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To Look or Not to Look: Controversies in Surgical Exploration of Penetrating Neck Trauma

To Look or Not to Look: Controversies in Surgical Exploration of Penetrating Neck Trauma. Anne Conlin, BA&Sc, MD PGY-2, Otolaryngology. Case. 46 year old male working in abattoir Was butchering beef when a live steer broke through gate, knocking him over

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To Look or Not to Look: Controversies in Surgical Exploration of Penetrating Neck Trauma

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  1. To Look or Not to Look:Controversies in Surgical Exploration of Penetrating Neck Trauma Anne Conlin, BA&Sc, MD PGY-2, Otolaryngology

  2. Case • 46 year old male working in abattoir • Was butchering beef when a live steer broke through gate, knocking him over • Sustained penetrating trauma to the neck w/ a meat hook

  3. Case • Treated at local ED w/ irrigation and antibiotics; penrose drain placed • Transferred to TOH

  4. Case • Hx • Pt. unsure of mechanism of injury • Complained of pain in the neck • Px • VSS, O2 sats >92% • General: moderate discomfort • Neck: 2 cm wound inferior to R body of mandible, penetrating platysma; pain on palpation; neck otherwise unremarkable

  5. What should we do? • Day call ENT staff: booked patient as P3 • Night call ENT staff: “Why are we here?”

  6. Objectives • Case presentation • Approach to penetrating neck wounds • To look or not to look? The controversy. • Adult population • Pediatric population • Summary

  7. An Approach to Penetrating Neck Trauma

  8. Penetrating Neck Trauma • 5-10% of all trauma admissions • Low overall mortality 0-11% • 30% of cases involve multi-system injury

  9. Approach to Penetrating Neck Trauma • Zone I • Sternal notch to cricoid cartilage • Zone II • Cricoid cartilage to angle of mandible • Zone III • Angle of mandible to base of skull

  10. Zone I • High risk of serious injury • Difficult region for exposure and control • Vital structures • Proximal carotid, vertebral & subclavian a • Major BV of upper mediastinum • Lung apices • Esophagus • Trachea • Thoracic duct

  11. Zone II • Easier access and control • Vital structures: • Carotid sheath: carotid a, jugular v, vagus n • Vertebral a • Esophagus • Trachea • Larynx • Recurrent laryngeal n • Spinal cord

  12. Zone III • Difficult region for exposure & control • Vital structures: • Distal carotid a • Vertebral a • Parotid & other salivary glands • Pharynx • CN IX, X, XI, XII • Spinal cord

  13. Vascular Including: Internal, external & common carotid arteries Vertebral & subclavian arteries Internal & external jugular veins Signs: ABCs External hemorrhage Hematoma Shock Present in: 25% Mortality: 50% Systems at Risk

  14. Pharyngo-esophageal Symptoms & Signs: Dysphagia & odynophagia Hemoptysis & hematemesis Subcutaneous emphysema Air bubbling at wound (w̸ cough) Often difficult to detect Potential consequences: Mediastinitis Sepsis Present in: 5% Systems at Risk

  15. Laryngotracheal Signs: Dyspnea Hoarseness Stridor Subcutaneous emphysema Present in: 10% Mortality: 20% Systems at Risk

  16. Nervous system Cranial nerves: Facial Glossopharyngeal Recurrent laryngeal Accessory Hypoglossal Spinal cord Brachial plexus: Median n – fist Radial n – wrist ext Ulnar n – finger abd MCC n – elbow flex Axillary n – arm abd GCS Uncommon injury Common missed injury Systems at Risk

  17. Mechanism of Injury • Stab wounds • depth & direction difficult to determine on exam • Bullets & projectiles • entry ± exit sites provide little information on amount of tissue injured

  18. Management of Penetrating Neck Trauma:Historical Approach

  19. Classic Approach to Penetrating Neck Wounds • Until 1950s: • Seen almost exclusively by military surgeons • Recommended mandatory exploration for all wounds penetrating the platysma • Rationale: high morbidity & mortality from missed injuries

  20. Controversy Arises • Mandatory surgical exploration was challenged in the 1970s & 1980s • Arteriography available • Health economics • Risk vs. benefit

  21. Annals of Surgery, 1985 • Retrospective study • 257 patients w/ injury penetrating platysma • Group I (1975-1981): mandatory exploration • Group II (1981-1984): selective neck exploration • Indications: hypotension, shock, profuse external bleed, expanding hematoma, dysphagia, neurological deficit, diminished carotid pulse, subQ emphysema, hemoptysis, hemetemesis, spitting blood, respiratory distress

  22. Annals of Surgery, 1985 • Group I: 69% of pt w/ mandatory exploration had no injury • Group II: 22% of pt w/ selective exploration had no injury; none of the observed pt required subsequent exploration • Group II: 2 mortalities in observed pt (MI; spinal cord transection) • Remainder of mortalities in explored patients

  23. The Importance of the Zones • Annals of Surgery study did not subgroup patients by zone of injury • Considerable variation in surgical access and structures at risk by zone of injury

  24. Investigations

  25. World Journal of Surgery, 1997 • Demetriades et al, 1997 • Prospective study, n=223 • Objective: to asses role of clinical examination, angiography, colour flow Doppler

  26. World Journal of Surgery, 1997 • Clinical examination • Emergency surgery: • Severe active bleeding • Refractory shock • Air bubbling at wound • Dyspnea • All other patients underwent investigations according to protocol

  27. World Journal of Surgery

  28. World Journal of Surgery

  29. Emergency Operations • 38 patients (17%) subjected to emergency operation • Only therapeutic in 30 (13.5% of all cases) • 6 had negative exploration • 2 had non-therapeutic surgery: thrombosed vertebral artery • One missed esophageal perforation during exploration • Deaths: 6 total; 5 due to non-neck injuries; unclear if deaths in surgery or non-surgery grp

  30. Results: Vascular Assessment • Angiography • 176 patients • 34 abnormalities (19.3%) • 14 required surgery (8%) • Most common: • vertebral artery occlusion (5%) • Others: • VA tear, ICA occlusion, CCA aneurysm/tear; unnamed vessel thrombosis

  31. Results: Vascular • Angiography + Colour Flow Doppler • 99 patients • w/ angiography as gold standard, CFD had: • Sensitivity = 91.7% • Specificity = 100% • PPV = 100% • NPV = 99% • 100% all-around if only injuries requiring surgery were considered

  32. Angiography complications Femoral hematoma in 5 patients (2.2%) Clinical Exam for Vascular Injury w/ angiography or surgical exploration as gold standard: NPV = 91.7% 100% if only injuries requiring surgery were considered Results: Vascular

  33. 216 patients clinically evaluated 64 had +SSx 10 required surgical repair 0 asymptomatic patients required operation Contrast swallow study 98 patients w/ Sx or proximity injury 2% esophageal injury (+Sx) Esophagoscopy 22 patients, all normal Laryngoscopy 149 patients w/ Sx or proximity injury 25 abnormal (VC dyskinesia, edema, blood) 5 required surgery Results: Aerodigestive Assessment

  34. Discussion • If policy of mandatory surgical exploration: • Non-therapeutic in 86.5% • Angiography has low yield and does not change management • 7.8% of asymptomatic patients had +ve AG • 0% asymptomatic patients had +ve AG finding requiring surgery

  35. Discussion • Esophageal studies • Selective contrast swallow study yield: 2% • Esophagoscopy yield: 0% • Overall • Clinical exam has 100% NPV for vascular and aerodigestive injuries requiring surgery • Clinical exam: 38.1% sensitivity for vascular and aerodigestive injuries requiring surgery • CFD is a reliable and inexpensive alternative to angiography

  36. Discussion • Developed algorithm • If this had been followed: • Total cost would be $30,500 vs. actual cost $444,500 • If CFD done instead of AG: $250,000 savings

  37. The Canadian Experience

  38. Canadian Journal of Surgery, 2001 • Retrospective chart review • 130 consecutive pt. w/ neck wounds penetrating platysma • Surgical exploration vs. observation

  39. CJS 2001 • Location: • Zone I: 15% • Zone II: 81% • Zone III: 4% • Mechanism: • Knife/broken bottle: 73% • GSW: 5%

  40. CJS, 2001 • Management • Observation: 50/130 (38%) • Surgery: 80/130 (62%)

  41. Important Findings • Zone II: • All zone II major vascular injuries were symptomatic on presentation • Neck exploration was negative in all asymptomatic zone II injured patients

  42. Asymptomatic Patients • 76% of all injuries were symptomatic on presentation • Mean hospital stay for asymptomatic patients treated w/ observation & surgical exploration was similar (3.5; 4.3; p=0.575)

  43. Missed Injuries • 1 pharyngeal injury missed in a pt who underwent surgical exploration • 1 pt developed pharyngocutaneous fistula after exploration & repair of lacerated trachea • Follow-up visits • 1 brachial plexus injury • 1 accessory nerve injury

  44. Long-term Disability • All neurologic • 3 pt managed by observation + 6 pt managed by surgery: • Phrenic (1) • Recurrent laryngeal (1) • Accessory (3) • Brachial plexus (4)

  45. Canadian Study Overall • Majority of patients were asymptomatic • Optimal management of asymptomatic Zone II injured patient is not known • Neck exploration does not rule-out the possibility for missed injury • Bottom-line: risk of death from missed esophageal injury, therefore, consider NPO x24 hrs, close observation x48 hrs, & low threshold for rigid esophagoscopy

  46. The Pediatric Experience

  47. Retrospective chart review Age ≤16 N=31 84% in Zone II Abujamra et al, 2003

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