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KEY POINTS

KEY POINTS

  • Penetrating wounds to the neck, particularly those that might involve cervical vascular structures, are grouped into three separate vertical zones with different operative exposures.

  • In zone I, a vascular injury from a penetrating wound or blunt trauma may cause a mediastinal or extrapleural hematoma seen on a chest x-ray or computed tomography (CT) scan of the chest, external hemorrhage from the thoracic outlet, or intrapleural exsanguination.

  • In zone II, a large lateral hematoma compressing or deviating the trachea mandates endotracheal intubation over a fiberoptic bronchoscope; failure of intubation mandates a cricothyroidotomy.

  • In zone III, exsanguinating hemorrhage from the base of the skull after a penetrating wound mandates insertion of a Fogarty balloon catheter for rapid tamponade.

  • When all patients with penetrating wounds through the platysma muscle in zone II of the neck are managed with a mandatory operative exploration, nearly 50% will have an unnecessary operation.

  • Diagnostic options in patients with vascular “soft” signs after a penetrating wound of the neck are CT arteriography or duplex ultrasonography/color flow Doppler in the modern era.

  • A fracture-dislocation of the cervical spine has a 30% or greater incidence of an associated blunt cerebrovascular injury.

  • Thirty to 40% of patients with blunt injury to the carotid artery and 10% to 15% of those with blunt injury to the vertebral artery will suffer a stroke without treatment.

  • Hyoid bone fractures are rare, and most can be managed conservatively.

  • Mild laryngeal trauma can be managed with supportive care, whereas more severe trauma will require surgical intervention.

  • Large laryngeal lacerations with exposed cartilage, disruption of the anterior commissure, cartilage fracture, injury to the recurrent laryngeal nerve, and cricotracheal separation are indications for operative repair.

  • Laryngeal stents are used in the presence of significant mucosal injuries, injury to the anterior commissure, or when there are multiple cartilaginous fracture lines that cannot be adequately stabilized.

INTRODUCTION

One of the first reported cases of cervical trauma was in Homer’s Iliad when Achilles delivered a fatal lance blow to Hector’s neck, “where the clavicle marks the boundary between the neck and thorax.” This was portrayed by Peter Paul Rubens in about 1631 and hangs in the Museum Boymans-van Beuningen in Rotterdam, the Netherlands.1 Treatment was first described by Ambrose Pare in the mid-16th century when he ligated the right carotid artery and jugular vein of a soldier who had suffered a bayonet wound.2 The patient survived, but was aphasic and developed a dense, left-sided hemiplegia.3 The first successful treatment of a major cervical vascular injury did not occur until 1803 when Fleming, aboard the HMS Tonnant, ligated the common carotid artery of a sailor after a suicide attempt while at sea. The sailor made a prolonged but complete recovery.4,5 A similar case was reported by Eves of Cheltenham, England, in 1849.6

ANATOMY

Knowledge of the surface landmarks of ...

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