eMedicine Specialties > Trauma > Head and Neck Trauma

Penetrating Neck Trauma: Treatment

Author: Daniel Mark Alterman, MD, RN, Resident Physician, Department of Surgery, University of Tennessee Graduate School of Medicine
Coauthor(s): Brian James Daley, MD, MBA, FACS, Associate Program Director, Professor, Department of Surgery, Division of Trauma and Critical Care, University of Tennessee School of Medicine; Eugene Y Cheng, MD, FCCM, Consulting Staff, Department of Anesthesiology, The Permanente Medical Group; Val Selivanov, MD, Consulting Staff, Administrative Chief, Department of Surgery, Kaiser Permanente of Santa Teresa
Contributor Information and Disclosures

Updated: Nov 19, 2009

Treatment

Medical Therapy

• Prehospital care
  • 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 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 may be required. Expeditious intubation of a tracheotomy produced by the penetrating injury sometimes may be lifesaving.
  • 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.
  • 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.

Surgical Therapy

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.

Preoperative Details

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.

Intraoperative Details

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.⁷

Recently, similar damage-control principles have been described for the critical vascular neck wound. Rezende-Neto and colleagues 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.⁸  After 36 hours, the patient was returned to the operating room for successful, definitive treatment.

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.

Postoperative Details

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.

Follow-up

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.

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.
• Fistulas - Esophagocutaneous, esophagotracheal, tracheocutaneous, venoarterial
• 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

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