Neck Injuries

• • All neck injuries are potentially life-threatening

  • Classified as blunt or penetrating with different treatments for each

  • Penetrating injuries are divided into zones I, II, and III

  • Blunt trauma rarely requires surgery but may cause fracture or dislocation of the cervical vertebrae, occlusion of the carotid or vertebral arteries, cerebrospinal fluid cysts, or laryngotracheal injuries

Symptoms and Signs

• • Injuries to the larynx and trachea may be asymptomatic or cause hoarseness, stridor, or dyspnea

  • Subcutaneous emphysema may occur with disruption of larynx or trachea

  • Severe chest pain and dysphagia with esophageal perforation (may be late appearing)

  • Cervical pain or tenderness

  • Decreased level of consciousness

  • Visible blood loss and hematoma usual with vascular injuries

  • Vascular bruit may suggest arterial injury

  • Subclavian artery injuries are best approached through a combined cervicothoracic incision

  • Venous injuries are best managed by ligation

  • Esophageal injuries should be sutured and drained, systemic antibiotics indicated

  • Minor tracheal/laryngeal injuries do not require treatment

  • Immediate tracheotomy for airway obstruction

  • With significant injury to tracheal cartilage silastic stent should be used for support

  • Tracheal lacerations should be closed after debridement and distal tracheostomy

  • Circumferential tracheal injuries require resection and anastomosis or reconstruction with synthetic material

  • Primary neurorrhaphy should be attempted for nerve injury

• • Zone I injuries occur at the thoracic outlet, extending from clavicles to cricoid cartilage

  • Zone II injuries occur in the area between the cricoid and the angle of the mandible

  • Zone III injuries occur between the angle of the mandible and the base of the skull

  • Zone I includes proximal carotid arteries, subclavian vessels, major vessels in the chest; proximal control requires thoracotomy

  • Zone III injuries are difficult to approach and may require disarticulation of the mandible

  • Esophageal injuries rarely occur in isolation and may be asymptomatic initially

• • If stable, diagnostic studies should be considered

  • Arteriography recommended for patients with zones I and III injuries to help with surgical approach

  • Classical approach to any zone II injury penetrating the platysma is operative exploration

  • Alternatively, work-up in stable patient should include arteriography or duplex Doppler, rigid endoscopy and rigid bronchoscopy as well as contrast study of esophagus to rule out high esophageal injuries that are easily missed on endoscopy

  • Plain films of soft tissues and cervical spine

  • Vertebral injuries should be suspected when bleeding from posterior or lateral wound cannot be controlled with pressure, or associated cervical transverse process fracture

• • Any injury that penetrates the platysma requires prompt surgical exploration or angiography to rule out major vascular injury

  • In zone II injuries, color Doppler may be acceptable alternative

  • Neurologic deficit related to arterial injury requires ligation of vessel rather than repair

  • Arteries damaged by high velocity missiles require debridement

  • If end-to-end anastomosis is not possible, autogenous vein graft can ...