1. Blunt and penetrating neck injury

2. reference
B.J.Bailey ,et al. Head & Neck surgery Otolaryngology.4th edition.2006
Charles W. Cummings, et al, Cummings Otolaryngology, Head & Neck Surgery, 5th ed
D.V. Feliciano ,et al. Trauma, 6th Edition.2008

3. Zones of the Neck
. Zone I: thoracic inlet to cricoid cartilage Zone II: cricoid cartilage to the angle of mandible Zone III: angle of the mandible to skull base

4. CLASSIFICATION

5. Zone I Superior Mediastinum Thoracic Duct Spinal Cord Brachial Plexus
From the clavicles to the cricoid
Trachea
Lungs
Proximal carotid and vertebral arteries
Jugular veins
Thoracic Vessels
Esophagus
Superior Mediastinum
Thoracic Duct
Spinal Cord
Brachial Plexus

6. Zone II From cricoid to angle of mandible Trachea Larynx
Carotid and vertebral aa.
Jugular Vein
Esophagus
Spinal Cord

7. Zone III Angle of mandible to base of skull
Distal carotid and vertebral arteries
Pharynx
Spinal cord

8. PENETRATING NECK TRAUMA
Presently, penetrating neck injury comprises 5% to 10% of all trauma cases.
All penetrating neck wounds are potentially dangerous and require emergency treatment.

9. Physical properties of penetrating objects
handgun
Rifle
Shotguns
Knife and stab injuries

10. Physical properties of penetrating objects
Kinetic energy= ½ mv2
m = mass
V = velocity
Degree of wound
Firearm
Low velocity ( < 1,000 ft/sec)  handgun ft/sec
high velocity ( > 1,000 ft/sec)  shotgun 1,200 ft/sec , rifle 2,200 ft/sec

11. Physical properties of penetrating objects
Gunshot wound  tissue injury from 2 mechanism
Direct tissue injury
Temporary caviation
Low velocity tissue damage
High velocity  tissue loss

13. KNIFE and STAB Knife, ice-pick, cut-glass, or razor-blade
more predictable pathways
single-entry wound may be from multiple stab wounds
cervical stab wounds have a higher incidence of subclavian vessel laceration because stabbings to the neck often occur in a downward direction with the knife slipping over the clavicle and into the subclavian vessels.
spinal injuries, neck stab wounds have a lower incidence than cervical bullet wounds.

14. Genaral trauma principle
A : airway with C-spine control
B : breathing and ventilation
C : circulation
D : disability and neurologic status
E : exposure and evaluation other injury

15. A : Airway Most casecarefully intubated transorally
If C –spine injury is suspected intubate with neck stabilized
Unstable airway with sig. bleed or edema in oral cavity or pharynx cricothyroidotomy or urgent tracheostomy

16. A : Airway
Multiple blind intubation attempts will risk enlarging a lacerated piriform sinus wound and extending it iatrogenically into the mediastinum.
Tracheal tear may be exacerbated by extending the neck

17. A : Airway
Obvious tracheal injury carefully intubated through entry wound using armored/reinforced ETT

18. B: Breathing Administer high-flow oxygen Monitor : pulse oximetry
Difficulty ventilation may upper airway or thoracic injury
Unequal breath sounds & asymmetric chest movement inadequate ventilation
Pneumothorax
Hemothorax
Tension pneumothorax

19. C : Circulation Control active bleeding with direct pressure
Do not clamp bleeding vessels
Subsequent injury to vascular or nervous structure
Avoid placing IV access at a location where the IV fluid would flow toward the site of injury
Avoid inserting NG tube at the initial resuscitation : gag & retching cause dislodge a clot & cause hemorrhage

20. D : Disability Neurodeficit indicate
directed nerve or spinal cord injury
cerebral ischemia cause by carotid artery injury
Need rapid sedation and paralysis for intubation
Immobilize the cervical spine in a neutral position

21. Vital structures of the neck
four groups:
the air passages (trachea, larynx, pharynx, lung);
vascular (carotid, jugular, subclavian, innominate, aortic arch vessels);
gastrointestinal (pharynx, esophagus)
neurologic (spinal cord, brachial plexus, peripheral nerves, cranial nerves [CNs])

22. SYMPTOM Airway Vascular System Reparatory distress Stridor Hemoptysis
Hoarseness
Tracheal deviation
Subcutaneous emphysema
Sucking wound
Vascular System
Hematoma
Persistent bleeding
  Neurologic deficit
Absent pulse
Hypovolemic shock
Bruit
Thrill
 Change of sensorium
From Stiernberg C, Jahrsdoerfer RA, Gillenwater A, et al. Gunshot wounds to the head and neck. Arch Otolaryngol Head Neck Surg. 1992;118:592

23. SYMPTOM Nervous System
   Hemiplegia    Quadriplegia    Coma    Cranial nerve deficit    Change of sensorium    Hoarseness
Esophagus/Hypopharynx
   Subcutaneous emphysema    Dysphagia    Odynophagia    Hematemesis    Hemoptysis    Tachycardia    Fever
From Stiernberg C, Jahrsdoerfer RA, Gillenwater A, et al. Gunshot wounds to the head and neck. Arch Otolaryngol Head Neck Surg. 1992;118:592

24. Mandatory versus Elective Exploration
Immediately life threatening: massive bleeding, expanding hematoma, hemodynamic instability, hemomediastinum, hemothorax, and hypovolemic shock.Immediate surgical exploration
Hemodynamically stable ,non–life-threatening features can undergo thorough imaging investigations to determine the extent of injury.

25. Injury

26. Zone 1 injury Below cricoid, dangerous area
Protect zone  bony thorax and clavicle
Motality rate 12 %
Potential for injury to great vessel and mediastinum
Mandatory exploration : not recommend
Angiography and esophageal evaluation: usually suggest
> 1/3 no symptom at presentation

27. Zone 1 injury Esophageal evaluation endoscopy , contrast esophagogram
Contrast medium
Barium- based
Gastrografin ( meglumine diatrizoate)
Combination tests should not miss an njury
CT scan
Determine the path of projectile

28. Zone 2 injury Largest zone,most common site of trauma 60-75%
Between angle of mandible & inf border of cricoid cartilage
Isolate venous injury & pharyngoesophageal injury most common structure missed clinically
All pt. are admitted for observation and 24 hr re-evaluation
50% of death  hemorrhage from vascular structure

29. Zone 2 injury Symptomatic  neck exploration Asymptomatic
Directed evaluation and serial exam
Arteriography,
Laryngotraheoscopy
flexible esophagoscopy
barium swallow
Requires adequate physician ,24 hr facility prepared for emergency testing and Surgery

31. Zone 3 injury Superior to angle mandible to skull base
Potential for injury to major blood vessel and CN near skull base
Arterial injury
may be asymptomatic at presentation
Surgical exposure and control bleeding may be difficult
amenable to definitive treatment by an interventional radiologist
Vertebral artery injury appear to be relatively rare
Should be imaged if bullet path is near the vertebral column
Four vessel angiography

33. Angiography : Zone1 & 3
Routine preoperative arteriography in stable case
Surgical approach is more difficult than zone 2
If wound involve both side of neck ( stable but symptomatic) four vessel angiography

34. Angiography : Zone1 & 3
1Arteriogram demonstrating common carotid artery injury with small hematoma
2extravasation of the internal carotid artery near the base of the skull (arrow).
3. A follow-up arteriogram of the internal carotid artery 1 week later shows enlargement of the pseudoaneurysm.

35. Angiography : Zone2 Easy accessible,low risk for exploration
Certain indication for an angiogram in zone 2
Stable pt. who has persistent hemorrhage
Neurodeficit compatible with adjacent vascular structure damage eg. Horner’s syndrome , hoarseness
Need exploration
Positive arteriography
Negative arteriography but positive clinical sign
Asymptomatic in zone 2
Controversy,
No sig difference btw. Clinical exam & angiography
CTA fast ,minimal invasive in hemostatic stable

36. Management of vascular injury zone 1
Vascular perforation  requires thoracic Sx
Mediastinotomy extension or formal lateral thoracotomy

37. Management of vascular injury zone 3
Injury at the skull base can be temporalize by pressure
Mandibulectomy in midline
Temporaly arteral bypass of carotid artery

38. Management of vascular injury
All vein in the neck can be safely ligated to control hemorrhage
injury both internal jugular vein  try repair
All external carotid artery suture ligation
Good collateral circulation

39. Management of vascular injury
Common carotid artery/internal carotid artery in zone 2
Approach along SCM
if no pulsating followed retrograde from facial artery/sup thyroid artery

40. Technique of vascular repair
End to end or autogenous graft reccomended when stenosis is evident by arteriography
Ligation of common or internal carotid a.reserved for irreparable injury and in pt, who are in a profound coma state
Delayed complication from unrepaired vascular injury
Aneurysm formation
Dissecting aneurysm
AV fistulas

41. Technique of vascular repair
Intervention radiologists used angiography technique to treat vascular injury
Embolization
Zone 3  high incidence of multiple vascular injury event
Complication of intervention angiography
Blood vessel injury
Inadvertent balloon detachment
Ischemic events
Pseudoaneurysm formation
Treatment failure

42. Pharynx and esophageal injury
Clinical sign and symptom  neck exploration
subcutaneous emphysema
Hematemesis
Hypopharyngeal blood
>50%of Pt.  asymptomatic at presentation
Combination of esophagoscopy and contrast esophagography
Most sensitive for detected injury
Delayed explore & repair beyond 24 hrs after injury poorer outcome

43. Digestive tract evaluation
Possible esophageal perforation  gastrografin swallow
Barium : extravasation & distort soft tissue plane and toxic

44. Digestive tract evaluation
Flexible esophagoscopy
Missed perforation : cricopharyngeus, hypopharynx
Negative endoscopy but air leak in soft tissue  mandatory neck explore
Infiltrate methylene blue : localize injury size
Combination of flexible and rigid endoscopy
Exam entire cervial and upper esophagus
No perforation missed

45. Digestive tract evaluation
Suspicious pharyngeal perforation
NPO for several days
S&S : fever , tachycardia,widening of mediastinum
Repeat endoscopy or neck exploration
Esophageal injury in the early phase
Two layer closure with wound irrigation
Debridement
Adequate drainage
Extensive esophageal injury  lateral cervical esophagostomy

46. Digestive tract evaluation
C-spine fx  omitted rigid esophagoscopy
Clinical exam
F/U exam frequently
Monitor V/S
Observe period hrs

47. Penetrating of hypopharynx
Superior to the level of arytenoid cartilage
IV ABO
NPO ทางปาก 5-7 days
Primary closure not always necessary
Inferior to the level of arytenoid cartilage
Dependent portion
Exploration with primary watertight closure
Use absorbable suture with drainage of adjacent neck space
NPO 5-7 days
Treat liked esophageal injury

48. Treatment Conservative Medical therapy
Adequate ventilation & oxygenation
Fluid resuscitation
Monitor neurolodic status
Pain control
ABO
Tetanus prophylaxis

49. Treatment Surgical approach Zone 1 Zone 2 Zone 3 Median sternotomy
Thoracotomy
Zone 2
Collar incision
Apron incision
Zone 3
Consult neuroSx

51. Blunt neck trauma motor vehicle accidents and sports
result in laryngeal, vascular, and digestive injury
easily underdiagnosed because their onset can be delayed
occult cervical spine injury

52. Blunt neck trauma careful observation : delayed onset
slow progression of airway edema
airway obstruction may not occur until several hours after the injur
CT may be helpful to determine degrees of injury to the larynx and vessels

53. Blunt neck trauma Blunt injury to the cervical vessels can lead to
thrombosis, intimal tears, dissection, and pseudoaneurysm
Treatment options for blunt artery injuries are based on
the mechanism, type of injury, and location

54. Blunt neck trauma Treatments for blunt artery injuries include
surgery, anticoagulation, and observation.
Surgical intervention for blunt vascular injuries includes ligation, resection, thrombectomy, and stent placement