Head and Neck Trauma Hosseini M. M.D

1. Head and Neck Trauma Hosseini M. M.D Head and Neck Surgeon Rasoul Akram Hospital Iran University

3. Airway • Vascular system • Nervous system • Esophagus/Hypopharynx • Bone

4. Signs and symptoms of penetrating neck trauma • Airway • Respiratory distress • Stridor • Cyanosis • Hemoptysis • Hoarseness • Tracheal deviation • Subcutaneous emphysema • Sucking wound

5. Vascular system • Hematoma • Persistent bleeding • Neurologic deficit • Absent pulse • Hypovolemic shock • Bruit • Thrill • Change of sensorium

6. Nervous system • Hemiplegia • Quadriplegia • Coma • Cranial nerve deficit • Change of sensorium • Hoarseness

7. Esophagus / hypopharynx • Subcutaneous emphysema • Dysphagia • Odynophagia • Hematemesis • Hemoptysis • Tachycardia • Fever

10. Zone I : • 1-Close proximity to thorax (dangerous) • 2-Protect by bony thorax and clavicle • 3-Surgical exploration is difficult • 4-Mortality 12% • 5-Mandatory exploration is not • recommended • 6-Angiography • 7-Right side : median sternotomy • 8-Left side : left anterior thoracotomy

11. Zone II : • 1-The most involved zone (60% - 75%) • 2-Mandetory versus selective

12. Zone III : • 1- Protect by skeletal structures • 2- Surgical exploration is difficult (need to divide or displace the mandible) • 3-Cranial nerves injuries • 4- Angiography and barium swallow (in stable patients and no lifethreating symptoms) • 5-Frequent intraoral examination

15. -       Temporal (frontal) Inability to raise the eyebrow -       Zygoma (malar) Inability to close the eyelids -       Buccal Inability to smile -       Marginal mandibular Inability to frown

16. Facial nerve injuries • 1-Maxillofacial trauma • 2-Serious functional disabilities and aesthetic defects • 3-Posterior half of parotid gland has deep laceration • 4-Repaired five or main trunk (clean,sharp division)

17. Signs of immediate Lifethreatening Injuries 1-Massive bleeding 2-Expanding hematoma 3-Nonexpanding hematoma in the presence of hemodynamic instability 4-Hemomediastinum 5-Hemothorax 6-Hypovolemic shock

18. Diagnostic evaluation • 1- Full examination of the unclothed body (entrance - exit ) • 2- Full neurologic examination • 3- Chest X - Ray ( Hemothorax pneumothorax-pneumomediastinum) • 4- Cervical spine X- Ray • 5- Flexible endoscopy – arteriography (24 hours available)

19. Angiography Indications : Wounds near vessel in zone I or zone III Contraindications : Expanding hematoma Profound shock Uncontrolled bleeding Accuracy :98.5%

20. Barium swallow • Indications : • Hematemesis • Drooling • Dysphagia • Vocal cord paralysis • Contraindications : • Intubated • Saliva in wound Unstable pt. • Accuracy : 90%

21. Direct laryngoscopyand broncoscopy • Indications : • Vocal cord paralysis • Hoarseness • Tenderness or crepitance • over larynx • Subcutaneous emphysema • Hemoptysis • Contraindications: None • Accuracy :100%

22. Esophagoscopy • Indications • Suspected but unconfirmed injury by Barium swallow • Intubated • Laryngeal or tracheal injury • Vascular injury inzone II or zone III • Contraindications :None • Accuracy :86%

23. The leading cause of death Frompenetrating neck injuries is hemorrhago from vascularstructures ( 50% )

24. Mandatory Versus Elective Exploration • 1-Lifethreatening • 2-Not lifethreatening

25. Stable patients: • 1-Mandatory exploration for all penetrating neck wounds • 2-Selective exploration with observation

26. Subcutaneous emphysema In the neck or face • 1-Sinus • 2- Hypopharynx • 3- Laryngothracheal complex • 4- Pulmonary parenchyma • 5- Esophagus

27. Esophageal injuries • 1-Blunt (rare) • 2-16/288 (when penetrate platysma) • 3-Air in mediastinum • 4-Pain • 5-Hematemesis • 6-Hoarseness • 7-Barium swallow • 8-Endoscopy (rigid) • 9-N.P.O (7-10 days)

28. Small injuries ofTrachea • Primary repair •     No tracheotomy • Absorbable sutures (3-0 or 4-0) •      Transversely sutures •      Ring above and below •      No drain

29. Large defects • Anterior : Convert to tracheotomy • Posterior &lateral : Close primary & tracheotomy • Very large defect : Primary anastomosis(5-6 rings)

30. Initial management 1-Airway 2-Blood perfusion maintenance 3-Clarification and classification of the severity of wound

33. Parotid duct injuries • -  Opening opposite the second upper molar • -  Orifice of Stensen s duct should be probed - Repair over catheter

41. Penterating Neck Injury Is immediately life-threatening Is not

42. Signs Of Immediate L. T. -Massive bleeding -Expanding hematoma -Nonexpanding hematoma in the presence of hemodynamic instability -Hemomediastinum -Hemothorax -Hemovolemic shock

43. Stable patient -Mandatory exploration for all pent.neck wounds -Selective exploration and observation -50-70% of pt. had negative exploration

44. -World war II mortality of penetrating neck wound 7-15% -End of vietnam war 3-6%

45. Transcervical injuries should be reported seperately from zone I , II , III injuries. Transcervical penetrating neck wounds when the projectile crosses the midline , have 100% vascular or aerodigestive injury.

46. Initial management 1-Airway establishment 2-blood perfusion maintenance 3-clarification & classification of severity of the wounds

47. Airway a-Intubation b-cricothyroidectomy c-tracheostomy

48. Direct transcervical tracheal intubation • Oral cavity • Pharynx • larynx

49. X-ray • Anterior • Lateral • Chest x-ray

50. Esophageal perforation • Gastrografin swallow • If g. is negative a barium swallow perform • Flexible esophagoscopy 86% • Contrast swallow 90% • Rigid esophagoscopy • Flexible+Rigid endoscopy