1. Injuries to the Neck
Jason Davis, MD

2. Blunt Neck Trauma Blunt arterial injuries Blunt airway injuries
Usually managed non-operatively
Operative tx similar to penetrating injuries (rare)
Almost always diagnosed by angiography
Blunt airway injuries
Managed similar to penetrating injuries
Occasionally surgical emergencies

3. Penetrating Neck Trauma
Categorized into 6 groups
Airway compromise
Isolated laryngotracheal injuries
Carotid artery injuries
Jugular vein injuries
Esophogeal injuries
Pharyngeal injuries
Helps in choosing incision, operative priorities

4. Airway Compromise Establish airway first Orotracheal intubation
Cricothyrotomy (emergent)
Tracheotomy (less emergent)
Nasotracheal not advised in most trauma settings

5. Airway Compromise Establish airway first Cricothyrotomy (emergent)
Landmarks: Thyroid & Cricoid cartilages
Stabilize thyroid cartilage (notched superiorly)
Transverse incision at Cricothyroid membrane
Vertical incision in emergencies w/ unknown injury
Extend through subcutaneous tissue, cricothyroid
Avoid injury to posterior tracheal wall
Twist 11-blade scalpel 900 to enlarge
Insert No. 4 – 6 (largest for most adults) airway
Convert to tracheotomy 48 – 72hrs

6. Cricothyrotomy

7. Airway Compromise Establish airway first Tracheotomy (less emergent)
Incision 1 – 2 fingerbreadths inferior to cricothyroid
Skin incision to anterior border of SCM bilaterally
May use wound. Mediasternotomy for distal injuries.
Conversion Cricothyrotomy to Tracheotomy
Believed less likely to stricture or cause tension
Literature does not support such a difference 7

8. Penetrating Neck Trauma
Traditional cervical neck divisions
Zone 1:
Zone 2:
Zone 3: 8

9. Penetrating Neck Trauma
Traditional cervical neck divisions
Zone 1: thoracic inlet to cricoid cartilage superiorly
Zone 2: cricoid cartilate to angle of mandible
Zone 3: angle of mandible and base of skull
Zone 2 – mandatory exploration if injury violates platysma
Zones 1, 3 - imaging studies, endoscopy to assess injuries
Consider injury depth, pt stability 9

10. Neck Exploration
Most common for unknown injuries associated w/ penetrating neck trauma
Anterior sternocleidomastoid incision offers rapid access to most vital neck structures
Carotid sheath, pharynx, cervical esophagus
Particularly important for bleeding, neuro deficits
May be lengthened for proximal/distal exposure
Include anter chest in prep for poss prox control
Greasy feel may indicate salivary amylase 10

11. Isolated Laryngotracheal Injuries
Most commonly not recognized pre-op, though laryngoscopy / bronchoscopy can be useful in the context of a suspicious history
Initial focus on establish airway, min debridement
Repair small trachea injury w/ absorbable
Post-op monitor for mediastinitis +cxr for pneumo-mediastinum, leaks or missed pharyngoesoph injury
Reconstruction / definitive repair semi-elective 11

12. Neck Exploration
*Curved posteriorly at mandible

13. Neck Exploration

14. Carotid Artery Injuries
Dissection comparable to CEA
Prox/distal control, protect nerves
Proximal exposure occasionally may require subluxation of mandible and division of stylohyoid lig, styloglossus/pharyngeus muscles at styloid process
May occlude more distal injuries w/ 4-5F fogarty
Repair vs ligation as per hemodynamic stability, complexity of injuries, and back-bleeding

15. Pharyngoesoph Injuries
Repair w/ 3.0 – 4.0 absorbable suture, 1-2 layers and drain (closed/penrose) x1 wk
Several doses post-op antibiotics (oral flora)
UGI & feeding before drains removed

16. Injuries at Base of Neck
Median sternotomy for inominate or R subclavian injuries
Left thoracotomy for L subclavian

17. Injuries at Base of Neck
Median sternotomy for inominate or R subclavian injuries
Left thoracotomy for L subclavian

18. Vertebral Artery Injuries
Most vertebral artery injuries dx w/ angiography and may be embolized

19. Blunt Cervical Injuries
Most often hyperextension w/ MVC
Blunt injury to cervical arteries ~rare
Angio or CTA dx if  cervical bruit <50yo, evidence of cerebral infarct on CT, basilar skull fx involving carotid canal, neurologic sx not explained by CT, or as per mechanism
Anticoag typically for dissection/aneurysm