Penetrating Neck Injuries

 Penetrating Neck Trauma

·         The neck is divided into zones:

o   Zone 1- Clavicles to cricoid cartilage.

o   Zone 2- Cricoid cartilage to angle of the mandible

o   Zone 3- Angle of the mandible to skull base

·         The possible injuries vary passed upon the zone and include but are not limited to the following.

o   Zone 1

§  Lung apex

§  Trachea

§  Brachiocephalic/subclavian vessels

§  Esophagus

o   Zone 2

§  Carotid/vertebral arteries

§  Jugular vein

§  Esophagus

§  Trachea

o   Zone 3

§  External/internal carotid artery

§  Jugular vein

§  Superior/anterior pharynx

·         Management of patients with penetrating wounds to the neck has historically been determined by zone of injury.

·         Because zones 1 and 3 are challenging to expose surgically, patients with injuries in zones 1 and/or 3 warrant thorough diagnostics because non-therapeutic surgery in these areas is both difficult and morbid.

·         Zones 1 and 3 should be approached surgically only if an injury is felt to be present. However, zone 2 of the neck is easily exposed surgically.

·         Controversy has existed as to whether patients with zone 2 injuries should undergo exhaustive diagnostics to exclude or characterize injuries in this area, or simply undergo neck exploration with limited or no preoperative evaluation of the trachea, esophagus and cervical vasculature (bronchoscopy, esophagography/esophagoscopy (or both) and angiography or CTA).

·         Helical CT angiography produces equivalent results to catheter-based angiography for exclusion of vascular injuries.

·         The anatomic detail provided by the neck CT may permit the clinician to exclude injury to the esophagus and trachea if the CT clearly shows a missile trajectory remote from the esophagus and trachea.

·         If the CT does not conclusively exclude injury to the esophagus or trachea, contrast esophagography and/or esophagoscopy (or both) and bronchoscopy should be performed.

·         Operative approach varies based upon zone

o   Zone 1: Sternotomy or high anterolateral thoracotomy for a known distal left subclavian artery or vein injury

o   Zone 2: Lateral neck incision along anterior border of sternocleidomastoid muscle

o   Zone 3: Jaw subluxation, sternocleidomastoid/diagastric release

References

A.      regarding the utility of CT/CTA for evaluating penetrating neck injury:

1.    Gracias VH, Reilly PM, Philpott J, Klein WP, Lee SY, Singer M, Schwab CW. Computed tomography in the evaluation of penetrating neck trauma: a preliminary study. Arch Surg 2001;136: 1231-5.

2.    Mazolewski PJ, Curry JD, Browder T, Fildes J. Computed tomographic scan can be used for surgical decision making in zone II penetrating neck injuries. J Trauma 2001;51:315-9.

3.    Múnera F, Soto JA, Palacio DM, Castañeda J, Morales C, Sanabria A, Gutiérrez JE, García G. Penetrating neck injuries: helical CT angiography for initial evaluation. Radiology 2002; 224:366-72.

4.    Fergusion E, Dennis JW, Vu JH, Frykberg ER. Redefining the role of arterial imaging in the management of penetrating zone 3 neck injuries. Vascular. May-jun 2005;13(3):158-63. [Medline].

B.      demonstrating the diagnostic accuracy of physical exam for vascular injuries in Zone II requiring intervention:

1.    Nason RW, Assuras GN, Gray PR, Lipschitz J, Burns CM. Penetrating neck injuries: analysis of experience from a Canadian trauma centre. Can J Surg 2001;44:122-6.

2.    Sriussadaporn S, Pak-Art R, Tharavej C, Sirichindakul B, Chiamananthapong S. Selective management of penetrating neck injuries based on clinical presentations is safe and practical. Int Surg 2001;86:90-3.

3.    Azuaje RE, Jacobson LE, Glover J, Gomez GA, Rodman GH Jr, Broadie TA, Simons CJ, Bjerke HS. Reliability of physical examination as a predictor of vascular injury after penetrating neck trauma. Am Surg 2003;69:804-7.

4.    Osborn TM, Bell RB, Qaisi W, Long WB. Computed tomographic angiography as an aid to clinical decision making in the selective management of penetrating injuries to the nec: a reduction in the need for operative exploration. J Trauma. Jun 2008;64(6):1466-71. [Medline].'

Disclaimer

These guidelines are not intended as a directive or to present a definitive statement of the applicable standard of patient care.  They are offered as an approach for quality assurance and risk management and are subject to (1) revision as warranted by the continuing evaluation of technology and practice; (2) the overall individual professional discretion and judgment of the treating provider in a given patient circumstance; and (3) the patient’s willingness to follow the recommended treatment.