eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Trauma

Penetrating Injuries of the Neck

Author: William M Lydiatt, MD, Professor and Division Director, Head and Neck Surgical Oncology, Department of Otolaryngology-Head and Neck Surgery, University of Nebraska Medical Center
Coauthor(s): Mary C Snyder, MD, Associate Professor, Division of Plastic Surgery, University of Nebraska Medical Center; Daniel D Lydiatt, DDS, MD, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Nebraska Medical Center
Contributor Information and Disclosures

Updated: Jan 5, 2009

Introduction

History of the Procedure

Penetrating neck trauma has been a significant cause of injury and death for centuries. The advent of gunpowder and the subsequent widespread use of firearms have increased the incidence of these injuries and the mortality rate associated with them.

Historically, military conflict has provided significant opportunities for the advancement of trauma surgery, including the management of penetrating cervical injuries. In the 16th century, Ambrose Paré performed the first documented surgical intervention for a traumatic cervical injury when he ligated the lacerated carotid artery and jugular vein of a wounded French soldier.

More than 4000 cases of neck wounds were reported during the American Civil War, with a mortality rate of approximately 15%. During World War I, the mortality rate for cervical injuries was approximately 11%, and, by World War II, this rate had declined to 7%. Wartime surgeons of the last century are credited with the development of many of the principles for the management of penetrating neck trauma.

Mandatory exploration of all wounds deep to the platysma was developed and widely practiced by military surgeons during World War II, and this practice may explain the decreased mortality rates associated with these injuries. In 1956, a landmark study by Fogelman and Stewart revealed a mortality rate of 6% in patients who underwent immediate surgical exploration versus a 35% mortality rate in patients who either underwent exploration in a delayed fashion or were not treated surgically.1 Mandatory exploration was advocated for the treatment of all penetrating neck injuries and became the mainstay of management at most major trauma centers.

The concept of selective management of these injuries was developed in the 1980s in response to the observation that while operative mortality rates were declining, the number of explorations with negative findings was increasing. The goal of selective management is to identify patients who would benefit from surgical management of their injuries in an attempt to decrease the number of unnecessary explorations. The optimal treatment of penetrating injuries to the neck continues to be debated today.

Problem

Neck wounds that extend deep to the platysma are considered penetrating injuries.

Frequency

In the United States, most penetrating neck traumas in the adult population are secondary to personal assaults. As the rate of violent crime has increased, so has the number of penetrating injuries to the neck. These types of injuries currently cause complications in 5-10% of all trauma cases. Some cases of penetrating neck trauma in adults and most cases in children are caused by accidents, such as falls on sharp objects and motor vehicle accidents. Accidental penetrating injuries are uncommon; their actual frequency rates are unreported.

Internationally, the rates of penetrating neck trauma are usually related to the violent crime rates of a particular country, as well as military conflict. Accidental injury rates are difficult to assess and generally unreported.

Etiology

The most common causes of penetrating neck trauma are missile injuries from firearms and stab injuries. Blast injuries with penetrating bomb and mortar fragments are less common. Accidental penetrating injuries are most often due to falls on sharp objects such as sticks or glass. Motor vehicle accidents are another cause of accidental penetrating injuries.

Pathophysiology

Penetrating missile trauma can be a low-velocity injury or a high-velocity injury. The wounding capacity of a missile is directly proportional to its velocity. Low-energy wounds are those caused by a projectile traveling at a velocity less than the speed of sound and usually result in the laceration of soft tissue with comminution of bone and the missile itself. High-energy wounds are produced by missiles traveling faster than the speed of sound. Large amounts of energy are transferred to the tissues of the body and result in perforating or avulsion wounds to the soft tissue, with ablation of cortical bone. The high energy imparted to the tissues (and therefore the degree of damage from high-velocity missiles) is often underestimated.

Stab injuries usually result in lesser degrees of injury than missile wounds. The rate of explorations with negative findings associated with mandatory surgical exploration of all stab injuries of the neck is 10% higher than the rate of explorations with negative findings in missile injuries.

Accidental injuries may result in the penetration of the platysma by a foreign object such as those made of metal, glass, or wood. Such injuries usually do not result in extensive collateral tissue damage, but foreign bodies may remain in the neck.

Penetrating neck wounds can cause injury to one or more of the major organ systems of the neck, including the great vessels, larynx and trachea, esophagus, and spinal column. Injuries to the vascular system occur in 25-56% of penetrating neck wounds, and injuries to the carotid and subclavian arteries are the most common cause of mortality. Approximately 20-30% of penetrating neck wounds result in laryngeal, tracheal, or esophageal injuries. In addition to the major structures, numerous smaller structures in the neck can be injured with penetrating trauma, which often results in significant morbidity.

Presentation

The treatment of a patient with a penetrating neck injury should follow the advanced trauma life support (ATLS) guidelines established by the American College of Surgeons, which begins with a rapid assessment of the airway, breathing, and circulation. Airway management in a patient with penetrating injury to the neck can be challenging. Expanding hematoma, subcutaneous emphysema, hoarseness, stridor, respiratory distress, hemoptysis, and hemodynamic instability all suggest injury to the airway and/or vasculature.

The approach to airway management must be individualized in these situations. A seemingly stable airway can be lost rapidly in a patient with penetrating neck trauma. With injury to the laryngotracheal complex, intubation can be attempted, but great care must be taken to recognize tracheal disruption, which can lead to intubation of a false passage. A marginal airway may be lost if intubation is not performed expertly. Significant trauma to the larynx or cricoid generally requires tracheotomy. Controlled tracheotomy with local anesthesia is always preferred to an emergency tracheotomy necessitated by unsuccessful intubation attempts.

Once the airway is stable, breathing and circulation are evaluated and managed in the standard manner, following the ATLS protocol. The secondary survey is conducted after the patient is initially stabilized, and any associated injuries are noted. A thorough history should be obtained; it should include details about the mechanism of injury such as the type of projectile, distance between the gun and the victim, caliber of weapon, and number of shots fired.

Physical examination of the patient should focus on the 3 major organ systems commonly involved in penetrating neck injury: airway, vascular system, and upper digestive tract.

  • Evaluation of the airway is focused on the respiratory status of the patient, such as the respiratory rate and signs of airway distress, including dyspnea and stridor. Vocal quality should be noted, and the patient should be questioned about changes in the voice. The neck and upper chest should be palpated for subcutaneous emphysema, and the larynx and trachea should be palpated for tenderness and crepitus. Flexible laryngoscopy, CT imaging, and/or direct laryngoscopy and bronchoscopy may be necessary to fully evaluate suspected airway injuries.
  • Injuries to the great vessels of the neck may be obvious on physical examination and may present as an exsanguinating wound or expanding hematoma. A significant vascular injury may be subtle, with findings such as an absent distal pulse, bruit, or isolated neurologic deficit. Suspected vascular injuries can be further evaluated with angiography and exploration.
  • Injuries to the esophagus and pharynx are difficult to diagnose and may be missed during the management of other immediately life-threatening injuries. Bleeding from the mouth, drooling, and subcutaneous emphysema are all suggestive of upper digestive tract injury. Careful examination of the oropharynx and hypopharynx should be performed at the bedside, if possible. A contrast-enhanced study of the esophagus and esophagoscopy should be performed if injury is suspected clinically.

Indications

All patients with suspected or confirmed injuries to the neck that extend deep to the platysma should be treated according to a protocol of either mandatory neck exploration or selective management, depending on the philosophy of the surgeon. If a surgeon who is experienced in the management of penetrating neck injuries is not available or if the facility is not equipped to treat a patient with this type of injury, the patient should be stabilized and transferred to an appropriate medical center.

Indications for immediate surgical management of penetrating neck injuries include hemodynamic instability, exsanguinating hemorrhage, or expanding hematoma. Patients in stable condition should undergo a thorough evaluation of the vascular structures of the neck and the aerodigestive tract prior to surgical intervention.

Relevant Anatomy

The lateral neck is divided into 3 zones; this system is useful in the evaluation and treatment of penetrating neck injuries.

  • Zone 1 extends from the clavicle to the cricoid cartilage and includes the thoracic inlet. This region contains the major vascular structures of the subclavian artery and vein, jugular vein, and common carotid artery, as well as the esophagus, thyroid, and trachea.
  • Zone 2 extends from the cricoid to the angle of the mandible and contains the common carotid artery, internal and external carotid arteries, jugular vein, larynx, hypopharynx, and cranial nerves X, XI, and XII.
  • Zone 3 is a small but critical area extending from the angle of the mandible to the skull base. This region contains the internal and external carotid arteries, jugular vein, lateral pharynx, and cranial nerves VII, IX, X, XI, and XII.

Contraindications

Every patient with a history of trauma should be evaluated and treated according to the ATLS guidelines established by the American College of Surgeons. Penetrating neck wounds that appear to be life threatening must be addressed immediately. A contraindication to immediate management of a non–life-threatening penetrating neck injury is a life-threatening injury in another body system that requires immediate attention. After stabilization of the patient's condition, the workup should proceed in a timely manner.

More on Penetrating Injuries of the Neck

Overview: Penetrating Injuries of the Neck
Workup: Penetrating Injuries of the Neck
Treatment: Penetrating Injuries of the Neck
Follow-up: Penetrating Injuries of the Neck
References
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Further Reading

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Keywords

penetrating injuries of the neck, penetrating neck trauma, traumatic neck injuries, penetrating cervical injuries, missile trauma to the neck, neck wounds, wounds deep to the platysma, penetrating neck injuries, penetrating neck traumas, personal assaults, motor vehicle accidents, MVA, missile injuries, firearm injuries, stab injuries, blast injuries, low-velocity injury, high-velocity injury, projectile injury, perforating wound, avulsion wound, foreign bodies, great vessels, larynx, trachea, esophagus, spinal column, carotid artery, subclavian artery, advanced trauma life support guidelines, ATLS guidelines, laryngotracheal complex, intubation, tracheotomy, airway, vascular system, upper digestive tract, laryngoscopy, bronchoscopy, esophagoscopy, vascular injuries, laryngotracheal injuries, pharyngeal injuries, esophageal injuries, mediastinitis

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Contributor Information and Disclosures

Author

William M Lydiatt, MD, Professor and Division Director, Head and Neck Surgical Oncology, Department of Otolaryngology-Head and Neck Surgery, University of Nebraska Medical Center
William M Lydiatt, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Head and Neck Society, and Nebraska Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Mary C Snyder, MD, Associate Professor, Division of Plastic Surgery, University of Nebraska Medical Center
Mary C Snyder, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Medical Association, and American Rhinologic Society
Disclosure: Nothing to disclose.

Daniel D Lydiatt, DDS, MD, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Nebraska Medical Center
Disclosure: Nothing to disclose.

Medical Editor

M Abraham Kuriakose, MD, DDS, FRCS, Chairman, Head and Neck Institute, Amrita Institute of Medical Sciences
M Abraham Kuriakose, MD, DDS, FRCS is a member of the following medical societies: American Association for Cancer Research, American Head and Neck Society, British Association of Oral and Maxillofacial Surgeons, and Royal College of Surgeons of England
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Stephen G Batuello, MD, Consulting Staff, Colorado ENT Specialists
Stephen G Batuello, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Physician Executives, American Medical Association, and Colorado Medical Society
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown

 
 
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