- Email: [email protected]
Neck Injuries
Neck Injuries Jennifer L. McDougal, MD
II. INITIAL ASSESSMENT A. Life-threatening airway obstruction or exsanguinating hemorrhage is addressed emergently. B. Endotracheal intubation is preferred, although a surgical airway may be necessary. C. Upon completion of the primary survey, the stable patient is assessed for evidence of neck injury in the secondary survey. 1. The rigid cervical collar must be removed in order to perform an adequate examination. The neck should be stabilized by an assistant during this procedure. 2. Signs and symptoms include expanding hematoma, pulsatile bleeding, airway obstruction, sucking or bubbling neck wounds, instability of the laryngeal cartilage, thrills suggesting arteriovenous fistula, crepitus in patients with aerodigestive injury, and bruits. Assessment is made for skeletal stability by examining the neck for pain and step-offs. 3. In patients with low-velocity penetrating injuries, such as stab wounds or shotgun wounds, determination of platysma muscle penetration is a crucial part of the initial evaluation a. Penetrating injuries that violate the platysma have a high incidence of involvement of deeper structures. b. Platysma penetration requires further evaluation or therapy, whereas superficial wounds may be managed in an ambulatory setting. c. The wound should NOT be probed, as this may dislodge clots and aggravate further bleeding. d. Foreign bodies that are lodged in this area should be left in place and removed in the operating room where hemorrhage and airway compromise can be safely managed. e. Insertion of a nasogastric tube is deferred in patients with suspected vascular injury in order to avoid the possibility of dislodging clot or stimulating bleeding. 157
20
NECK INJURIES
A. Mechanism of injury and anatomic location dictate the priorities in the evaluation and treatment of neck injuries. B. Penetrating injuries constitute the vast majority and are more likely to injure the soft tissue, vascular structures, and aerodigestive organs. C. Blunt trauma has a greater predilection for musculoskeletal and neurological injuries. D. Airway compromise from laryngotracheal injuries, along with sustained hemorrhage from injuries to the major vessels, causes most of the mortalities from neck injuries.
20
I. INTRODUCTION
158 III. Zones of the Neck
f. Plain radiographs should be obtained to locate missiles or rule out retained foreign bodies. III. ZONES OF THE NECK A. The neck is divided into 3 zones (Fig. 20-1) for the purpose of determining priorities, obtaining diagnostic studies, and preoperative planning of surgical procedures. 1. Zone I is the horizontal area between the clavicles and cricoid cartilage that includes the great vessels, trachea, esophagus, innominate vein at the thoracic outlet, and apices of both lungs. a. Penetrating injuries to this area usually require significant preoperative planning. b. At Parkland Memorial Hospital, multiple diagnostic studies are performed in these patients to help identify injuries and appropriately plan surgical approaches. i. A hemodynamically stable patient with a zone 1 injury will undergo aortic arch and great vessel visualization with computed tomographic angiography (CTA), bronchoscopy, and rigid esophagoscopy ii. In patients with a low suspicion for esophageal injury, cineesophagography can be substituted for rigid esophagoscopy to avoid general anesthesia.
Zone III Angle of mandible
Cricoid
Zone II
Zone I
FIGURE 20-1 Anatomic zones of the neck. (From Moore EE, Mattox KL, Feliciano DV (eds): Trauma. East Norwalk, CT, Appleton & Lange, 1987, p306.)
IV. Vascular Injuries 159
IV. VASCULAR INJURIES A. Vascular and airway injuries account for the majority of deaths due to neck trauma. B. The common carotid artery is the most frequently injured structure in most series, occurring in approximately 5% of all vascular injuries. C. The internal jugular vein is the most commonly injured vein. D. A normal vascular examination may be present in 10% to 30% of patients with vascular injuries, thus allowing for the possibility of missed injuries when relying solely on physical examination. E. Radiologic examination is essential to the identification and localization of carotid injuries. 1. Arteriography has been the “gold standard” for assessing the carotid. 2. A study at Parkland Memorial Hospital has demonstrated that CT angiography with at least a 16-channel detector is an acceptable, less invasive method of screening for blunt carotid and vertebral injuries. The use of 0.5-mm-thick images and 3-dimensional reconstructions provide a definite advantage over catheter angiography. This has become the procedure of choice at Parkland Memorial Hospital.
20 NECK INJURIES
c. Most injuries to zone 1 can be approached through a median sternotomy. d. Proximal left subclavian artery injuries will require a left anterolateral thoracotomy for proximal control. e. A right thoracotomy may be required for high esophageal injuries. 2. Zone II extends from the cricoid cartilage to the angle of the mandible and contains the trachea, carotid artery, jugular vein, vertebral vessels, esophagus, and cervical spine. a. Anatomic structures in zone II are easily accessible through an oblique neck incision along the sternocleidomastoid muscle with minimal morbidity. b. There are no significant differences in missed injuries between surgical exploration and nonoperative evaluation by angiography, bronchoscopy, and esophagography. i. Operative management has cost advantages and low morbidity, and thus operative exploration of zone II injuries is favored at Parkland. 3. Zone III extends from the angle of the mandible to the base of the skull and contains vascular structures including the internal carotid and vertebral arteries. a. Operative exposure is frequently limited and distal control of vascular injuries can be challenging, especially with high carotid lesions. b. CT angiography is the preferred method of evaluation for stable patients at Parkland. c. Several maneuvers can improve operative exposure, including mandibular subluxation; however, this needs to be achieved prior to making the neck incision.
160 IV. Vascular Injuries
3. Radiologic examinations also provide useful information regarding the collateral circulation and presence of vascular anomalies, which may affect the surgical management. a. Only 20% of all individuals have a complete circle of Willis, an important factor when contemplating ligation of the carotid artery. b. Approximately 3% of patients obtain blood supply to their spinal cord from the vertebral artery, thus rendering vertebral artery ligation a disastrous complication in this group of patients. F. Operative management 1. Indications for neck exploration include expanding hematoma, pulsatile hemorrhage, neurologic deficit, presence of a thrill or bruit, and/or airway compromise. 2. All carotid artery or internal jugular venous injuries are repaired, when possible, with lateral arteriorrhaphy or venorrhaphy. 3. Patients with severe venous injuries who have a patent contralateral jugular vein can undergo ligation of the injured jugular vein. 4. It is important to remember that air emboli occur frequently after major venous injuries, and that irrespective of the type of repair used, subsequent thrombosis is common. 5. Major carotid artery injuries may require a vein patch or interposition graft; thus, the contralateral groin should be prepared and draped to allow simultaneous vein harvest. 6. At Parkland, patients requiring prolonged reconstruction or additional repair of concomitant aerodigestive tract injuries undergo routine vascular shunting. 7. Ligation of the external carotid artery may be considered in the unstable patient with multiple injuries. 8. Ligation of the internal carotid artery may be fraught with severe neurologic complications and is avoided. a. Internal carotid artery ligation may be considered in the patient with carotid occlusion without distal flow and a dense neurologic deficit. 9. A decision must be made regarding the safety of repair and restoration of flow in patients with a severe neurologic deficit. a. This is made more difficult in the patient with a concomitant head injury. b. Parkland recommends repair of carotid artery injuries if technically possible in all patients who are not comatose and are hemodynamically stable. i. If the patient has evidence of a dense stroke and no antegrade flow, the risk of death may be increased; therefore, ligation without repair may be a satisfactory alternative. 10. Distal carotid injuries located near the base of the skull are often difficult to control operatively due to limited exposure. a. These may require embolization or ligation if collateral circulation is adequate.
VI. Laryngeal Injuries 161
V. PHARYNGEAL INJURIES A. Pharyngeal injuries generally occur as a result of penetrating trauma. B. These injuries may produce minimal signs and symptoms; hence they are frequently missed, resulting in postinjury infections. C. When identified during exploration, these injuries are repaired with at least two layers of absorbable suture and drained adequately. 1. Proper mucosal apposition will reduce the incidence of postoperative leaks. D. An isolated hypopharyngeal wound can be managed conservatively with nasogastric tube feeding and antibiotics. E. Cervical osteomyelitis is a disastrous complication occasionally associated with pharyngo-esophageal injuries that occur in combination with penetrating cervical spine wounds. 1. Contamination with pharyngeal flora is a contributing factor. 2. This complication can be reduced by aggressive debridement, including distal and ligamentous structures, stable spinal fixation, and appropriate antimicrobial therapy. VI. LARYNGEAL INJURIES A. Laryngeal injuries are usually mucosal tears, fractures of bony or cartilaginous structures, or avulsions and transections. B. Laryngeal injuries are classified as supraglottic, transglottic, or cricoid in location.
20 NECK INJURIES
b. Insertion of a small balloon catheter will facilitate temporary hemostasis in a high, distal lesion. c. In situations with poor collateral flow, an extracranial-intracranial bypass procedure may be necessary in order to prevent neurologic sequelae. 11. At Parkland Memorial Hospital, intraoperative completion angiography is performed to confirm a patent vascular repair without narrowing, as failure to do so may result in postoperative thrombosis. G. For blunt cerebrovascular injuries and small intimal flap injuries from penetrating trauma, anticoagulation is advocated when there are no existing contraindications for heparinization. 1. Although open surgical repair remains the gold standard, minimally invasive therapies including endovascular stenting are now being used at Parkland. H. The majority of vertebral artery injuries are not life threatening and can be managed nonoperatively. 1. Many of these injuries, especially high distal arteriovenous fistulae, are treated with embolization in the presence of adequate collateral circulation. 2. Proximal vertebral artery injuries can be managed by operative proximal and distal ligation.
162 VIII. Esophageal Injuries
C. Indications for surgery include significant mucosal disruption or avulsion, arytenoid dislocation, and exposed cartilage. D. Timing of the operation is important, and studies have shown improved results with early operation. E. In one series, 87% of injuries repaired within 24 hours had a good airway, compared with 69% in patients treated within 2 to 7 days postoperatively. F. The preferred method for evaluating the larynx and trachea is by combined use of direct laryngoscopy and bronchoscopy. G. The most common complications of laryngeal injury are infection, airway stenosis or obstruction, and voice changes. 1. Infection is treated by debridement, drainage, and antibiotics. 2. Airway stenosis is resolved by tracheal or laryngeal reconstruction. H. A fractured larynx is a contraindication to endotracheal intubation. VII. TRACHEAL INJURIES A. Isolated tracheal injuries are rare with both blunt and penetrating trauma. B. The associated injuries are often more dramatic, and subtle trauma to the trachea may be overlooked. C. Indicators of possible tracheal injury include sucking neck wounds, crepitus on examination, soft tissue air on plain radiographs, and hemoptysis. D. Bronchoscopy is accurate in identifying the injury. E. One-layer repair with absorbable monofilament suture is the preferred method of treatment at Parkland. 1. In the presence of tissue loss, mobilization of the trachea can obtain up to 5 cm of length and provide a tension-free repair. 2. Interposition of vascularized tissue (e.g., omohyoid or sternocleidomastoid muscle) is essential when there is a concomitant esophageal or arterial injury to prevent the development of a fistula. 3. Damage control can be accomplished by the insertion of a T-tube. VIII. ESOPHAGEAL INJURIES A. Cervical esophageal injuries occur infrequently. B. During a 3-year prospective study at Parkland Memorial Hospital, 11 cervical esophageal injuries were identified. C. Penetrating trauma is the more common etiology, although these injuries may be associated with blunt trauma, such as cervical spine fractures and crush injuries. D. Missed injuries are not uncommon since they are often masked by trauma to surrounding organs that precludes their identification. E. Early detection of esophageal injuries is essential as mortality rates have been reported to be as high as 17% following a 12-hour delay.
IX. Musculoskeletal 163
IX. MUSCULOSKELETAL A. Skeletal and ligamentous injuries are more common following blunt trauma. B. Evaluation 1. Flexion and extension radiographs, as well as other specialized imaging techniques, may need to be delayed while emergent problems are addressed. 2. When evaluating potential skeletal injuries in the neck, the physician must be compulsive in visualizing the C7-T1 interspace, as well as the odontoid. 3. At Parkland Memorial Hospital, we use CT as the primary modality for evaluating the cervical spine. 4. MRI studies may occasionally be warranted to completely evaluate for ligamentous injury. C. Specific injuries 1. A stable burst fracture (Jefferson fracture) of the atlas (C1) occurs as a result of impaction of the ring of C1 against the occipital condyles. a. It is commonly seen with an axial load imparted to the top of the head.
20 NECK INJURIES
F. Diagnostic techniques 1. Although diagnostic studies, such as contrast radiography and endoscopy, are fairly reliable, false-negative results do occur. 2. Flexible endoscopy is much less reliable in identifying cervical esophageal injuries. a. One series showed that flexible endoscopy had a sensitivity of only 38% compared to 89% for rigid esophagoscopy. G. Operative issues 1. These injuries may be elusive in the operating room, and a careful search must be performed, including the posterior aspect. 2. Esophageal injuries should be repaired in two layers, and all repairs should have closed-suction drainage and antibiotic prophylaxis. 3. Tenuous repairs are buttressed with a pleural or muscle flap. 4. Massive injuries may require resection or exclusion with distal ligation, gastrostomy tube placement, and proximal diversion in the form of an esophagostomy. H. Complications 1. Missed injuries can cause infectious complications, such as mediastinitis, cervical abscesses, and sepsis, but the more common problems seen following repair of these injuries are fistula formation and dysphagia. 2. Esophageal leaks are attributed to inadequate debridement, poor surgical technique when repairing the injury, and devascularization of the wall. 3. The incidence of esophagocutaneous fistula is about 10% to 30%. 4. All patients should have a contrast study performed prior to starting an oral diet.
164 XII. Suggested Readings
2. Odontoid fractures are often associated with falls, blows to the head, motor vehicle collisions, and some sports (e.g., gymnastics). a. A type 1 fracture extends through the tip of the odontoid. b. A type 2 extends through the body. c. A type 3 involves the base and the body of C2. 3. Severe extension injuries may cause a hangman’s fracture (i.e., a fracture of the pedicle of the axis and a dislocation of C2 on C3). a. Owing to the large diameter of the spinal canal at this level, a neurologic deficit may not occur. D. Treatment of skeletal and ligamentous injuries is by external stabilization or internal fixation, depending on the stability of the fracture. X. LYMPHATICS A. The thoracic duct is the most commonly injured lymphatic in the neck. B. These injuries may be identified during neck exploration but are usually discovered late in the hospital course. 1. Unexplained fever, abscess formation, or abnormal fluid collections should raise the suspicion of a thoracic duct injury. 2. Drainage of milky white fluid from suction drains placed at the time of surgery or aspiration of this material is often the first sign of a lymph fistula, lymphocele, or even a chylothorax. C. Conservative management is usually adequate as these collections resolve spontaneously. D. However, if prolonged drainage continues, thoracic duct ligation is preferable to attempts at primary repair. E. Wide drainage usually results in resolution of these complications. F. Delayed ligation can be performed if conservative management fails. XI. PEARLS AND PITFALLS A. Defer insertion of nasogastric tube in patients with suspected vascular neck injuries. B. Do not remove impaled foreign bodies in the emergency department, as their removal may precipitate uncontrollable hemorrhage. C. Use liberal indications for four-vessel angiography in patients with blunt neck injury to identify stretch or intimal flaps. XII. SUGGESTED READINGS Britt LD: Neck injuries: Evaluation and management. In Moore EE, Mattox KL, Feliciano DV (eds): Trauma. New York, Mc-Graw Hill, pp 445-457. Leopold DA: Laryngeal trauma. Arch Otolaryngol 109:106, 1983. Weigelt JA, Thal ER, Synder WH III, et al: Diagnosis of penetrating cervical esophageal injuries. Am J Surg 154:619, 1987.
II. INITIAL ASSESSMENT A. Life-threatening airway obstruction or exsanguinating hemorrhage is addressed emergently. B. Endotracheal intubation is preferred, although a surgical airway may be necessary. C. Upon completion of the primary survey, the stable patient is assessed for evidence of neck injury in the secondary survey. 1. The rigid cervical collar must be removed in order to perform an adequate examination. The neck should be stabilized by an assistant during this procedure. 2. Signs and symptoms include expanding hematoma, pulsatile bleeding, airway obstruction, sucking or bubbling neck wounds, instability of the laryngeal cartilage, thrills suggesting arteriovenous fistula, crepitus in patients with aerodigestive injury, and bruits. Assessment is made for skeletal stability by examining the neck for pain and step-offs. 3. In patients with low-velocity penetrating injuries, such as stab wounds or shotgun wounds, determination of platysma muscle penetration is a crucial part of the initial evaluation a. Penetrating injuries that violate the platysma have a high incidence of involvement of deeper structures. b. Platysma penetration requires further evaluation or therapy, whereas superficial wounds may be managed in an ambulatory setting. c. The wound should NOT be probed, as this may dislodge clots and aggravate further bleeding. d. Foreign bodies that are lodged in this area should be left in place and removed in the operating room where hemorrhage and airway compromise can be safely managed. e. Insertion of a nasogastric tube is deferred in patients with suspected vascular injury in order to avoid the possibility of dislodging clot or stimulating bleeding. 157
20
NECK INJURIES
A. Mechanism of injury and anatomic location dictate the priorities in the evaluation and treatment of neck injuries. B. Penetrating injuries constitute the vast majority and are more likely to injure the soft tissue, vascular structures, and aerodigestive organs. C. Blunt trauma has a greater predilection for musculoskeletal and neurological injuries. D. Airway compromise from laryngotracheal injuries, along with sustained hemorrhage from injuries to the major vessels, causes most of the mortalities from neck injuries.
20
I. INTRODUCTION
158 III. Zones of the Neck
f. Plain radiographs should be obtained to locate missiles or rule out retained foreign bodies. III. ZONES OF THE NECK A. The neck is divided into 3 zones (Fig. 20-1) for the purpose of determining priorities, obtaining diagnostic studies, and preoperative planning of surgical procedures. 1. Zone I is the horizontal area between the clavicles and cricoid cartilage that includes the great vessels, trachea, esophagus, innominate vein at the thoracic outlet, and apices of both lungs. a. Penetrating injuries to this area usually require significant preoperative planning. b. At Parkland Memorial Hospital, multiple diagnostic studies are performed in these patients to help identify injuries and appropriately plan surgical approaches. i. A hemodynamically stable patient with a zone 1 injury will undergo aortic arch and great vessel visualization with computed tomographic angiography (CTA), bronchoscopy, and rigid esophagoscopy ii. In patients with a low suspicion for esophageal injury, cineesophagography can be substituted for rigid esophagoscopy to avoid general anesthesia.
Zone III Angle of mandible
Cricoid
Zone II
Zone I
FIGURE 20-1 Anatomic zones of the neck. (From Moore EE, Mattox KL, Feliciano DV (eds): Trauma. East Norwalk, CT, Appleton & Lange, 1987, p306.)
IV. Vascular Injuries 159
IV. VASCULAR INJURIES A. Vascular and airway injuries account for the majority of deaths due to neck trauma. B. The common carotid artery is the most frequently injured structure in most series, occurring in approximately 5% of all vascular injuries. C. The internal jugular vein is the most commonly injured vein. D. A normal vascular examination may be present in 10% to 30% of patients with vascular injuries, thus allowing for the possibility of missed injuries when relying solely on physical examination. E. Radiologic examination is essential to the identification and localization of carotid injuries. 1. Arteriography has been the “gold standard” for assessing the carotid. 2. A study at Parkland Memorial Hospital has demonstrated that CT angiography with at least a 16-channel detector is an acceptable, less invasive method of screening for blunt carotid and vertebral injuries. The use of 0.5-mm-thick images and 3-dimensional reconstructions provide a definite advantage over catheter angiography. This has become the procedure of choice at Parkland Memorial Hospital.
20 NECK INJURIES
c. Most injuries to zone 1 can be approached through a median sternotomy. d. Proximal left subclavian artery injuries will require a left anterolateral thoracotomy for proximal control. e. A right thoracotomy may be required for high esophageal injuries. 2. Zone II extends from the cricoid cartilage to the angle of the mandible and contains the trachea, carotid artery, jugular vein, vertebral vessels, esophagus, and cervical spine. a. Anatomic structures in zone II are easily accessible through an oblique neck incision along the sternocleidomastoid muscle with minimal morbidity. b. There are no significant differences in missed injuries between surgical exploration and nonoperative evaluation by angiography, bronchoscopy, and esophagography. i. Operative management has cost advantages and low morbidity, and thus operative exploration of zone II injuries is favored at Parkland. 3. Zone III extends from the angle of the mandible to the base of the skull and contains vascular structures including the internal carotid and vertebral arteries. a. Operative exposure is frequently limited and distal control of vascular injuries can be challenging, especially with high carotid lesions. b. CT angiography is the preferred method of evaluation for stable patients at Parkland. c. Several maneuvers can improve operative exposure, including mandibular subluxation; however, this needs to be achieved prior to making the neck incision.
160 IV. Vascular Injuries
3. Radiologic examinations also provide useful information regarding the collateral circulation and presence of vascular anomalies, which may affect the surgical management. a. Only 20% of all individuals have a complete circle of Willis, an important factor when contemplating ligation of the carotid artery. b. Approximately 3% of patients obtain blood supply to their spinal cord from the vertebral artery, thus rendering vertebral artery ligation a disastrous complication in this group of patients. F. Operative management 1. Indications for neck exploration include expanding hematoma, pulsatile hemorrhage, neurologic deficit, presence of a thrill or bruit, and/or airway compromise. 2. All carotid artery or internal jugular venous injuries are repaired, when possible, with lateral arteriorrhaphy or venorrhaphy. 3. Patients with severe venous injuries who have a patent contralateral jugular vein can undergo ligation of the injured jugular vein. 4. It is important to remember that air emboli occur frequently after major venous injuries, and that irrespective of the type of repair used, subsequent thrombosis is common. 5. Major carotid artery injuries may require a vein patch or interposition graft; thus, the contralateral groin should be prepared and draped to allow simultaneous vein harvest. 6. At Parkland, patients requiring prolonged reconstruction or additional repair of concomitant aerodigestive tract injuries undergo routine vascular shunting. 7. Ligation of the external carotid artery may be considered in the unstable patient with multiple injuries. 8. Ligation of the internal carotid artery may be fraught with severe neurologic complications and is avoided. a. Internal carotid artery ligation may be considered in the patient with carotid occlusion without distal flow and a dense neurologic deficit. 9. A decision must be made regarding the safety of repair and restoration of flow in patients with a severe neurologic deficit. a. This is made more difficult in the patient with a concomitant head injury. b. Parkland recommends repair of carotid artery injuries if technically possible in all patients who are not comatose and are hemodynamically stable. i. If the patient has evidence of a dense stroke and no antegrade flow, the risk of death may be increased; therefore, ligation without repair may be a satisfactory alternative. 10. Distal carotid injuries located near the base of the skull are often difficult to control operatively due to limited exposure. a. These may require embolization or ligation if collateral circulation is adequate.
VI. Laryngeal Injuries 161
V. PHARYNGEAL INJURIES A. Pharyngeal injuries generally occur as a result of penetrating trauma. B. These injuries may produce minimal signs and symptoms; hence they are frequently missed, resulting in postinjury infections. C. When identified during exploration, these injuries are repaired with at least two layers of absorbable suture and drained adequately. 1. Proper mucosal apposition will reduce the incidence of postoperative leaks. D. An isolated hypopharyngeal wound can be managed conservatively with nasogastric tube feeding and antibiotics. E. Cervical osteomyelitis is a disastrous complication occasionally associated with pharyngo-esophageal injuries that occur in combination with penetrating cervical spine wounds. 1. Contamination with pharyngeal flora is a contributing factor. 2. This complication can be reduced by aggressive debridement, including distal and ligamentous structures, stable spinal fixation, and appropriate antimicrobial therapy. VI. LARYNGEAL INJURIES A. Laryngeal injuries are usually mucosal tears, fractures of bony or cartilaginous structures, or avulsions and transections. B. Laryngeal injuries are classified as supraglottic, transglottic, or cricoid in location.
20 NECK INJURIES
b. Insertion of a small balloon catheter will facilitate temporary hemostasis in a high, distal lesion. c. In situations with poor collateral flow, an extracranial-intracranial bypass procedure may be necessary in order to prevent neurologic sequelae. 11. At Parkland Memorial Hospital, intraoperative completion angiography is performed to confirm a patent vascular repair without narrowing, as failure to do so may result in postoperative thrombosis. G. For blunt cerebrovascular injuries and small intimal flap injuries from penetrating trauma, anticoagulation is advocated when there are no existing contraindications for heparinization. 1. Although open surgical repair remains the gold standard, minimally invasive therapies including endovascular stenting are now being used at Parkland. H. The majority of vertebral artery injuries are not life threatening and can be managed nonoperatively. 1. Many of these injuries, especially high distal arteriovenous fistulae, are treated with embolization in the presence of adequate collateral circulation. 2. Proximal vertebral artery injuries can be managed by operative proximal and distal ligation.
162 VIII. Esophageal Injuries
C. Indications for surgery include significant mucosal disruption or avulsion, arytenoid dislocation, and exposed cartilage. D. Timing of the operation is important, and studies have shown improved results with early operation. E. In one series, 87% of injuries repaired within 24 hours had a good airway, compared with 69% in patients treated within 2 to 7 days postoperatively. F. The preferred method for evaluating the larynx and trachea is by combined use of direct laryngoscopy and bronchoscopy. G. The most common complications of laryngeal injury are infection, airway stenosis or obstruction, and voice changes. 1. Infection is treated by debridement, drainage, and antibiotics. 2. Airway stenosis is resolved by tracheal or laryngeal reconstruction. H. A fractured larynx is a contraindication to endotracheal intubation. VII. TRACHEAL INJURIES A. Isolated tracheal injuries are rare with both blunt and penetrating trauma. B. The associated injuries are often more dramatic, and subtle trauma to the trachea may be overlooked. C. Indicators of possible tracheal injury include sucking neck wounds, crepitus on examination, soft tissue air on plain radiographs, and hemoptysis. D. Bronchoscopy is accurate in identifying the injury. E. One-layer repair with absorbable monofilament suture is the preferred method of treatment at Parkland. 1. In the presence of tissue loss, mobilization of the trachea can obtain up to 5 cm of length and provide a tension-free repair. 2. Interposition of vascularized tissue (e.g., omohyoid or sternocleidomastoid muscle) is essential when there is a concomitant esophageal or arterial injury to prevent the development of a fistula. 3. Damage control can be accomplished by the insertion of a T-tube. VIII. ESOPHAGEAL INJURIES A. Cervical esophageal injuries occur infrequently. B. During a 3-year prospective study at Parkland Memorial Hospital, 11 cervical esophageal injuries were identified. C. Penetrating trauma is the more common etiology, although these injuries may be associated with blunt trauma, such as cervical spine fractures and crush injuries. D. Missed injuries are not uncommon since they are often masked by trauma to surrounding organs that precludes their identification. E. Early detection of esophageal injuries is essential as mortality rates have been reported to be as high as 17% following a 12-hour delay.
IX. Musculoskeletal 163
IX. MUSCULOSKELETAL A. Skeletal and ligamentous injuries are more common following blunt trauma. B. Evaluation 1. Flexion and extension radiographs, as well as other specialized imaging techniques, may need to be delayed while emergent problems are addressed. 2. When evaluating potential skeletal injuries in the neck, the physician must be compulsive in visualizing the C7-T1 interspace, as well as the odontoid. 3. At Parkland Memorial Hospital, we use CT as the primary modality for evaluating the cervical spine. 4. MRI studies may occasionally be warranted to completely evaluate for ligamentous injury. C. Specific injuries 1. A stable burst fracture (Jefferson fracture) of the atlas (C1) occurs as a result of impaction of the ring of C1 against the occipital condyles. a. It is commonly seen with an axial load imparted to the top of the head.
20 NECK INJURIES
F. Diagnostic techniques 1. Although diagnostic studies, such as contrast radiography and endoscopy, are fairly reliable, false-negative results do occur. 2. Flexible endoscopy is much less reliable in identifying cervical esophageal injuries. a. One series showed that flexible endoscopy had a sensitivity of only 38% compared to 89% for rigid esophagoscopy. G. Operative issues 1. These injuries may be elusive in the operating room, and a careful search must be performed, including the posterior aspect. 2. Esophageal injuries should be repaired in two layers, and all repairs should have closed-suction drainage and antibiotic prophylaxis. 3. Tenuous repairs are buttressed with a pleural or muscle flap. 4. Massive injuries may require resection or exclusion with distal ligation, gastrostomy tube placement, and proximal diversion in the form of an esophagostomy. H. Complications 1. Missed injuries can cause infectious complications, such as mediastinitis, cervical abscesses, and sepsis, but the more common problems seen following repair of these injuries are fistula formation and dysphagia. 2. Esophageal leaks are attributed to inadequate debridement, poor surgical technique when repairing the injury, and devascularization of the wall. 3. The incidence of esophagocutaneous fistula is about 10% to 30%. 4. All patients should have a contrast study performed prior to starting an oral diet.
164 XII. Suggested Readings
2. Odontoid fractures are often associated with falls, blows to the head, motor vehicle collisions, and some sports (e.g., gymnastics). a. A type 1 fracture extends through the tip of the odontoid. b. A type 2 extends through the body. c. A type 3 involves the base and the body of C2. 3. Severe extension injuries may cause a hangman’s fracture (i.e., a fracture of the pedicle of the axis and a dislocation of C2 on C3). a. Owing to the large diameter of the spinal canal at this level, a neurologic deficit may not occur. D. Treatment of skeletal and ligamentous injuries is by external stabilization or internal fixation, depending on the stability of the fracture. X. LYMPHATICS A. The thoracic duct is the most commonly injured lymphatic in the neck. B. These injuries may be identified during neck exploration but are usually discovered late in the hospital course. 1. Unexplained fever, abscess formation, or abnormal fluid collections should raise the suspicion of a thoracic duct injury. 2. Drainage of milky white fluid from suction drains placed at the time of surgery or aspiration of this material is often the first sign of a lymph fistula, lymphocele, or even a chylothorax. C. Conservative management is usually adequate as these collections resolve spontaneously. D. However, if prolonged drainage continues, thoracic duct ligation is preferable to attempts at primary repair. E. Wide drainage usually results in resolution of these complications. F. Delayed ligation can be performed if conservative management fails. XI. PEARLS AND PITFALLS A. Defer insertion of nasogastric tube in patients with suspected vascular neck injuries. B. Do not remove impaled foreign bodies in the emergency department, as their removal may precipitate uncontrollable hemorrhage. C. Use liberal indications for four-vessel angiography in patients with blunt neck injury to identify stretch or intimal flaps. XII. SUGGESTED READINGS Britt LD: Neck injuries: Evaluation and management. In Moore EE, Mattox KL, Feliciano DV (eds): Trauma. New York, Mc-Graw Hill, pp 445-457. Leopold DA: Laryngeal trauma. Arch Otolaryngol 109:106, 1983. Weigelt JA, Thal ER, Synder WH III, et al: Diagnosis of penetrating cervical esophageal injuries. Am J Surg 154:619, 1987.