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Penetrating injuries to the neck
Penetrating Injuries to the Neck Pitfalls in Management
W. D. Mclnnis, MD, San Antonio, Texas A. B. Cruz, MD, San Antonio, Texas J. B. Aust, MD, San Antonio, Texas
For the past twenty years the standard of excellence for management of penetrating injuries to the neck has been based on the premise that all wounds penetrating the platysma should be explored. No attempt to define the severity of the injury is indicated [1,2]. The practice of early operative intervention in penetrating neck wounds has evolved from the high mortality (20 per cent) with these injuries during the World Wars. The fact that neck wounds that appear benign may harbor significant injuries has been the basis for exploring penetrating injuries to the neck at The University of Texas Health Science Center at San Antonio. The purpose of this paper is to review our experience with penetrating neck injuries to justify the exploration of all clinically benign neck wounds, to evaluate our methods of handling the various injuries, and to present our mortality statistics [3]. Material and Methods A total of one hundred patients with neck injuries penetrating the platysma admitted to The University of Texas Teaching Hospitals in San Antonio from January 1970 through December 1974 were reviewed. (Table I.) There were fifty gunshot wounds, forty stab wounds, and ten accidental injuries. Ninety of the patients in this study were male and ten female, with an average age of 30.5 years.
Epidemiology The events related to the various injuries are summarized in Table II. From records we were able to determine the various factors involved in seventy-eight of the one hundred injuries. The From the Department of Surgery, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive. San Antonio, Texas. Reprint requests should be addressed to W. D. Mclnnis. MD, Department of Surgery, University of Texas Health Science Center, 7703 Floyd Curl Drive, San Antonio. Texas 79204. Presented at the Combined Meeting of the James Ewing Society and the Society of Head and Neck Surgeons, New Orleans, Louisiina, March 25-29.1975.
416
“true” accidents include two people being hit with foreign bodies ejected from lawn mowers, one from a foreign body ejected from a fireplace explosion, and one when children were playing with an “unloaded” gun. Management Management of these patients included: complete physical examination, noting associated injuries and bleeding, hematomas, or subcutaneous emphysema in the neck; x-ray films of the chest (essential) and of the soft tissue of the neck (optional); immediate exploration in eighty-six patients, including all patients with positive physical examination and most patients with negative physical examination; and further evaluation in fourteen patients with negative physical examination, consisting of barium swallow, arteriography, and endoscopy. Physical examination determines the site of injury, whether or not the platysma is penetrated, the presence or absence of an exit wound, whether or not there is a hematoma in the neck, and whether or not there is evidence of subcutaneous air not adjacent to the injury site. The absence of continued bleeding, a hematoma, or subcutaneous air, with the site of injury being the only pertinent physical finding, was considered a negative physical examination. The presence of either continued bleeding, a hematoma, or subcutaneous air was considered a positive physical examination. Of the one hundred patients with penetrating injuries to the neck, eighty-six underwent immediate neck exploration. All but two patients with positive physical examination and penetrating injuries to the neck were explored immediately. One patient with a gunshot wound to the anterior neck had through and through injury to the larynx, above the arytenoids, with immediate hoarseness. Treatment consisted of endoscopy and tracheostomy. The other patient with a positive physical examination who was not explored is an “interest”
TheAmerican
Journal of Surgery
Penetrating Neck injuries
TABLE I
Summary of One Hundred Patients with Penetrating Injuries to the Neck
TABLE II
Epidemiology
Type of Occurrence
Number Wound Gunshot wounds Low velocity (.22, .25, and .32 caliber) High velocity (.38 caliber) Shotgun Total Stab wounds Knives or razors Broken bottles Total Accidental Traffic accidents Power mower ejections Fire explosion Foreign body without obvious entrance Total
of Patients
38 10 2 50
Alcohol related Heroin addicts “True” accidents Traffic accidents Suicide attempts Domestic altercation Robbery victims
Number 47 11 4 6 4 3 3
35 5 40
6 2 1 1 10
case. The child presented with a neck mass initial-
ly diagnosed as “mumps.” The mass increased in size over one week and cervical x-ray films were obtained. The foreign body apparently was swallowed and had penetrated the cervical esophagus. This was treated with incision and drainage of the abscess. It is included because of the confusion in diagnosis it caused. (Figure 1.) For various reasons fourteen patients were not explored. Six patients refused neck exploration and four patients had negative physical examination hours after injury. Planned neck exploration was delayed in two patients because of more urgent cases. Two patients were not explored for previously cited reasons. All patients not explored were further studied by either Gastrografine swallow, arteriography, indirect laryngoscopy, or endoscopy with topical anesthesia. All were followed closely, with meticulous examinations to support nonoperative treatment. None of these fourteen patients had early or late sequelae. The majority of the patients were explored under general endotracheal anesthesia. The risks of probing puncture wounds or of inadequate exploration with local anesthesia have been amply elucidated in the literature [1,2,4]. When clinically indicated, local infiltration anesthesia may be used. Clinical indications include cooperative patients with clinically negative slash wounds in whom exposure is adequate due to the injury. One patient was explored using local anesthesia because the injuring knife traversed the neck and the
volume 130. October 1975
Figure 7. The arrow indicates the toreign body In thts child’s neck. lWs chikl had a delayed diagnosis because soft tissue x-ray films were not obtained inttially.
patient could not be safely intubated. (Figures 2 and 3.) The patients were explored through either vertical or transverse incisions, The vertical incision was made along the medial border of the sternocleidomastoid. The transverse incision was an extended low collar incision. All patients were draped in the operating room so that the original incision could be extended if additional exposure was necessary. Fifty-five transverse incisions and thirty-one vertical incisions were made. In three patients the initial incision was extended to a median sternotomy for vascular control. Table III shows the significant structures injured in this series. The technics for repairing the various injuries were the standard procedures uniformly practiced in most medical centers [1,2,4-71. Arterial injuries generally were repaired by primary anastomosis. The two patients with internal carotid injuries underwent repair without shunts. In one of these patients, death resulted from bleeding into a brain infarct. Smaller branches of the external carotid were ligated as encountered. The external jugular and internal jugular veins were routinely ligated when transected. Small
417
Mclnnis, Cruz, and Aust
Cervical spine injuries were treated according to progression of the neurologic deficit. Patients rendered immediately flaccid were not decompressed. Patients with a progression of the neurologic symptoms underwent decompression laminectomy. Morbidity and Mortality
Figure 2. The patient presented in the emergency room wifh the butcher knife completely traversing the neck. Because of the clinical proximify of the knife to fhe great vessels, if was elected to explore this cooperative patient using local infiltration anesthesia prior to removing the injuring weapon.
puncture wounds of the internal jugular vein were repaired. Massive injuries to the pharynx, hypopharynx, and larynx with a blast effect are usually associated with upper airway obstruction within twentyfour hours due to edema. When these injuries were encountered, the patients were intubated initially or underwent tracheostomy when other injuries were also present. Injuries to the larynx and supporting structures were treated by primary repair, stinting, and tracheostomy. Esophageal injuries were treated by primary anastomosis and drainage. The thoracic duct injury was treated by ligation. The thyroid injuries were treated with electrocoagulation for bleeding. The submandibular gland was either electrocoagulated or removed, depending on the extent of injury. The parotid gland was not removed in any instance. The parotid duct was repaired and stinted. Facial nerve injuries were repaired when branches were identifiable. Mandibular fractures were treated by open reduction and internal fixation.
416
In this series four complications occurred after neck exploration. There were two wound infections, one in a patient after negative neck exploration. One patient had disruption of a median sternotomy after exploration for suspected injury to the subclavian artery. One patient had rebleeding in the recovery room after primary repair of a laceration of the external carotid artery. The patient was reexplored and the external carotid artery was ligated. Of the two deaths in this series, the first occurred in a twenty-eight year old male who sustained a .38 caliber gunshot wound to the neck. The neck was explored; however, an esophageal perforation was overlooked. Mediastinitis developed and the patient died of sepsis on the tenth day post injury. The second death resulted from a .38 caliber gunshot wound to the neck in a seven year old female who presented with hemiparesis. Injuries to the neck included a fracture of the mandible, injury to the hypopharynx, and a through and through injury to the internal carotid artery. The artery was repaired without a shunt. The patient bled postoperatively into a cerebral infarct and died on the fourth postoperative day. Autopsy findings indicated that the patient had sustained the infarct prior to the arterial repair, which accounted for the hemiparesis. Comments Prompt surgical exploration of all penetrating injuries to the neck should continue to be the optimal treatment. The difficulties inherent in the clinical evaluation of such an injury are well known [1,4,5]. The late complications due to overlooked injuries have been adequately elucidated. A recent report [&?I intimates that penetrating injuries to the neck need not be explored. We do not agree with this approach. The mortality associated with a negative neck exploration is due to the inherent risk of anesthesia alone. We had no untoward complications from true negative exploration of the neck. Hospitalization averaged three days for patients after negative neck exploration.
The American Journal of Surgery
Penetrating
Neck Injuries
Flgun,3. x-ray ittmsof the patient shown 1tn F&we 2.
This review supports the concept that therapy for penetrating injuries to the neck should be individualized. In specific cases, we were able to justify selective exploration with no increased morbidity or mortality. Patients who refuse exploration, patients presenting many hours after injury, or patients presenting in a triage area with negative physical examination may safely be managed nonoperatively. This should not be considered “conservative” management. In actuality, the justification for nonexploration requires more time, effort, and investigation by the surgeon than does the routine of exploring all penetrating injuries. These patients must be examined at least every two hours for any signs or symptoms of injury not previously determined. Further support for nonoperative management consists of endoscopy, Gastrografin swallow, and arteriography. Pitfalls to avoid are evident. Neck exploration must be thorough. Examining only the vessels is inadequate. One of the two deaths in this series resulted from an overlooked esophageal perforation in a neck that was explored. The initial examination of these patients must be complete and include tests of cranial nerve function. In this series forty-seven patients had associated injuries to eighty-one organ systems. The other death was associated with a lack of appreciation of the initial physical findings. This young patient presented more than six hours after a gunshot wound to the neck and was hemiparetic on
Volume 130, October 1975
TABLE
III
Injured
Structures
Structure Vessel injuries Artery Common carotid External carotid Internal carotid Vein internal jugular External jugular Anterior jugular Injuries to nonvascular structures Pharynx and hypopharynx Larynx Thyroid Submandibular gland Esophagus Parotid gland Thoracic duct Nerves Facial nerve Spinal accessory nerve Hypoglossal nerve Superior laryngeal nerve Recurrent laryngeal nerve Brachial plexus Bone Mandibular fractures Maxillary fractures Associated injuries (47 patients) Extremities Chest Abdomen Cervical spine Central nervous system
Number
8 8 2 13 11 1 in the neck 13 9 9 8 4 3 1
9 1 30 22 13 12 4
419
Mclnnis, Cruz, and Aust
The routine use of general endotracheal anesthesia for neck exploration is believed to be safest. Specifid indications for neck exploration under local anesthesia were given.
Summary
Figure 4. 77& diagram Mustrates the standard lnckdons and the available extenstons. The soitd lines are tfw vertlcal and transverse InotWons. The crosshatches indicate how these primary lncfsk~ns may be extended to either a median stemotomy or “trapdoor” Iocision. it Is tmportant to drape a patient intt/aMy so that elther extension may be used. We extended the inttiai tnctsh to a median stemotomy In three patients In this se&s. These extenskms were necessary for vascular control of structures In the base of the neck.
initial examination. At exploration, a complete transection of the internal carotid artery was repaired. Postoperatively, the patient had a progression of the neurologic deficit. At autopsy, the cause of death was shown to be bleeding into a central nervous system infarct. This infarct was believed to be present preoperatively. In this specific patient, ideal therapy might have been ligation of the carotid artery rather than primary repair. Similar injuries have been discussed in the literature
11,491.
The surgeon exploring penetrating injuries to the neck must be prepared for simultaneous exploration outside the neck [IO-121. Our experience indicates that the routine practice of draping the patient, so that the incision can be extended to control bleeding, is important. In three of the eightysix neck explorations, the initial incision was extended to a median sternotomy. Vascular injuries at the thoracic outlet can be readily controlled when such an eventuality is anticipated. (Figure 4.)
420
One hundred patients with penetrating injuries to the neck were evaluated. The safest, most expeditious method of managing a penetrating injury to the neck is still prompt surgical exploration. Patients with positive physical examination have definite indications for surgery. In our series, 93 per cent of these patients had significant injuries. Patients with negative physical examinations are still optimally treated with neck explorations, The mortality of this series was 2 per cent. In specific situations, nonoperative management of penetrating injuries to the neck may be useful. This modality, however, should not be construed as “conservative” management. Specific pitfalls noted include inadequate neck exploration, failure to completely examine the patient, and being unprepared for exploration outside the neck.
References 1. Ashworth C, Williams LF, Byrne JJ: Penetrating wounds of the neck. Am JSurg 121: 387, 1971. 2. Jones RF, Terre6 JC, Salyer KE: Penetrating wounds of the neck: an analysis of 274 cases. J Trauma 7: 228, 1987. 3. Fitchett VH, Promerantz M, Butsch DW, Simon R, Eiseman B: Penetrating wounds of the neck. Arch Surg 99: 307, 1989. 4. Shirkey AL, Beall AC Jr, DeBakey ME: Surgical management of penetrating wounds of the neck. Arch Surg 88: 955, 1983. 5. Stone HH, Callahan GS: Soft tissue injuries of the neck. Surg Gynecol Obstet 117: 745, 1983. 6. Hunt TK, B&dell FW, Dkimoto J: Vascular injuries of the base of the neck. Arch Surg 98: 586.1969. 7. Hohm RA: Penetrating neck injuries. Literature Conferences UT San Antonio VI: 197, 1974. 8. May M, Chadaratan P, West JW, Dgura JH: Penetrating neck wounds: selective exploration. Laryngoscope 85: 57, 1975. 9. Hubay CA: Soft tissue injuries of the cervical region. /nt AbstrSurg 111: 511, 1980. 10. Bricker DL, Noon GP, Beall AC Jr, DeBakey ME: Vascular injuries of the thoracic outlet. J Trauma 10: 1, 1970. 11. lmamoglu K, Read RC. Huebl HC: Cervicomedfastinal vascular injury. Surgsry61: 274. 1967. 12. Steenburg RW, Ravitch MM: Cervico-thoracic approach for subctavian vessel injury from compound fracture of the clavicle. Ann Surg 757: 839, 7963.
The American Journal cl Surgery
W. D. Mclnnis, MD, San Antonio, Texas A. B. Cruz, MD, San Antonio, Texas J. B. Aust, MD, San Antonio, Texas
For the past twenty years the standard of excellence for management of penetrating injuries to the neck has been based on the premise that all wounds penetrating the platysma should be explored. No attempt to define the severity of the injury is indicated [1,2]. The practice of early operative intervention in penetrating neck wounds has evolved from the high mortality (20 per cent) with these injuries during the World Wars. The fact that neck wounds that appear benign may harbor significant injuries has been the basis for exploring penetrating injuries to the neck at The University of Texas Health Science Center at San Antonio. The purpose of this paper is to review our experience with penetrating neck injuries to justify the exploration of all clinically benign neck wounds, to evaluate our methods of handling the various injuries, and to present our mortality statistics [3]. Material and Methods A total of one hundred patients with neck injuries penetrating the platysma admitted to The University of Texas Teaching Hospitals in San Antonio from January 1970 through December 1974 were reviewed. (Table I.) There were fifty gunshot wounds, forty stab wounds, and ten accidental injuries. Ninety of the patients in this study were male and ten female, with an average age of 30.5 years.
Epidemiology The events related to the various injuries are summarized in Table II. From records we were able to determine the various factors involved in seventy-eight of the one hundred injuries. The From the Department of Surgery, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive. San Antonio, Texas. Reprint requests should be addressed to W. D. Mclnnis. MD, Department of Surgery, University of Texas Health Science Center, 7703 Floyd Curl Drive, San Antonio. Texas 79204. Presented at the Combined Meeting of the James Ewing Society and the Society of Head and Neck Surgeons, New Orleans, Louisiina, March 25-29.1975.
416
“true” accidents include two people being hit with foreign bodies ejected from lawn mowers, one from a foreign body ejected from a fireplace explosion, and one when children were playing with an “unloaded” gun. Management Management of these patients included: complete physical examination, noting associated injuries and bleeding, hematomas, or subcutaneous emphysema in the neck; x-ray films of the chest (essential) and of the soft tissue of the neck (optional); immediate exploration in eighty-six patients, including all patients with positive physical examination and most patients with negative physical examination; and further evaluation in fourteen patients with negative physical examination, consisting of barium swallow, arteriography, and endoscopy. Physical examination determines the site of injury, whether or not the platysma is penetrated, the presence or absence of an exit wound, whether or not there is a hematoma in the neck, and whether or not there is evidence of subcutaneous air not adjacent to the injury site. The absence of continued bleeding, a hematoma, or subcutaneous air, with the site of injury being the only pertinent physical finding, was considered a negative physical examination. The presence of either continued bleeding, a hematoma, or subcutaneous air was considered a positive physical examination. Of the one hundred patients with penetrating injuries to the neck, eighty-six underwent immediate neck exploration. All but two patients with positive physical examination and penetrating injuries to the neck were explored immediately. One patient with a gunshot wound to the anterior neck had through and through injury to the larynx, above the arytenoids, with immediate hoarseness. Treatment consisted of endoscopy and tracheostomy. The other patient with a positive physical examination who was not explored is an “interest”
TheAmerican
Journal of Surgery
Penetrating Neck injuries
TABLE I
Summary of One Hundred Patients with Penetrating Injuries to the Neck
TABLE II
Epidemiology
Type of Occurrence
Number Wound Gunshot wounds Low velocity (.22, .25, and .32 caliber) High velocity (.38 caliber) Shotgun Total Stab wounds Knives or razors Broken bottles Total Accidental Traffic accidents Power mower ejections Fire explosion Foreign body without obvious entrance Total
of Patients
38 10 2 50
Alcohol related Heroin addicts “True” accidents Traffic accidents Suicide attempts Domestic altercation Robbery victims
Number 47 11 4 6 4 3 3
35 5 40
6 2 1 1 10
case. The child presented with a neck mass initial-
ly diagnosed as “mumps.” The mass increased in size over one week and cervical x-ray films were obtained. The foreign body apparently was swallowed and had penetrated the cervical esophagus. This was treated with incision and drainage of the abscess. It is included because of the confusion in diagnosis it caused. (Figure 1.) For various reasons fourteen patients were not explored. Six patients refused neck exploration and four patients had negative physical examination hours after injury. Planned neck exploration was delayed in two patients because of more urgent cases. Two patients were not explored for previously cited reasons. All patients not explored were further studied by either Gastrografine swallow, arteriography, indirect laryngoscopy, or endoscopy with topical anesthesia. All were followed closely, with meticulous examinations to support nonoperative treatment. None of these fourteen patients had early or late sequelae. The majority of the patients were explored under general endotracheal anesthesia. The risks of probing puncture wounds or of inadequate exploration with local anesthesia have been amply elucidated in the literature [1,2,4]. When clinically indicated, local infiltration anesthesia may be used. Clinical indications include cooperative patients with clinically negative slash wounds in whom exposure is adequate due to the injury. One patient was explored using local anesthesia because the injuring knife traversed the neck and the
volume 130. October 1975
Figure 7. The arrow indicates the toreign body In thts child’s neck. lWs chikl had a delayed diagnosis because soft tissue x-ray films were not obtained inttially.
patient could not be safely intubated. (Figures 2 and 3.) The patients were explored through either vertical or transverse incisions, The vertical incision was made along the medial border of the sternocleidomastoid. The transverse incision was an extended low collar incision. All patients were draped in the operating room so that the original incision could be extended if additional exposure was necessary. Fifty-five transverse incisions and thirty-one vertical incisions were made. In three patients the initial incision was extended to a median sternotomy for vascular control. Table III shows the significant structures injured in this series. The technics for repairing the various injuries were the standard procedures uniformly practiced in most medical centers [1,2,4-71. Arterial injuries generally were repaired by primary anastomosis. The two patients with internal carotid injuries underwent repair without shunts. In one of these patients, death resulted from bleeding into a brain infarct. Smaller branches of the external carotid were ligated as encountered. The external jugular and internal jugular veins were routinely ligated when transected. Small
417
Mclnnis, Cruz, and Aust
Cervical spine injuries were treated according to progression of the neurologic deficit. Patients rendered immediately flaccid were not decompressed. Patients with a progression of the neurologic symptoms underwent decompression laminectomy. Morbidity and Mortality
Figure 2. The patient presented in the emergency room wifh the butcher knife completely traversing the neck. Because of the clinical proximify of the knife to fhe great vessels, if was elected to explore this cooperative patient using local infiltration anesthesia prior to removing the injuring weapon.
puncture wounds of the internal jugular vein were repaired. Massive injuries to the pharynx, hypopharynx, and larynx with a blast effect are usually associated with upper airway obstruction within twentyfour hours due to edema. When these injuries were encountered, the patients were intubated initially or underwent tracheostomy when other injuries were also present. Injuries to the larynx and supporting structures were treated by primary repair, stinting, and tracheostomy. Esophageal injuries were treated by primary anastomosis and drainage. The thoracic duct injury was treated by ligation. The thyroid injuries were treated with electrocoagulation for bleeding. The submandibular gland was either electrocoagulated or removed, depending on the extent of injury. The parotid gland was not removed in any instance. The parotid duct was repaired and stinted. Facial nerve injuries were repaired when branches were identifiable. Mandibular fractures were treated by open reduction and internal fixation.
416
In this series four complications occurred after neck exploration. There were two wound infections, one in a patient after negative neck exploration. One patient had disruption of a median sternotomy after exploration for suspected injury to the subclavian artery. One patient had rebleeding in the recovery room after primary repair of a laceration of the external carotid artery. The patient was reexplored and the external carotid artery was ligated. Of the two deaths in this series, the first occurred in a twenty-eight year old male who sustained a .38 caliber gunshot wound to the neck. The neck was explored; however, an esophageal perforation was overlooked. Mediastinitis developed and the patient died of sepsis on the tenth day post injury. The second death resulted from a .38 caliber gunshot wound to the neck in a seven year old female who presented with hemiparesis. Injuries to the neck included a fracture of the mandible, injury to the hypopharynx, and a through and through injury to the internal carotid artery. The artery was repaired without a shunt. The patient bled postoperatively into a cerebral infarct and died on the fourth postoperative day. Autopsy findings indicated that the patient had sustained the infarct prior to the arterial repair, which accounted for the hemiparesis. Comments Prompt surgical exploration of all penetrating injuries to the neck should continue to be the optimal treatment. The difficulties inherent in the clinical evaluation of such an injury are well known [1,4,5]. The late complications due to overlooked injuries have been adequately elucidated. A recent report [&?I intimates that penetrating injuries to the neck need not be explored. We do not agree with this approach. The mortality associated with a negative neck exploration is due to the inherent risk of anesthesia alone. We had no untoward complications from true negative exploration of the neck. Hospitalization averaged three days for patients after negative neck exploration.
The American Journal of Surgery
Penetrating
Neck Injuries
Flgun,3. x-ray ittmsof the patient shown 1tn F&we 2.
This review supports the concept that therapy for penetrating injuries to the neck should be individualized. In specific cases, we were able to justify selective exploration with no increased morbidity or mortality. Patients who refuse exploration, patients presenting many hours after injury, or patients presenting in a triage area with negative physical examination may safely be managed nonoperatively. This should not be considered “conservative” management. In actuality, the justification for nonexploration requires more time, effort, and investigation by the surgeon than does the routine of exploring all penetrating injuries. These patients must be examined at least every two hours for any signs or symptoms of injury not previously determined. Further support for nonoperative management consists of endoscopy, Gastrografin swallow, and arteriography. Pitfalls to avoid are evident. Neck exploration must be thorough. Examining only the vessels is inadequate. One of the two deaths in this series resulted from an overlooked esophageal perforation in a neck that was explored. The initial examination of these patients must be complete and include tests of cranial nerve function. In this series forty-seven patients had associated injuries to eighty-one organ systems. The other death was associated with a lack of appreciation of the initial physical findings. This young patient presented more than six hours after a gunshot wound to the neck and was hemiparetic on
Volume 130, October 1975
TABLE
III
Injured
Structures
Structure Vessel injuries Artery Common carotid External carotid Internal carotid Vein internal jugular External jugular Anterior jugular Injuries to nonvascular structures Pharynx and hypopharynx Larynx Thyroid Submandibular gland Esophagus Parotid gland Thoracic duct Nerves Facial nerve Spinal accessory nerve Hypoglossal nerve Superior laryngeal nerve Recurrent laryngeal nerve Brachial plexus Bone Mandibular fractures Maxillary fractures Associated injuries (47 patients) Extremities Chest Abdomen Cervical spine Central nervous system
Number
8 8 2 13 11 1 in the neck 13 9 9 8 4 3 1
9 1 30 22 13 12 4
419
Mclnnis, Cruz, and Aust
The routine use of general endotracheal anesthesia for neck exploration is believed to be safest. Specifid indications for neck exploration under local anesthesia were given.
Summary
Figure 4. 77& diagram Mustrates the standard lnckdons and the available extenstons. The soitd lines are tfw vertlcal and transverse InotWons. The crosshatches indicate how these primary lncfsk~ns may be extended to either a median stemotomy or “trapdoor” Iocision. it Is tmportant to drape a patient intt/aMy so that elther extension may be used. We extended the inttiai tnctsh to a median stemotomy In three patients In this se&s. These extenskms were necessary for vascular control of structures In the base of the neck.
initial examination. At exploration, a complete transection of the internal carotid artery was repaired. Postoperatively, the patient had a progression of the neurologic deficit. At autopsy, the cause of death was shown to be bleeding into a central nervous system infarct. This infarct was believed to be present preoperatively. In this specific patient, ideal therapy might have been ligation of the carotid artery rather than primary repair. Similar injuries have been discussed in the literature
11,491.
The surgeon exploring penetrating injuries to the neck must be prepared for simultaneous exploration outside the neck [IO-121. Our experience indicates that the routine practice of draping the patient, so that the incision can be extended to control bleeding, is important. In three of the eightysix neck explorations, the initial incision was extended to a median sternotomy. Vascular injuries at the thoracic outlet can be readily controlled when such an eventuality is anticipated. (Figure 4.)
420
One hundred patients with penetrating injuries to the neck were evaluated. The safest, most expeditious method of managing a penetrating injury to the neck is still prompt surgical exploration. Patients with positive physical examination have definite indications for surgery. In our series, 93 per cent of these patients had significant injuries. Patients with negative physical examinations are still optimally treated with neck explorations, The mortality of this series was 2 per cent. In specific situations, nonoperative management of penetrating injuries to the neck may be useful. This modality, however, should not be construed as “conservative” management. Specific pitfalls noted include inadequate neck exploration, failure to completely examine the patient, and being unprepared for exploration outside the neck.
References 1. Ashworth C, Williams LF, Byrne JJ: Penetrating wounds of the neck. Am JSurg 121: 387, 1971. 2. Jones RF, Terre6 JC, Salyer KE: Penetrating wounds of the neck: an analysis of 274 cases. J Trauma 7: 228, 1987. 3. Fitchett VH, Promerantz M, Butsch DW, Simon R, Eiseman B: Penetrating wounds of the neck. Arch Surg 99: 307, 1989. 4. Shirkey AL, Beall AC Jr, DeBakey ME: Surgical management of penetrating wounds of the neck. Arch Surg 88: 955, 1983. 5. Stone HH, Callahan GS: Soft tissue injuries of the neck. Surg Gynecol Obstet 117: 745, 1983. 6. Hunt TK, B&dell FW, Dkimoto J: Vascular injuries of the base of the neck. Arch Surg 98: 586.1969. 7. Hohm RA: Penetrating neck injuries. Literature Conferences UT San Antonio VI: 197, 1974. 8. May M, Chadaratan P, West JW, Dgura JH: Penetrating neck wounds: selective exploration. Laryngoscope 85: 57, 1975. 9. Hubay CA: Soft tissue injuries of the cervical region. /nt AbstrSurg 111: 511, 1980. 10. Bricker DL, Noon GP, Beall AC Jr, DeBakey ME: Vascular injuries of the thoracic outlet. J Trauma 10: 1, 1970. 11. lmamoglu K, Read RC. Huebl HC: Cervicomedfastinal vascular injury. Surgsry61: 274. 1967. 12. Steenburg RW, Ravitch MM: Cervico-thoracic approach for subctavian vessel injury from compound fracture of the clavicle. Ann Surg 757: 839, 7963.
The American Journal cl Surgery