Penetrating Injuries of the Neck

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

Frequency

Incidence of penetrating neck injury is closely related to incidence of violent crime and military conflict. In the United States, most penetrating neck injuries in the adult population are secondary to assault. Less frequently, some injuries to adults and most pediatric cases result from accidents involving a fall or motor vehicle accidents. However, the actual frequency of accidental penetrating neck trauma remains unreported.

In the United States, penetrating neck injuries contributed to less than 2% of all reported injuries in 2013. Despite the relative infrequency, severe neck injuries are associated with a high case fatality rate.[4]

Penetrating neck trauma is more frequent during military conflict.[5] Neck injuries accounted for as many as 17% of all injuries sustained by US troops in Iraq and Afghanistan. Most of these involved penetrating wounds and carried a mortality rate of up to 4%.[6]

The incidence of penetrating neck trauma in pediatric patients younger than age 15 years is extremely low (0.28%). Stab injuries (44%) far outnumber injuries due to gunshots (24%) in this age group. The overall mortality rate of 5.6% is linked to independent risk factors such as vascular injury and hypotension upon presentation to the emergency department.[7]

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.

Penetrating missile trauma can be a low-velocity injury or a high-velocity injury.[5] The wounding capacity of a missile is directly proportional to its velocity. Low-energy wounds caused by a projectile traveling at a velocity less than the speed of sound 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 major organ systems of the neck, including the great vessels, larynx and trachea,[8] 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.

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.[9, 10] 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.[11] 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 appropriate imaging modalities 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.

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 local availability of resources and the philosophy of the surgeon.[12] 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.

Prehospital trauma management protocols have been evolving, and evidence suggests that cervical spine immobilization in patients with a penetrating neck injury and intact neurologic status may not be useful and may be detrimental to quick assessment, airway securement, and injury management.[13, 12]

Airway compromise, massive subcutaneous emphysema, bubbling air through the wound, active bleeding, expanding hematoma, neurologic deficits, and hematemesis suggest major vascular or aerodigestive tract injuries. Patients who present with these “hard signs” and those with hemodynamic instability should be transferred to the operating room after a secure airway has been established.[10]

Patients in stable condition should undergo a thorough evaluation of the vascular structures of the neck and the aerodigestive tract prior to surgical intervention.

The lateral neck is divided into 3 zones; this system is useful in the evaluation and treatment of penetrating neck injuries.[14]

• 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.

Every patient with a history of trauma should be evaluated and treated according to the ATLS guidelines established by the American College of Surgeons.[9] 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.

Laboratory and radiologic workup for patients with penetrating trauma to the neck requires a tailored approach based on their injury location, severity, and hemodynamic status.

All trauma patients should undergo the following preliminary laboratory tests:

• 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

• Consider blood typing and cross-match for patients with blood loss

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.

Patients with stable vitals and no hard clinical signs of major vascular or aerodigestive tract injury can be evaluated with a variety of imaging modalities.

CT scanning[15]

Multi-detector CT angiography (MDCTA) can be used to obtain noninvasive, fast, and reliable assessment of vascular and aerodigestive tract injuries. A recent prospective multicenter study found MDCTA to be 100% sensitive and 97.5% specific in hemodynamically stable patients with soft signs following penetrating neck injuries.[16] MDCTA can be a valuable tool in identifying patients who can be safely observed and direct therapy in others by facilitating anatomical localization of injury and identifying the trajectory of the object resulting in the injury. Additionally, CT imaging may identify retained foreign bodies. 

MDCTA may be used in lieu of invasive arteriography for vascular assessment, except when beam artifact from a retained foreign body hinders a reliable study or when angiographic embolization of a known vascular injury is anticipated.[12]

The sensitivity of MDCTA in detecting arterial injuries following penetrating neck trauma ranges between 75.7% and 82.2%. The technique is highly specific in identifying penetrating injuries to the arteries in the neck (96.4-98.4%). The sensitivity of the test in detecting internal carotid and vertebral artery injuries was far better than that for external carotid artery injuries.[17]

A CT scan of the neck is useful for the evaluation of patients with suspected laryngeal injuries and a stable patent airway. 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.

A CT scan is generally the best imaging modality in the evaluation of a 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. When 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. Duplex ultrasounds may be used in lieu of invasive arteriography for assessment of zone 2 neck injuries.[12]

Radiography

Plain radiographs of the neck may be useful in identifying 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.

Guidelines

While clinicians should tailor the use of imaging studies and other ancillary diagnostic tests in the context of the patient's clinical condition; other, coexisting injuries; and care priorities determined as part of trauma evaluation, the American College of Radiology Appropriateness Criteria for penetrating neck injury, published in 2017, may provide a framework for imaging for patients who suffer penetrating neck injuries[18] :

• In patients with penetrating neck injuries with clinical soft injury signs and in patients with hard signs of injury who do not require immediate surgical exploration, CT angiography of the neck is the preferred imaging procedure to evaluate the extent of injury
• When a clinical concern remains for vascular injury despite a normal or equivocal CT angiography scan of the neck, catheter-based arteriography is useful for further evaluation; the benefit of arteriography is the ability to perform, in tandem, an endovascular procedure if needed
• If a concern remains for aerodigestive injury despite a normal or equivocal CT angiography scan of the neck, a radiographic single-contrast esophagram may be considered, but it should be used in conjunction with direct visualization techniques

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.

However, techniques such as MDCTA have high sensitivity and specificity in predicting and evaluating vascular injuries to the neck.[16] As a result, invasive angiography is only obtained when beam artifact from a retained foreign body hinders a reliable study or when angiographic embolization of a known vascular injury is required.

Angioembolization techniques can be used to control bleeding, especially in areas that are difficult to access, such as the base of the 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.

Patients with penetrating neck wounds without evidence of aerodigestive or vascular injury on clinical evaluation are admitted and observed for at least 24 hours. Ideally, these patients are monitored in the intensive care unit by nursing staff experienced in the care of patients with traumatic injuries, and repeat examinations are performed by a physician every 8 hours. Coverage with broad-spectrum antibiotics is standard, and treatment with H2 blockers is recommended.

Laryngotracheal injuries that do not require surgical repair are managed with serial examination, elevation of the head end of the bed, and corticosteroids. Esophageal tears are the most common injuries to be diagnosed late after a penetrating neck wound. Signs and symptoms suggestive of an occult esophageal injury include fever, tachycardia, chest pain, and widening of the mediastinum on chest radiographs. Mediastinitis is a potentially life-threatening complication of an undiagnosed esophageal injury that requires immediate attention and surgical intervention. Most vascular injuries present in the first 48 hours following injury with delayed bleeding, neurologic deficit, or hematoma development.

A study by Christian et al indicated that in properly selected patients, nonoperative management of penetrating injuries to the internal jugular vein carries a similar risk of morbidity and mortality as does operative management (although the rate of pneumothorax occurrences and ventilator days were higher in the study’s operative management patients).[19]

At the authors' institution, patients with penetrating neck injuries are treated according to a protocol of selective exploration. The decision to move a patient to the operating room is based on the initial presentation, physical examination findings, and results of the previously discussed imaging and diagnostic procedures. Patients with life-threatening injuries undergo immediate surgical exploration, followed by triple endoscopy (laryngoscopy, bronchoscopy, and esophagoscopy). Patients in stable condition undergo thorough investigation and then proceed to either surgical exploration and endoscopy or close observation.

The condition of all patients with penetrating neck injuries should be stabilized prior to any surgical procedure, emergent or elective. Stabilization includes the establishment of an airway, by means of intubation or tracheotomy, and resuscitation with intravenous fluids or blood products as needed. At minimum, preoperative radiologic studies should include anteroposterior and lateral plain radiographs of the neck. This allows evaluation of the cervical spine as well as estimation of the path and location of the missile in the neck. Further preoperative evaluation, as previously discussed, depends on the presentation and stability of the patient's condition. In the event of emergent exploration, blind clamping should not be exercised and hemostasis may require direct pressure or balloon tamponade until transfer to the operating room.[20]

Vascular injuries

The approach for vascular repair depends on the zone of injury. Zone 1 injuries are usually exposed via an oblique supraclavicular incision. Resection of the middle portion of the clavicle may be required for adequate visualization of the subclavian artery. Additionally, mediastinotomy extension or formal lateral thoracotomy may be necessary to control intrathoracic hemorrhage. Consultation with a thoracic surgeon is appropriate with zone 1 vascular injuries.

Vascular injuries in zone 2 are exposed through a standard neck dissection incision that follows the natural skin-tension lines in the middle portion of the neck. All veins in the neck may be ligated, although repair of one internal jugular vein should be considered if ligation of both veins is necessary. The external carotid artery and its branches may be safely ligated, if needed, for control of hemorrhage. Techniques for repair of the common and internal carotid arteries include lateral arteriorrhaphy, end-to-end anastomosis, and grafting. Ligation is considered only when attempts to repair the artery have failed. Shunt creation may be necessary to visualize and repair the carotid artery.

Zone 3 vascular injuries are difficult to access surgically and may require mandibular subluxation or mandibulotomy for exposure. The incision is similar to that used in zone 2, although it should be placed 2 cm below the mid mandible and 1 cm below the facial notch to avoid injury to the marginal branch of the facial nerve in a patient with a long neck. Vascular repair techniques are similar to those used in zone 2, but they are inherently more difficult because of the limited access. The digastric muscle may be split to provide access to the internal carotid. Angiography with embolization may be more successful in controlling arterial disruption at the skull base than surgical exploration and repair.

Laryngotracheal injuries

If a laryngotracheal injury is identified with physical examination or flexible laryngoscopy or if exploration is performed for another injury, direct laryngoscopy and bronchoscopy should be performed. Esophagoscopy should also be performed in patients with these injuries, because as many as 50% of patients with an airway injury also have a digestive tract injury. All laryngotracheal injuries may result in airway compromise; delayed compromise is possible. Physicians must be aware of the airway status at all times during the evaluation of patients with laryngotracheal injuries, and they must be prepared to secure the airway with tracheotomy if necessary.

The degree and type of injury must be carefully evaluated during endoscopic examination. Laryngeal injuries are classified by location (supraglottic, transglottic, cricoid, or tracheal) and type (hematoma, mucosal tears or lacerations, cartilage fractures and/or dislocations, or laryngotracheal disruption).

The surgical management of laryngeal trauma is based on the extent of injury during initial and endoscopic evaluation. Minor lacerations, small hematomas, and nondisplaced single fractures may be managed with observation and serial examination. Lacerations involving the anterior commissure or with exposed cartilage, multiple or displaced cartilage fractures, vocal cord immobility or arytenoid dislocation, or other injuries sufficient to cause airway compromise should be managed with exploration and repair. Occasionally, small lacerations and minor dislocations can be repaired endoscopically.

Timing of the repair of laryngotracheal injuries remains controversial. Some authors recommend waiting 3-5 days to allow swelling to subside, but better results have been obtained with earlier repair. Exploration of laryngeal injuries begins with an apron incision, and a midline thyrotomy allows entry into the larynx. Mucosal lacerations are repaired, and fractures are reduced and fixated with wire or permanent suture. Large tissue losses may be repaired with skin grafts or regional muscle flaps. The thyrotomy incision is closed, and drains are placed in the neck. Massive laryngeal injuries may require total laryngectomy in rare cases.

Tracheal injuries are usually approached via a lateral or transverse neck incision, with extension to a sternotomy or thoracotomy if needed. Small tracheal tears are closed primarily. More extensive tracheal injuries must be débrided to expose healthy mucosa. Sections of the trachea with deficits as large as 2-3 cm can usually be closed without excessive tension, but wider gaps may require extensive mobilization. Prophylactic tracheostomy is discouraged in patients with small tracheal wounds because of the increased risk of infection-related complications, but a tracheotomy almost always is required in more extensive injuries. Stent placement in laryngotracheal injuries after repair is controversial; it is usually recommended in anterior commissure injuries, comminuted fractures, and unstable fractures following reduction. Recurrent laryngeal nerve injuries should be repaired to help maintain muscle tone.

Pharyngeal or esophageal injuries

If a pharyngeal or esophageal injury is suspected on the basis of findings from clinical and radiologic evaluation or exploration for another injury, the upper digestive tract should be carefully evaluated. Some centers advocate a combination of flexible and rigid esophagoscopy to examine the entire cervical and upper thoracic esophagus.

Occasionally, pharyngeal injuries can be repaired transorally, but most esophageal injuries should be approached through a standard neck incision overlying the anterior border of the sternocleidomastoid muscle. Esophageal tears should be thoroughly irrigated, débrided, and closed in two layers. A muscle flap may be placed over the suture line to minimize fistula formation. Drains should be placed prior to closure of the neck. Extensive esophageal injuries may require lateral cervical esophagostomy followed by delayed closure.

Postoperatively, patients are monitored closely in the intensive care unit. Serial examinations are performed to identify any missed injuries. Use of broad-spectrum antibiotics and H2 blockers is standard for all patients with penetrating neck wounds. Anticoagulants may be indicated following repair of vascular injuries, if their use is not contraindicated by other injuries. Patients who undergo repair of laryngotracheal injuries receive antibiotics and H2 blockers or proton pump inhibitors for several weeks to reduce granulation tissue formation. After repair of esophageal injuries, patients are not given anything by mouth for 7-10 days; a nasogastric tube is placed for feeding.

Depending on the type and degree of injury, patients with penetrating neck trauma are likely to require frequent outpatient follow-up care. If an injury to a major organ system is never identified and if recovery is uncomplicated, long-term follow-up is not necessary. Significant vascular injuries can result in neurologic sequelae requiring short-term or long-term rehabilitation. Major carotid injuries and repairs should be evaluated postoperatively with Doppler ultrasonography; possible stenosis or aneurysm formation should be assessed.

Patients with laryngotracheal injuries require frequent examination with flexible and/or direct laryngoscopy to assess healing. If a tracheotomy is present, decannulation should be attempted as soon as possible, and stents placed during repair of laryngotracheal injuries should be removed in a timely manner. Repeat examinations are indicated to assess long-term vocal cord function and the development of stenosis. Esophageal injuries may result in stenosis, which requires endoscopic evaluation and possible dilation.

Early complications in patients with penetrating neck injuries include those related to the type and degree of injury. Bleeding may manifest at the time of presentation or may be delayed in patients treated with observation or surgical exploration. The management of acute hemorrhage and hematoma is discussed in previous sections. All patients with neck trauma are at risk for wound infections and sepsis because of the mechanism of injury and the potential communication with the aerodigestive tract. Mediastinitis is perhaps the most significant acute complication in these patients; it usually results from the delayed diagnosis of an esophageal injury. The mortality rates from esophageal injuries were found to increase from 11-17% after a delay in diagnosis of only 12 hours.

Long-term complications following vascular injuries may include neurologic deficits, carotid stenosis, or aneurysm formation. Laryngotracheal injuries may result in long-term tracheotomy dependence, subglottic stenosis, vocal cord paralysis and voice changes, and dysphagia. Esophageal injuries also may result in long-term dysphagia, usually secondary to stricture formation.

The current mortality rate for penetrating neck injury is 3-6%, with 50% of deaths caused by hemorrhage from vascular injuries. Vascular injuries cause complications in 40% of cases of penetrating neck injury, and 10% of patients have an injury to the carotid artery. Aerodigestive tract injuries occur in 23-30% of patients with penetrating neck wounds, and esophageal injuries are associated with mortality rates of 11-17%.

A retrospective study by Forner et al of adult patients indicated that compared with penetrating neck injuries, the in-hospital mortality rate is lower and the length of hospital stay is shorter for blunt injuries to the neck. The crude mortality rates were 4.9% versus 6.0% for blunt versus penetrating injuries, respectively, with adjusted analysis confirming that mortality rates for blunt injuries were decreased (odds ratio = 0.66) and that length of stay was significantly reduced (rate ratio = 0.92).[21]

Controversy persists regarding the ideal treatment of patients with penetrating neck trauma. Advocates of mandatory exploration of penetrating neck wounds believe that surgery is a time-tested management strategy that allows rapid diagnosis of potentially life-threatening injuries that may be missed on physical examination. A prospective study of 393 patients with stab wounds by Apeffelstaedt and Muller revealed that clinical signs were absent in 30% of neck explorations with positive findings and in 58% of those with negative findings.[22] They also reported a very low complication rate and a mean hospital stay of 1.5 days. The authors concluded that mandatory exploration is safe, does not prolong hospital stays, and prevents unnecessary diagnostic procedures.

Advocates of selective management cite the high rates of negative findings at neck exploration, which range from 30-89%. Additionally, other studies have revealed a prolongation of hospital stay by 1.4 days in patients with negative findings at exploration. Most centers have adopted a form of selective management instead of mandatory exploration, but the criteria for surgical intervention, as well as the protocols for diagnostic investigations, vary widely.

The American College of Radiology Appropriateness Criteria for penetrating neck injury, published in 2017, include the following recommendations[18] :

• In patients with penetrating neck injuries with clinical soft injury signs and in patients with hard signs of injury who do not require immediate surgical exploration, CT angiography of the neck is the preferred imaging procedure to evaluate the extent of injury
• When a clinical concern remains for vascular injury despite a normal or equivocal CT angiography scan of the neck, catheter-based arteriography is useful for further evaluation; the benefit of arteriography is the ability to perform, in tandem, an endovascular procedure if needed
• If a concern remains for aerodigestive injury despite a normal or equivocal CT angiography scan of the neck, a radiographic single-contrast esophagram may be considered, but it should be used in conjunction with direct visualization techniques