Neck Trauma

David Ray Velez, MD

See Also:
*Neck Exploration

Zone Management

Zones of the Neck

Zone I: Thoracic Inlet to Cricoid Cartilage
Zone II: Cricoid Cartilage to Angle of Mandible
- Most Commonly Injured Zone
Zone III: Angle of Mandible to Base of Skull

“Hard Signs” of Injury – Definitive Indications of Arterial/Structural Injury

“Soft Signs” of Injury – Possible Indications of Arterial/Structural Injury

Initial Management

Stable and No Hard Signs: CTA
- Historically All Zone II Injuries Required Surgical Exploration
- May Consider Observation Alone if Stable and Asymptomatic with No Hard or Soft Signs
Unstable or Hard Signs: Surgical Exploration

Gaining Vascular Control at Surgery

Approach:
- Incision is Made Along the Anterior Border of the Sternocleidomastoid Muscle (SCM) – Similar to a Carotid Endarterectomy
- If Bilateral Exploration is Required – Can Make Bilateral Incisions that Connect Inferiorly in a “U”-Shape
Zone I: Proximal Control Requires Median Sternotomy
Zone II: Direct Control
Zone III: Distal Control Requires Mandible Disarticulation vs Antegrade Embolectomy Catheter
- Generally Considered the Most Challenging

Zones of the Neck

Blunt Cerebrovascular Injury (BCVI)

Penetrating Arterial Injury

Internal Carotid Artery (ICA) Injury:
- Options for Surgical Repair:
  - Primary Arteriorrhaphy
  - Patch Angioplasty
  - End-to-End Anastomosis
  - Vein or PTFE Graft
  - ECA Transposition to Injured ICA
- Ligation Indications:
  - Hemodynamically Unstable
  - Very Severe Neck Injury
  - Zone III ICA Injury at the Skull Base
- High Risk for Stroke/CVA if Ligated (75-80%)
External Carotid Artery (ECA) Injury:
- May Attempt to Repair if Stable and Controlled
- Safe to Ligate if Needed

Venous Injury

Generally Ligate Small Veins without Concern
Internal Jugular (IJ) Vein: Transverse Venorrhaphy if Able
- Safe to Ligate if Necessary for Major Hemorrhage or Hemodynamic Instability

Larynx/Trachea Injury

Most Common in Penetrating Trauma
Symptoms:
- Neck Pain
- Dysphagia
- Dyspnea
- Cough or Hemoptysis
- Subcutaneous Emphysema
- Air Bubbling from Wound
- Pneumothorax (PTX)
- Vocal Cord Paralysis
Diagnosis: Laryngoscopy/Bronchoscopy
Treatment of Small Injuries: Repair Transversely in 1-Layer with Absorbable Suture
- 2-Layer Repairs Risk Stenosis
- Include Tracheal Rings in the Repair
Treatment of Large Injuries: Primary Anastomosis
- Can Generally Perform Primary Anastomosis for Injuries Up to 5-6 Tracheal Rings in Length with Mobilization
- Strongly Consider Tracheostomy – Place in Standard Position or Possibly Through the Injured Site
Consider Reinforcement with a Vascularized Pedicle or Intercostal or Strap Muscles

Larynx Laceration

Esophagus Injury

Hardest Cervical Injury to Identify
Most Common in Penetrating Trauma
Most Common Site: Cervical #1, Thoracic #2, and Abdominal #3
Diagnosis:
- Able to Swallow: Water-Soluble Esophagram
  - If Negative but High-Suspicion: Dilute-Barium Esophagram
  - If Still Negative: Esophagoscopy
  - *Contrast Studies Have High False-Negative Rates (25%)
- Intubated or Unable to Swallow: Esophagoscopy
Primary Treatment: Surgical Repair, Buttress, and Leave a Drain
- First Extend the Myotomy to See the Full Length of Mucosal Injury
- Close in Two Layers: Inner Absorbable, Outer Permanent
  - Strength Layer: Submucosa (No Serosa in the Esophagus)
- Buttress in the Neck: Strap Muscles or SCM
Devastating Injury (Repair Not Immediately Feasible): Cervical Esophagostomy (Spit Fistula)