Penetrating neck trauma is an important area of trauma care that is continually evolving. A remarkable number of changes have occurred in the treatment paradigm as new technologies have developed and as surgeons have explored the outcomes from different treatment protocols. Therapy has evolved from no treatment (before effective anesthesia and instrumentation), to nonoperative management, to routine exploration, to selective exploration and adjunctive invasive or noninvasive assessment.
Penetrating neck injuries remain challenging, as there are a number of important structures in a small area and injury to any of these structures may not be readily apparent. See the image below.
View Image
A Zone II penetrating neck injury in a young boy. This child fortunately had no other documented injuries.
Signs and symptoms
Evidence of significant injury to vital structures of the neck may be indicated by the following clinical manifestations:
Hypotension – Nonspecific; may be related to the neck injury or may indicate trauma elsewhere
See Presentation for more detail.
Diagnosis
Laboratory studies
The following laboratory studies may be useful:
Hemoglobin concentration
A blood specimen for typing
A toxicologic screen
Coagulation studies
Imaging studies
In penetrating neck injuries, computed tomography (CT) angiography of the neck is the preferred imaging procedure to evaluate the extent of injury. Catheter-based arteriography is useful for further evaluation and an x-ray barium swallow single contrast may be considered in conjunction with direct visualization techniques if there remains a concern for aerodigestive injury.
See Workup for more detail.
Management
The standard of care is immediate surgical exploration for patients who present with signs and symptoms of shock and continuous hemorrhage from the neck wound. The type of incision depends on the neck zone and the structures at risk for injury.
For centuries, carotid ligation was the only reliable treatment of severe penetrating neck injury. In 1552, Ambrose Pare ligated both common carotid arteries and the jugular vein of a soldier with a traumatic neck injury. The patient survived but developed aphasia and hemiplegia. In 1803, Fleming ligated a lacerated common carotid artery and reported a successful outcome with a 5-month follow-up. The noted author George Orwell suffered a penetrating neck injury causing a unilateral vocal fold paresis in 1936 as a result of his involvement in Spain's Civil War.
Nonoperative management of penetrating neck wounds was the standard until World War I.
During World War II, a more aggressive approach to neck exploration was adopted. The types of injuries seen on the battlefields of World War II and the then available diagnostic armamentarium are significantly different from those in the modern civilian trauma center. The changes associated with improved imaging modalities and nonmilitary injuries have resulted in a dramatic change in the treatment paradigm for penetrating neck injury. Continual advances in anesthesia and perioperative management since World War II have improved the care and the outcome of these patients.
Penetrating neck trauma involves a missile or sharp object penetrating the skin and violating the platysma layer of the neck. This includes gunshot wounds, stab or puncture wounds, and impalement injuries.[1, 2, 3]
Although penetrating injury to the neck represents a relatively small portion of all trauma cases (5-10%), it produces injuries with a high degree of mortality as well as complex clinical situations that can be challenging for providers.[4]
Two factors in the mechanism of injury or kinematics in penetrating neck trauma determine the extent of damage to the tissue: (1) weapon characteristics and (2) the location of injury and human tissues involved.
Weapon characteristics
The amount of kinetic energy delivered by the wounding agent has to be considered together with its interaction with the involved tissue. Kinetic energy (KE) is described by the following equation: KE = 1/2 mass × velocity (squared).
Low-energy weapons include hand-driven weapons, such as knives or ice picks, which damage with only their sharp point or cutting edge. Firearms may be classified as medium-energy (ie, handguns) and high-energy weapons (ie, military assault weapons), with the latter usually defined as having 461 joules or more.
Projectiles (ie, bullets, missiles) often are differentiated by mass, velocity, shape, and construction because these characteristics affect the extent of tissue disruption. Bullet velocity is the most important characteristic considered, with high velocity defined as greater than 2500 ft/s.
Location of injury and human tissues involved
Tissue injury results from either a direct impact by the penetrating projectile or tissue displacement from temporary cavitation.
Wound sites and, if present, the wounding agent in the neck provide an indication of the likely injury complex.
Penetrating neck injuries, like any trauma, may be classified as intentional or nonintentional. The objects causing these injuries can be divided into stabbing instruments (eg, knives, cutting instruments, puncturing objects, impaling objects) and shooting instruments (eg, missiles, projectiles). Wounding instruments have specific characteristics that affect surgical findings. For example, stab wounds typically have a 10% higher rate of negative exploration than injuries from projectiles. Conversely, the higher energy and ballistic force associated with a gunshot wound to the neck should cause clinical suspicion and thorough investigation to determine if injury is present.
The current mortality rate in civilians with penetrating neck injuries ranges from 3-6%. During World War II, the mortality rate was 7%, and, in World War I, it was 11%. Higher mortality rates occur with injuries to large vessels, such as the carotid or subclavian arteries and veins.
More recent experience in the treatment of casualties from the Iraq War at Walter Reed Army Medical Center reported the common carotid artery as the most frequently injured cervical vessel.[5]
A study by Patel et al found that the number of patients with penetrating neck injuries who presented to UK emergency departments doubled between 2016 and 2021. These injuries represented 11% of all penetrating trauma in 2021, and 87% of the patients were male. Although violent crime was the most common cause of penetrating neck injuries, the number of these injuries related to self-harm tripled from 2018 to 2021.[6]
In few other regions of the body are so many vital structures (that would be of immediate concern following injury) located in so small a volume. An injury is not considered to have penetrated the neck unless the injury penetrates the platysma muscle layer. Injuries through the platysma and injuries crossing the midline usually cause a greater degree of damage. The sternocleidomastoid muscle delineates the posterior and anterior regions of the neck. The area of the neck posterior to the cervical vertebral body and the scalene muscles is composed mainly of muscle, bone, and nonvital vessels and lymphatics. Most of the vital structures are located in the anterior or lateral regions.
The neck may be divided into 3 zones using anatomic landmarks. Each zone has a group of vital structures that can be injured and may determine the kind of trauma management.
Zone I is the horizontal area between the clavicle/suprasternal notch and the cricoid cartilage encompassing the thoracic outlet structures. The proximal common carotid, vertebral, and subclavian arteries and the trachea, esophagus, thoracic duct, and thymus are located in zone I. This area is considered to be fairly well protected by the bony thorax but is vulnerable to penetrating injuries through the upper thoracic aperture.
Zone II is the area between the cricoid cartilage and the angle of the mandible. It contains the internal and external carotid arteries, jugular veins, pharynx, larynx, esophagus, recurrent laryngeal nerve, spinal cord, trachea, thyroid, and parathyroids. This area is at particular risk for injuring in penetrating trauma, as it contains many vital structures without significant overlying protective tissue.
Zone III is the area that lies between the angle of the mandible and the base of the skull. It has the distal extracranial carotid and vertebral arteries and the uppermost segments of the jugular veins.
Tight fascial compartments of neck structures may limit external hemorrhage from vascular injuries, minimizing the chance of exsanguination. However, these tight fascial boundaries may increase the risk of airway compromise because the airway is relatively mobile and compressible by an expanding hematoma.
The standard of care is immediate surgical exploration for patients who present with signs and symptoms of shock and continuous hemorrhage from the neck wound. The type of incision depends on the neck zone and the structures at risk for injury.
The following specific injuries must be confirmed and treated during neck exploration:
No role exists for probing or local exploration of the neck in the trauma bay or emergency department because this may dislodge a clot and initiate uncontrollable hemorrhage. If no significant injuries requiring urgent intervention are present, the patient may proceed to diagnostic workup as indicated.
Vascular trauma is present in 25% of penetrating neck injuries, with mortality rates approaching 50% in some studies. Tracheobronchial injuries may have an incidence of less than 10% to as high as 20% and a mortality rate of as high as 20%. The injured cervical esophagus can result in devastating complications and eventual outcomes, such as leakage of saliva, bacteria, refluxed acid, pepsin, and even bile. Undiagnosed, this can produce early suppurative infection and an intense necrotizing inflammatory response in the neck, as well as a more devastating outcome if it descends to the mediastinum. An 11-17% increase in the overall mortality rate has been observed after delays of 12 hours in the diagnosis of esophageal injuries.
Two reports demonstrate the importance of the setting in which penetrating neck injuries occur, particularly treatment protocols in combat zones. Sarkar et al presented 2 cases from Western Baghdad,[7] and Ramasamy et al performed a retrospective medical record review of British military casualties from Iraq and Afghanistan who sustained penetrating neck injuries to determine the need for prehospital cervical immobilization, given current ATLS protocols requiring spinal precautions when a significant mechanism of injury may damage the cervical spine.[8]
In the study by Ramasamy et al, of 90 patients with a penetrating neck injury, 66 (73%) were from explosions and 24 (27%) were from gunshot wounds. In 20 (22%) patients, cervical spine injuries were present; only 6 (7%) survived to reach the hospital, and 4 of these 6 died within 72 hours of their injuries.[8] Of 56 survivors that reached a surgical facility, only 1 (1.8%) had an unstable cervical spine injury requiring surgical stabilization, and this patient subsequently died due to a concomitant head injury.
The investigators determined a high mortality rate is associated with penetrating ballistic trauma to the neck.[8] Furthermore, it appears unlikely that survivors of penetrating ballistic trauma to the neck will have unstable cervical spines; therefore, not only is the risk/benefit ratio of mandatory spinal immobilization unfavorable, but cervical collars may also hide potential life-threatening conditions, in addition to putting medical teams at prolonged personal risk.[8]
In a retrospective study by Forner et, which included a cohort of 20,285 patients, mortality was higher in those who had penetrating neck trauma (6.0%) than in those who sustained blunt neck injuries (4.9%).[9]
Complications
Missed injuries or delayed diagnosis can occur after any injury to the neck, particularly in patients presenting with minimal manifestations.
Persistent hemorrhage - Usually from a missed arterial or venous injury, particularly in zone I and zone III
Pseudoaneurysms - A later sequela from a missed vascular injury, which often is not bleeding actively during treatment
Arterial dissection - Incomplete transmural vessel injury may cause this disruption between the layers of the arterial wall.
Infections - Most often occur from missed esophageal or laryngotracheal injuries; severe inflammation, abscess formation, or mediastinitis may result.
Stenosis or obstruction of luminal structures - May happen due to the inflammatory response and scarring around the injured esophagus, larynx, trachea, or vessels
Neurologic deficits - May occur due to the direct injury to a peripheral nerve or to ischemic infarct caused by arterial injury
Anastomotic or repair disruption - About 1% of surgical repairs leak and result in hemorrhage, infection, or fistula formation.
Luminal stenosis or obstruction - The surgical repair and the inflammation can cause the narrowing of the lumen of the injured esophagus, larynx, trachea, or vessels.
Infectious complications - Occurring particularly with injuries to the trachea and esophagus, severe inflammatory response in the neck, abscess formation, fistulas, or mediastinitis may result.
Neurologic complications - Can occur as strokes related to major vascular injuries or directly to peripheral nerves
Thrombosis of an internal jugular vein - Can occur regardless of the method of venorrhaphy
Massive air emboli - May result from major venous injuries and is an important cause of bilateral, diffuse stroke identified as hypodense lesions on CT scan of the brain
Hypotension – Nonspecific; may be related to the neck injury or may indicate trauma elsewhere
Proposed hard signs of airway injury include the following:
Subcutaneous emphysema – Tracheal, esophageal, or pulmonary injury
Air bubbling through the wound
Stridor or respiratory distress – Laryngeal and/or esophageal injury
Several so-called hard signs that strongly indicate vascular injury are as follows:
Hematoma (expanding) – Vascular injury
Active external hemorrhage from the wound site – Arterial vascular injury
Bruit/thrill – Arteriovenous fistula
Pulselessness/pulse deficit
Distal ischemia (neurologic deficit in this case)
The evaluation of a patient with penetrating neck trauma always should start with advanced trauma life support (ATLS), a paradigm that begins with a directed primary survey emphasizing airway, breathing, and circulation (ABC). After patients are stabilized, they undergo a secondary survey that includes a complete history and a thorough physical examination. These steps, together with the studies discussed in Workup, are used to identify the likely injury complex and to direct further treatment or diagnostic testing.
There is evidence to suggest that the hard signs of airway injury are more reliable and result in less negative operative explorations compared with hard signs of vascular injury. The rate of negative exploration for patients with hard signs of vascular injury varies widely, but it may be estimated at 10%. However, series that report these cases as "nonsignificant" injury or as negative explorations lack clear definition, and it is difficult to draw any useful conclusion from the data.
As an anatomic region, the neck contains multiple vital structures in a relatively unprotected environment. As such, diagnostic workup should include a focused and rapid physical examination, proceeding to radiographic investigation or surgical intervention in thoughtful but efficient manner.
Hemoglobin concentration is useful to evaluate for the immediate need for transfusion and to document the starting point for future comparison.
A blood specimen for typing is useful should transfusion be required. As patients who have had prior transfusions become alloimmunized, early recognition of antibody formation is essential to provide compatible blood products.
A toxicologic screen is indicated for the patient with an altered sensorium. This is important to help differentiate the altered sensorium of intoxication from a neurologic etiology following penetrating neck trauma with an arterial injury component.
Coagulation studies may be of use when anticoagulant use is suspected or in the setting of hemorrhage and massive transfusion.
Hypotension and exsanguination should prompt immediate operative exploration in most centers, as should hard signs of injury on physical examination. These include but are not limited to the following: expanding or pulsatile hematoma, respiratory distress, air bubbling through a neck wound, hoarseness or stridor, or extensive subcutaneous emphysema. As this group of patients is at significant risk for rapid decompensation, diagnostic studies should be pursued only after resuscitation as indicated, establishment of a secure airway, and a focused physical assessment.
Two-dimensional Doppler studies are a noninvasive alternative to angiography to evaluate vascular injury in critical areas (principally in zone II). Its role in zone III evaluation is quite limited, given the obvious anatomic limitations of ultrasound in this region. This study typically incorporates a static B mode image of the interrogated vessel in combination with real-time ultrasound and Doppler velocity determination coupled with spectral analysis. This is covered in the umbrella term Duplex. Three-dimensional images for reformation are increasingly available but require costly imaging systems that may not be readily available in the emergency department. Such tests may be best used in stable patients with zone II injuries without any signs of vascular injury to complete the examination of the regional vital structures.
Esophagography is essential to evaluate for an esophageal perforation. Selecting the oral contrast medium for esophageal injury detection is controversial. One school of thought contends that oral iodinated aqueous contrast media better demonstrates perforations and anastomotic leakage with less risk of complications than barium; the sensitivity of this technique in detecting esophageal injury increases from 70-89% when combined with esophagoscopy. The other school of thought contends that aqueous contrast media is hypertonic and, if extravasated into the mediastinum, induces a local inflammatory reaction. Barium solution is inert in the mediastinum and has been used for decades within the tracheobronchial tree for contrast bronchography prior to the advent of flexible bronchoscopy.
CT angiography (CTA) is a widely accepted adjunctive screening tool. A review by Woo et al reports that the use of CTA is associated with less operative exploration, less negative explorations, and reduced use of invasive studies, such as conventional angiography.[5] Physical examination findings supplemented by CTA should have a prominent role in the selective management of penetrating neck injuries. Particularly in regards to vascular injury, CTA demonstrates exceptional sensitivity and specificity.[10]
In patients with penetrating neck trauma, CTA alone may not be sufficient to rule out esophageal injuries. Because a delay in diagnosis can increase morbidity, further diagnostic workup is warranted if there is concern about esophageal injury.[11]
Renewed interest as to the optimal management of wartime penetrating neck injuries has been addressed by Fox et al in the delayed assessment of war casualties at Walter Reed Army Medical Center.[12] A significant number of delayed evaluations found injuries, and retained missile fragments, were a limitation to accurate assessment at the zone of injury with CT examination. They assert that, for the military injury, arteriography remains the criterion standard.
American College of Radiology (ACR) Appropriateness Criteria recommend that in penetrating neck injuries, CT angiography of the neck is the preferred imaging procedure to evaluate the extent of injury. The guidelines also note that catheter-based arteriography is useful for further evaluation and an x-ray barium swallow single contrast may be considered in conjunction with direct visualization techniques if there remains a concern for aerodigestive injury.[13]
In certain settings, CT angiography may be used even in patients with "hard signs" of injury who otherwise exhibit clinical stability in order to aid in operative planning and reduce the incidence of negative neck exploration. This remains an ongoing topic of discussion.[14]
Direct laryngoscopy - For evaluation of oropharyngeal and tracheal injuries
Flexible bronchoscopy - For delineation of tracheal and bronchial injuries
Esophagoscopy - Flexible esophagoscopy can be used to detect an esophageal injury with less risk of procedure-related complications than rigid esophagoscopy (ie, rupture and complications from general anesthesia). Concerns exist regarding the introduction of oropharyngeal flora into the tissue planes of the neck when performing upper endoscopy in the presence of a perforation because visualization of the central lumen is aided by continuous gas insufflation through the endoscope.
Classic management of penetrating neck injuries includes mandatory neck exploration to evaluate for the presence of injury. With the advance of noninvasive imaging modalities, most notably CT angiography, came a paradigm shift in the management of these injuries. Selective exploration of neck injuries with early protocols was based on anatomic zones of injury. Experience with selective exploration notably indicated a high rate of negative exploration, particularly in asymptomatic patients with zone 2 injuries who underwent mandated neck explorations. Additionally, the location of an external wound may not reliably indicate the presence or location of an internal injury.
Thus, some authors have proposed a "no-zone" management approach to penetrating neck trauma, treating the neck as a whole and choosing to explore or image each patient by the presentation and symptoms, not exclusively by the anatomic location of the injury.[4] This systems-based approach has been increasingly used.[15, 16]
A thorough understanding of the anatomy and zones of the neck is important for preoperative planning and surgical management (see "Intraoperative Details" below).
Resuscitative efforts are imperative, with the emphasis on the ABCs.
The airway is cleared of any obstruction and assessed for possible injury.
A depressed sensorium and demonstrated poor oxygenation and ventilation are indications to establish a more optimal airway (ie, through endotracheal intubation) and possibly start mechanical ventilation.
Control of bleeding with direct pressure on the wound site is adequate initially. Large-bore intravenous catheters for fluid resuscitation are inserted. Studies suggest that resuscitation targets with regard to blood pressure be lowered to the range of a mean arterial pressure of 50 mm Hg until definitive hemorrhage control is possible. The concern is that aggressive resuscitation may elevate the blood pressure and increase hemorrhage through an uncontrolled injury site.
Cervical spine precautions are implemented with suspected spinal cord injury, but these injuries are rare.
Expeditious transport to an adequate emergency care facility is warranted.
Medical therapy
To secure a definitive airway, translaryngeal endotracheal intubation should be performed in penetrating neck injuries accompanied by respiratory failure or in cases in which urgent exploration is necessary.
If translaryngeal intubation fails, as occurs in extensive facial or mandibular fractures, a cricothyroidotomy (see the video below) may be required. Expeditious intubation of a tracheotomy produced by the penetrating injury sometimes may be lifesaving.
In the setting of hematoma and bleeding the normal anatomy of the neck can be significantly distorted, hampering attempts at endotracheal intubation or cricothyroidotomy.
Adequate ventilation and oxygenation usually entails invasive mechanical ventilation. Noninvasive ventilation has little role in treating patients with penetrating neck trauma.
A warmed balanced sodium chloride solution (ie, Ringer lactate) is the initial resuscitation fluid of choice. Colloid resuscitation strategies may include starch products or component products for transfusion of red blood cells or clotting factors as appropriate.[17]
Evaluate and monitor the neurologic status of the patient with consideration for spinal cord injury, as well as vascular trauma with cerebral circulatory compromise.
After the primary survey and resuscitation and stabilization of the patient (if possible without an operation), attention is directed to the identification of specific injuries to determine whether surgical treatment is indicated. If no significant injuries requiring surgery are present, observation or expectant management may proceed.
The standard of care is immediate surgical exploration for patients who present with signs and symptoms of shock and continuous hemorrhage from the neck wound. Surgical management varies in difficulty depending on the area of neck injury. Surgical exposure of the injury is particularly difficult in zone I and zone III. Vascular control may be problematic in zone I (proximal control) and zone III (distal control). This consequently leads to the higher mortality rates in patients with vascular injuries in these neck zones.
Continue resuscitative efforts and establish a complete list of possible injuries, by diagnostic tests if necessary. Other sites of injury include the adjacent thorax and head or other distant body parts in multiple injuries. Preparation for surgery also includes tetanus prophylaxis, antibiotic prophylaxis (gram-positive coverage), and a specimen for blood typing should component therapy be required.
A stabilizing measure that has been reported to be useful involves the placement of a Foley catheter through the injury tract and the balloon inflated to tamponade bleeding. Several series have reported the use of this stabilizing measure, followed by angiography and other ancillary testing to guide the use of operative management. Navsaria reported the use of this strategy in South Africa with a high rate of successful nonoperative management with negative angiography and adjunctive tests.[18]
Similar damage-control principles have been described for the critical vascular neck wound. Rezende-Neto et al performed a limited neck exploration without definitive repair of a ligated internal jugular vein and closed a wound over two Foley balloons and rapidly moved the patient to the intensive care unit for resuscitation.[19] After 36 hours, the patient was returned to the operating room for successful, definitive treatment.
A study compared outcomes with Foley catheter tamponade with those obtained with traditional use of external pressure. The study concluded that for penetrating neck and maxillofacial injuries in a combat environment, Foley catheter balloon tamponade significantly reduced mortality when compared with direct pressure techniques through its effect on preventing delayed bleeding.[20]
The type of incision depends on the neck zone and the structures at risk for injury. An additional consideration is proper exposure to gain adequate proximal and distal control of the involved blood vessels. The standard neck incision, parallel to the medial border of the sternocleidomastoid muscle, can be used for most zone II injuries and can be extended cephalad for zone III injuries, specifically for injuries to the distal carotid or vertebral arteries. Extension of the standard neck incision, transversely to the opposite side, can be performed for bilateral injuries.
A transverse or collar-type incision can be performed for suspected injuries traversing the cervical region, providing exposure to both sides and obviating the need for bilateral neck incisions.
A supraclavicular incision provides good exposure for zone I injuries. Removal of the head of the clavicle with an oscillating saw may provide better exposure. In conjunction, an anterolateral thoracotomy incision also may be used for thoracic inlet injuries.
The trapdoor or open-book thoracotomy includes a median sternotomy with an anterolateral extension and a supraclavicular extension for more exposure of zone I injuries.
The specific injuries described below must be confirmed and treated during neck exploration. Note that multiple structures frequently are injured from penetrating neck injury because of the numerous vital structures that are contained in a small area.
Carotid artery injuries are the most common, with an incidence of approximately 9%. They also pose one of the most immediate life-threatening situations. The objective of surgical care is to arrest hemorrhage yet maintain cerebral blood flow and preserve neurologic function. Arteriorrhaphy, vein patch, or segmental repair with autogenous reversed saphenous vein graft can be performed to repair the injury. Arterial repair is shown to have lower morbidity and mortality rates than ligation. The presence of neurologic deficits, coma, and shock, especially preoperatively, are poor prognostic signs but are not absolute contraindications for carotid artery repair. Carotid ligation is advocated in patients who are comatose with no evidence of antegrade flow in the internal carotid artery. Ligation also can be an option when uncontrollable hemorrhage is present and temporary shunt placement is technically difficult.
Vertebral artery injuries have been diagnosed with increasing frequency with liberal use of arteriography, particularly 4-vessel angiography. The treatment of choice in the well-perfused patient is expectant management. Definitive intervention is indicated if a pseudoaneurysm, an arteriovenous fistula, or persistent bleeding is documented. Surgical repair can be performed, but, if the circle of Willis is patent, ligation is always an option. Angiographic embolization has advantages for this difficult-to-access artery, but distal control is still a problem.
Jugular vein injury repair is contingent on the condition of the patient. Repair can be performed by simple lateral closure, resection and reanastomosis, or saphenous vein graft reconstruction, particularly the internal jugular. Repairing at least one side is very important if both internal jugular veins are injured. The external jugular vein can be ligated without any adverse effects.
Laryngotracheal injuries also are common, with a combined incidence of 10% among cases of penetrating neck trauma. Tracheal injuries can be repaired primarily in one layer of sutures. Interposition of adjacent omohyoid or sternocleidomastoid muscles should be performed when esophageal and arterial repair to prevent fistula formation are performed concomitantly. Tracheostomy is indicated when injury is severe, but performing it through the site of surgical repair should be avoided. A soft intralaryngeal stent in extensive disruption of the cartilaginous support of the larynx is recommended.
Esophageal injuries are the third most common in penetrating neck trauma (6%). Signs and symptoms of dysphagia, hematemesis, subcutaneous crepitus, retropharyngeal air, and injuries to adjacent structures are strong indicators of esophageal injury. Early diagnosis lessens the probability of delayed treatment and missed injury, which can be devastating (ie, mediastinitis). The recommended management of esophageal injury is primary repair and adequate drainage. Oral feeding may be initiated after a barium swallow study shows no evidence of a leak. For extensive injuries or in cases of delayed diagnosis with significant infection, the better option is to establish a controlled fistula with catheter drainage or an esophagostomy. Hypopharyngeal wounds sometimes can be treated with just a nasogastric tube for feeding and parenteral antibiotics. Feeding can be through a feeding jejunostomy or parenteral nutrition.
Nerve injuries account for about 1-3% of cases of penetrating neck trauma. Injury to the vagus, recurrent laryngeal nerve, or brachial plexus should be repaired primarily when feasible (ie, a well-perfused patient without active hemorrhage). Spinal cord injury caused by penetrating trauma is managed expectantly. Steroids have not been shown to benefit injury from penetrating neck trauma.
Thoracic duct injuries, albeit difficult to demonstrate, can occur. They should be ligated to prevent chylous fistula and infections in the neck and mediastinum.
Thyroid injuries are uncommon despite the thyroid's size and location in the neck. Injuries can cause significant bleeding that often is controlled with direct pressure or suture ligation. Extensive injury may require an ipsilateral lobectomy to resolve the bleeding.
Severe parotid injury is rarely seen. Parotid injuries with associated vessel injury requiring parotidectomy have been reported.
Vascular injuries are managed postoperatively to ensure hemorrhage is stopped and blood supply and drainage to affected organs is adequate. Continually monitor the neurologic status of the patient. Ancillary angiographic and Doppler ultrasound studies can be performed to evaluate suspected complications with the repaired vessels.
Demonstration of good oxygenation and ventilation and the ability to maintain a patent airway are the parameters generally used to remove ventilatory support and extubation. Repairs of laryngotracheal injuries may require flexion of the neck to reduce tension.
A barium swallow study is performed after 5-7 days to evaluate the integrity of an esophageal injury repair. Oral feeding is initiated if no evidence of leak is present. The drains and feeding tubes also are discontinued. Parenteral antibiotics often are administered for the same duration. For those with controlled fistulas, definitive repair is performed after resolution of infection. Uncontrolled fistulae require the placement of additional drains and possible reexploration. Reexploration is performed for uncontrolled sepsis, as well as failure of percutaneous drainage methods.
It is important to note that many patients who undergo emergent intervention for neck injuries (as well as emergent intervention such as laparotomy or thoracotomy) should be considered for postoperative CT imaging, which may reveal other clinically significant injuries that can alter the management of the patient.[21]
After the initial postoperative recovery period, the patient should be monitored closely for complications. Breakdown of surgical repairs occasionally may occur. A high level of suspicion is needed for the early detection of postoperative complications or the need for diagnostic tests to confirm or rule out suspected problems. Long-term sequelae are uncommon. Cervical esophageal stenosis is rare but is treated adequately by bougienage.
The definitive management of penetrating neck trauma continues to be under debate and investigation. Among these investigations is the question of whether the mechanism of injury should dictate the specific management approach. For example, the question exists as to whether a different approach should be applied to gunshot injuries compared to stab wounds.
The debate between mandatory neck exploration and selective management is ongoing. Going forward, continued efforts are needed to guide patient selection and appropriate application of non-invasive imaging modalities to determine the presence of injuries.
The optimal surgical management of the carotid artery injury is another controversy in need of resolution. The issues involve whether severe neurologic deficits (ie, coma) and demonstrated absence of antegrade flow in the internal carotid artery contraindicate repair. In several studies, the reestablishment of antegrade flow in these cases has been suggested to be hazardous because it may convert an ischemic infarction into a hemorrhagic infarction.
Further controversy exists regarding the optimal management of vascular injuries identified solely on screening CT angiography in the absence of clinical signs of vessel injury. However, most of these discussions arise in the setting of blunt neck injury. The use of these rapidly developing endovascular techniques for the treatment of subclinical injuries in the neck lacks clear guidelines at present.
The Eastern Association for the Surgery of Trauma has the following published recommendations regarding penetrating neck trauma.[22]
In regard to mandatory vs selective neck exploration in Zone II injuries:
Level 1: Selective operative management and mandatory exploration of penetrating injuries to Zone II of the neck are equally justified and safe.
In regard to diagnosis of vascular injury:
Level 2: CT angiography or duplex ultrasonography can be used in lieu of arteriography to rule out an arterial injury in penetrating injuries to Zone II of the neck.
Level 3: CT of the neck (even without CT angiography) can be used to rule out a significant vascular injury if it demonstrates that the trajectory of the penetrating object is remote from vital structures. With injuries in proximity to vascular structures, minor vascular injuries such as intimal flaps may be missed.
In regard to diagnosis of esophgeal injury:
Level 2: Either contrast esophagography or esophagoscopy can be used to rule out an esophageal perforation that requires operative repair. Diagnostic workup should be expeditious because morbidity increases if repair is delayed by more than 24 hours.
In regard to the value of physical examination:
Level 3: (1) Careful physical examination, including auscultation of the carotid arteries, is >95% sensitive for detecting arterial injuries that require repair. Given the potential morbidity of missed injuries, imaging is still recommended. (2) Physical examination is inadequate to rule out injuries to the aerodigestive tract.
Management of specific vascular injuries:
Level 2: (1) Except for minimal intimal irregularities or small pseudoaneurysms without neurologic deficits, penetrating injuries to the internal carotid artery should be repaired, even when severe neurologic deficits are present. (2) Angiographic approaches to the vertebral artery are preferred to operative approaches for patients with bleeding from vertebral artery injuries. (3) Ligation of the jugular vein is appropriate for complex injuries or unstable patients.
In regard to spinal immobilization
Level 2: Immobilization of the cervical spine is unnecessary unless there is overt neurologic deficit or an adequate physical examination can not be performed (eg, the unconscious victim).
Daniel Mark Alterman, RN, MD, Resident Physician, Department of Surgery, University of Tennessee Graduate School of Medicine
Disclosure: Nothing to disclose.
Coauthor(s)
Brian J Daley, MD, MBA, FACS, FCCP, CNSC, Professor and Program Director, Department of Surgery, Chief, Division of Trauma and Critical Care, University of Tennessee Health Science Center College of Medicine
Disclosure: Nothing to disclose.
Specialty Editors
Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Robert L Sheridan, MD, Assistant Chief of Staff, Chief of Burn Surgery, Shriners Burns Hospital; Associate Professor of Surgery, Department of Surgery, Division of Trauma and Burns, Massachusetts General Hospital and Harvard Medical School
Disclosure: Nothing to disclose.
Chief Editor
John Geibel, MD, MSc, DSc, AGAF, Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, Professor, Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow; Fellow of the Royal Society of Medicine
Disclosure: Nothing to disclose.
Additional Contributors
Lewis J Kaplan, MD, FACS, FCCM, FCCP, Professor of Surgery, Division of Trauma, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania; Section Chief, Surgical Critical Care, Philadelphia Veterans Affairs Medical Center
Disclosure: Nothing to disclose.
Acknowledgements
Eugene Y Cheng, MD, FCCM Consulting Staff, Department of Anesthesiology, The Permanente Medical Group
Disclosure: Nothing to disclose.
Val Selivanov, MD Consulting Staff, Administrative Chief, Department of Surgery, Kaiser Permanente of Santa Teresa
Val Selivanov, MD is a member of the following medical societies: American College of Surgeons
){kind=link}