy.'~, 76 Extensive dhbridement, closure, and buttressing with adjacent strap muscles and wide drainage have been advocated by Cheadle and Richard~0n.l~ Exclusion operations may become necessary,sRalthough they carry significant mortality.36,h5 Abbott et all reported favorable results with the use of a T-tube for the treatment of delayed perforations of the Boerhaave type. Hatzitheofilou et a143used this technique in four cases in which a significant delay from injury to repair made direct closure impossible and achieved a successful outcome in three. A large

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22 to 24 Fr T-tube is inserted via the perforation with the ends projecting 3 cm above and below the lesion and the long limb reaching through the chest wall. The perforation is closed above and below the tube. This technique adds little to the operating time and has the advantage of converting the perforation to a controlled fistula." 58 Uneventful healing after nonoperative management of small cervical esophageal injuries has been reported by some although this policy has not gained widespread support.

Combined Tracheoesophageal Injuries

The management of combined tracheoesophageal wounds merits special attention. The severity of these injuries is shown in the study of Feliciano et al,29in which 74% of patients with tracheoesophageal trauma developed major complications. There is consensus that vascularized muscle flaps should separate the tracheal from the esophageal repair and that drains should not cross over the carotid artery. If the ipsilateral carotid is injured, drainage should be directed to the opposite side of the neck. The role of a proximal esophagostomy in extensive tracheoesophageal injuries is not clear. Although it has been suggested that esophagostomy should be considered at the first 0peration,2~ other studies93,94 do not support such diversion, reporting good results with simple primary repair.

Thoracic Duct Injuries

Thoracic duct injuries are rare and are usually associated with subclavian vascular injuries. They are often missed at the initial operation and present early after injury as a milky fluid leak through a transcutaneous fistula or a drain in the neck or through the chest tube if the pleural cavity has been violated? A total protein level greater than 3 g/dL, a total fat content between 0.4 and 4.0 g/dL, alkaline pH, a triglyceride level of more than 200 mg/dL, and a marked lymphocytic predominance in the white blood cell count of the fluid confirm the diagnosis,32although these findings are not always present. Conservative treatment of up to 2 weeks with total parenteral nutrition or low-fat diet usually heals the fistula.32It is rare that surgical intervention is necessary. If the drainage persists after 2 weeks with no signs of output decrease, various surgical options may be ~ o n s i d e r e dOpen . ~ ~ or thoracoscopic ligation of the duct,31,96 sealing with fibrin pleurodesis with OK-432,78 and pleuroperitoneal shuntingl5 have all been used with success in case reports.

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Address reprint requests to Demetrios Demetriades, MD, PhD, FACS Division of Trauma and Critical Care Los Angeles County/University of Southern California Medical Center 1200 North State Street Los Angeles, CA 90033