Penetrating Injuries of the Neck Workup

  • Author: William M Lydiatt, MD; Chief Editor: Arlen D Meyers, MD, MBA   more...
 
Updated: Feb 28, 2012
 

Laboratory Studies

  • All trauma patients undergo preliminary laboratory tests of the following:
    • Hemoglobin and hematocrit level to determine the degree of blood loss or detect underlying anemia
    • Glucose level, which can affect level of consciousness
    • Electrolyte levels (basic electrolyte panel) to detect metabolic disturbances
  • An arterial blood gas concentration is obtained in every patient with respiratory compromise.
  • After initial stabilization, laboratory studies are tailored to each patient's injuries and past medical history.
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Imaging Studies

  • Radiography
    • Initial radiographic evaluation includes plain radiography of the neck and chest radiography. Plain radiographs of the neck are useful to identify foreign bodies and free air.
    • Air in the prevertebral or deep neck spaces suggests injury to the larynx or trachea.
    • Pneumomediastinum and pneumothorax are suggestive of airway injury.
  • CT scanning[3]
    • CT evaluation of the neck is often valuable for the evaluation of laryngeal injuries. Patients in stable condition who may have a laryngeal injury but who do not require immediate surgical treatment should undergo CT scanning of the neck. Patients with open lacerations of the larynx, lacerations crossing the vocal cords, disruption of the anterior commissure, subluxed arytenoid cartilages, exposed cartilage, or obvious crush injuries of the larynx require surgery and are not likely to benefit from CT evaluation.
    • CT scanning is generally the best imaging modality in the evaluation of penetrating injury when a retained foreign body is suspected. It is useful in identifying metallic objects, including missiles, as well as most radiolucent foreign bodies, including those made of plastic and wood. CT scanning is also useful in defining the relationships of foreign bodies to surrounding muscles, bone, and soft tissues. However, CT scanning is limited in the identification of very small foreign bodies and those with a density similar to that of the surrounding soft tissues, such as some wood fragments. In cases in which a foreign body is strongly suspected, exploration may be indicated despite a negative finding on CT scan.
  • Contrast-enhanced esophagography
    • Esophageal injuries may be diagnosed with contrast-enhanced esophagography; however, the sensitivity of this test is reported to be only 70-80%.
    • The use of water-soluble contrast material such as Gastrografin is preferred to prevent barium-induced mediastinitis or pneumonitis.
    • In comparison, barium studies are reported to have a higher sensitivity, and some authors recommend repeating esophagography with barium in patients with a negative Gastrografin finding who have a high likelihood of esophageal injury.
  • Doppler ultrasonography: This study is used to assess stenosis or aneurysm formation after major injuries to the carotid artery are repaired.
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Diagnostic Procedures

  • Flexible laryngoscopy
    • Flexible laryngoscopy is an extremely useful technique for the evaluation of patients with laryngotracheal trauma. It is easily performed at the bedside and provides excellent depiction of the upper airway and larynx.
    • Both the oropharynx and hypopharynx are examined for hematomas or lacerations. The larynx is inspected for mucosal tears, exposed cartilage, hematoma, and edema. The position and motion of the arytenoid cartilages are noted, as is the degree of vocal cord closure.
  • Angiography
    • The merits of routine angiography versus selective angiography continue to be debated. Many authors believe that physical examination is inadequate for the evaluation of arterial injuries in penetrating neck injury and recommend routine angiography for all proximity injuries. In a prospective study that included 176 hemodynamically stable patients with penetrating neck injury, routine angiography depicted vascular injuries in 19%, and only 8% required intervention. Most centers follow a protocol of selective angiography in which both symptomatic and asymptomatic zone 1 and zone 3 injuries are routinely evaluated with angiography. These zones are difficult to assess clinically, and surgical access is challenging. Zone 2 injuries are usually explored surgically if they are symptomatic, and they can be followed up clinically or evaluated with angiography if they are asymptomatic.
    • Recent advances in interventional radiology have resulted in the increasing use of embolization techniques to control bleeding, especially in areas that are difficult to access, such as the base of skull. Balloon occlusion can be used to control hemorrhage temporarily until vascular access is obtained, or vessels can be embolized if they are considered expendable or surgically inaccessible.
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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  Division of Plastic Surgery, Monument Plastic Surgery

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.

Specialty Editor Board

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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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.

Christopher L Slack, MD  Private Practice in Otolaryngology and Facial Plastic Surgery, 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 of Otolaryngology, Dentistry, and Engineering, 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 Unrestricted gift Unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Medvoy Ownership interest Management position; Cerescan Imaging Consulting; Headwatersmb Consulting fee Consulting; Venturequest Royalty Consulting

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