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Head and Neck Trauma Hosseini M. M.D Head and Neck Surgeon Rasoul Akram Hospital Iran University.

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Presentation on theme: "Head and Neck Trauma Hosseini M. M.D Head and Neck Surgeon Rasoul Akram Hospital Iran University."— Presentation transcript:

1 Head and Neck Trauma Hosseini M. M.D Head and Neck Surgeon Rasoul Akram Hospital Iran University

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3 Airway Vascular system Nervous system Esophagus/Hypopharynx Bone

4 Signs and symptoms of penetrating neck trauma Airway Airway Respiratory distress Respiratory distress Stridor Stridor Cyanosis Cyanosis Hemoptysis Hemoptysis Hoarseness Hoarseness Tracheal deviation Tracheal deviation Subcutaneous emphysema Subcutaneous emphysema Sucking wound Sucking wound

5 Vascular system Hematoma Hematoma Persistent bleeding Persistent bleeding Neurologic deficit Neurologic deficit Absent pulse Absent pulse Hypovolemic shock Hypovolemic shock Bruit Bruit Thrill Thrill Change of sensorium Change of sensorium

6 Nervous system Hemiplegia Hemiplegia Quadriplegia Quadriplegia Coma Coma Cranial nerve deficit Cranial nerve deficit Change of sensorium Change of sensorium Hoarseness Hoarseness

7 Esophagus / hypopharynx Esophagus / hypopharynx Subcutaneous emphysema Subcutaneous emphysema Dysphagia Dysphagia Odynophagia Odynophagia Hematemesis Hematemesis Hemoptysis Hemoptysis Tachycardia Tachycardia Fever Fever

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10 Zone I : 1-Close proximity to thorax (dangerous) 1-Close proximity to thorax (dangerous) 2-Protect by bony thorax and clavicle 2-Protect by bony thorax and clavicle 3-Surgical exploration is difficult 3-Surgical exploration is difficult 4-Mortality 12% 4-Mortality 12% 5-Mandatory exploration is not 5-Mandatory exploration is not recommended recommended 6-Angiography 6-Angiography 7-Right side : median sternotomy 7-Right side : median sternotomy 8-Left side : left anterior thoracotomy 8-Left side : left anterior thoracotomy

11 Zone II : 1-The most involved zone (60% - 75%) 1-The most involved zone (60% - 75%) 2-Mandetory versus selective 2-Mandetory versus selective

12 Zone III : Zone III : 1- Protect by skeletal structures 1- Protect by skeletal structures 2- Surgical exploration is difficult (need to divide or displace the mandible) 2- Surgical exploration is difficult (need to divide or displace the mandible) 3-Cranial nerves injuries 3-Cranial nerves injuries 4- Angiography and barium swallow 4- Angiography and barium swallow (in stable patients and no lifethreating symptoms) (in stable patients and no lifethreating symptoms) 5-Frequent intraoral examination 5-Frequent intraoral examination

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15 - Temporal (frontal) Inability to raise the eyebrow Inability to raise the eyebrow - Zygoma (malar) Inability to close the eyelids Inability to close the eyelids - Buccal Inability to smile Inability to smile - Marginal mandibular Inability to frown Inability to frown

16 Facial nerve injuries 1-Maxillofacial trauma 1-Maxillofacial trauma 2-Serious functional disabilities 2-Serious functional disabilities and aesthetic defects and aesthetic defects 3-Posterior half of parotid gland 3-Posterior half of parotid gland has deep laceration has deep laceration 4-Repaired five or main trunk 4-Repaired five or main trunk (clean,sharp division) (clean,sharp division)

17 Signs of immediate Lifethreatening Injuries 1-Massive bleeding 2-Expanding hematoma 3-Nonexpanding hematoma in the presence of hemodynamic instability 4-Hemomediastinum5-Hemothorax 6-Hypovolemic shock

18 Diagnostic evaluation 1- Full examination of the 1- Full examination of the unclothed body (entrance - exit ) unclothed body (entrance - exit ) 2- Full neurologic examination 2- Full neurologic examination 3- Chest X - Ray ( Hemothorax 3- Chest X - Ray ( Hemothorax pneumothorax-pneumomediastinum) pneumothorax-pneumomediastinum) 4- Cervical spine X- Ray 4- Cervical spine X- Ray 5- Flexible endoscopy – arteriography 5- Flexible endoscopy – arteriography (24 hours available) (24 hours available)

19 Angiography Indications : Indications : Wounds near vessel in Wounds near vessel in zone I or zone III zone I or zone III Contraindications : Contraindications : Expanding hematoma Expanding hematoma Profound shock Profound shock Uncontrolled bleeding Uncontrolled bleeding Accuracy : 98.5% Accuracy : 98.5%

20 Barium swallow Barium swallow Indications : Indications : Hematemesis Hematemesis Drooling Drooling Dysphagia Dysphagia Vocal cord paralysis Vocal cord paralysis Contraindications : Contraindications : Intubated Intubated Saliva in wound Unstable pt. Saliva in wound Unstable pt. Accuracy : 90% Accuracy : 90%

21 Direct laryngoscopy and broncoscopy Indications : Indications : Vocal cord paralysis Vocal cord paralysis Hoarseness Hoarseness Tenderness or crepitance Tenderness or crepitance over larynx over larynx Subcutaneous emphysema Subcutaneous emphysema Hemoptysis Hemoptysis Contraindications : None Contraindications : None Accuracy : 100% Accuracy : 100%

22 Esophagoscopy Esophagoscopy Indications Indications Suspected but unconfirmed injury Suspected but unconfirmed injury by Barium swallow by Barium swallow Intubated Intubated Laryngeal or tracheal injury Laryngeal or tracheal injury Vascular injury in zone II or zone III Vascular injury in zone II or zone III Contraindications : None Contraindications : None Accuracy : 86% Accuracy : 86%

23 The leading cause of death From penetrating neck injuries is hemorrhago from vascular structures ( 50% )

24 Mandatory Versus Elective Exploration 1-Lifethreatening 1-Lifethreatening 2-Not lifethreatening 2-Not lifethreatening

25 Stable patients: 1-Mandatory exploration for all 1-Mandatory exploration for all penetrating neck wounds penetrating neck wounds 2-Selective exploration with 2-Selective exploration with observation observation

26 Subcutaneous emphysema In the neck or face 1-Sinus 1-Sinus 2- Hypopharynx 2- Hypopharynx 3- Laryngothracheal complex 3- Laryngothracheal complex 4- Pulmonary parenchyma 4- Pulmonary parenchyma 5- Esophagus 5- Esophagus

27 Esophageal injuries 1-Blunt (rare) 1-Blunt (rare) 2-16/288 (when penetrate platysma) 2-16/288 (when penetrate platysma) 3-Air in mediastinum 3-Air in mediastinum 4-Pain 4-Pain 5-Hematemesis 5-Hematemesis 6-Hoarseness 6-Hoarseness 7-Barium swallow 7-Barium swallow 8-Endoscopy (rigid) 8-Endoscopy (rigid) 9-N.P.O (7-10 days) 9-N.P.O (7-10 days)

28 Small injuries of Trachea Primary repair Primary repair No tracheotomy No tracheotomy Absorbable sutures (3-0 or 4-0) Absorbable sutures (3-0 or 4-0) Transversely sutures Transversely sutures Ring above and below Ring above and below No drain No drain

29 Large defects Anterior : Anterior : Convert to tracheotomy Convert to tracheotomy Posterior &lateral : Posterior &lateral : Close primary & tracheotomy Close primary & tracheotomy Very large defect : Very large defect : Primary anastomosis(5-6 rings) Primary anastomosis(5-6 rings)

30 Initial management Initial management 1-Airway 1-Airway 2-Blood perfusion maintenance 2-Blood perfusion maintenance 3-Clarification and classification 3-Clarification and classification of the severity of wound of the severity of wound

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33 Parotid duct injuries - Opening opposite the second - Opening opposite the second upper molar upper molar - Orifice of Stensen s duct should - Orifice of Stensen s duct should be probed be probed - Repair over catheter - Repair over catheter

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41 Penterating Neck Injury - Is immediately life-threatening - Is not

42 Signs Of Immediate L. T. -Massive bleeding -Expanding hematoma -Nonexpanding hematoma in the presence of hemodynamic instability -Hemomediastinum-Hemothorax -Hemovolemic shock

43 Stable patient -Mandatory exploration for all pent.neck wounds -Selective exploration and observation % of pt. had negative exploration

44 -World war II mortality of penetrating neck wound 7-15% -End of vietnam war 3-6%

45 Transcervical injuries should be reported seperately from zone I, II, III injuries. Transcervical penetrating neck wounds when the projectile crosses the midline, have 100% vascular or aerodigestive injury.

46 Initial management 1-Airway establishment 2-blood perfusion maintenance 3-clarification & classification of severity of the wounds

47 Airway a-Intubation b-cricothyroidectomy c-tracheostomy

48 Direct transcervical tracheal intubation Oral cavity Oral cavity Pharynx Pharynx larynx larynx

49 X-ray Anterior Anterior Lateral Lateral Chest x-ray Chest x-ray

50 Esophageal perforation Gastrografin swallow If g. is negative a barium swallow perform Flexible esophagoscopy 86% Contrast swallow 90% Rigid esophagoscopy Flexible+Rigid endoscopy

51 Air in the soft tissue:neck exploration NG tube(neck level)+methylene blue

52 Early esophageal perforation Debridment Debridment Two layer closure Two layer closure Wound irrigation Wound irrigation Adequate drainage Adequate drainage Muscle flap Muscle flap Appropriate AB Appropriate AB

53 Extensive esophageal injury Lateral cervical esophagostomy Lateral cervical esophagostomy Later definitive repair Later definitive repair

54 Direct laryngoscopy Bronchoscopy Rigid esophagoscopy anesthesia (spine fracture)

55 Air in the soft tissue Hemoptysis Hematemesis Others

56 24 hours (3 times) hours

57 Laryngotracheal injury Laryngeal laceration (stenosis+voice) repair early(24h) Laryngeal laceration (stenosis+voice) repair early(24h) Significant glottic and supraglottic laceration+displaced cartilage surgical approximation Significant glottic and supraglottic laceration+displaced cartilage surgical approximation

58 Endoscopy+CT a-Small laceration (observation) a-Small laceration (observation) b-Large laceration (thyrotomy or open fracture reduction)+mucosal repair b-Large laceration (thyrotomy or open fracture reduction)+mucosal repair

59 Simple tracheal laceration repair without tracheostomy Simple tracheal laceration repair without tracheostomy Severe tracheal injury 6-weeks tracheostomy (below or at the site of injury) Severe tracheal injury 6-weeks tracheostomy (below or at the site of injury)


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