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Injuries to the Neck

Injuries to the Neck. Jason Davis, MD. Blunt Neck Trauma. Blunt arterial 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

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Injuries to the Neck

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  1. Injuries to the Neck Jason Davis, MD

  2. Blunt Neck Trauma • Blunt arterial 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

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

  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

  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 possprox control • Greasy feel may indicate salivary amylase

  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/ 3.0 - 4.0 absorbable Post-op monitor for mediastinitis +cxr for pneumo-mediastinum, leaks or missed pharyngoesoph injury Reconstruction / definitive repair semi-elective

  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 stylohyoidlig, 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

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