Penetrating and Blunt Neck Trauma

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Penetrating and Blunt Neck Trauma

Trauma
Author Credentials 

Scott K. Walton, MD
Department of Otolaryngology, Head and Neck Surgery
Madigan Army Medical Center
9040A Jackson Ave
Tacoma, WA 98431
Email: scott.k.walton.mil@mail.mil

Derek J. Rogers, MD
Chief, Otolaryngology Clinic and Pediatric Otolaryngology
Madigan Army Medical Center
9040A Jackson Ave
Tacoma, WA 98431
Email: derek.j.rogers.mil@mail.mil

Module Summary

Penetrating and blunt neck injuries remain a significant cause of ER presentations and currently make up 1 - 5% of all traumatic injuries, frequently presenting with other concurrent injuries. Mortality for neck trauma patients is quoted between 3% and 6%, a significant improvement over the last century. A clear understanding of the anatomy of the neck and the vital structures found within its three zones is crucial during the initial evaluation and subsequent treatment of these patients. Advances in both imaging and diagnostic procedures of the neck and aerodigestive tracts have significantly changed the ability to care for these patients in a safe and efficient manner. Evolution regarding the management of these patients has led to controversy regarding the most appropriate initial approach. However, a more selective surgical management as opposed to mandatory exploratory surgery predominates recently, and evidence supports the idea of avoiding unnecessary surgical intervention when possible. Continued advances and multidisciplinary management will lead the way forward in improving morbidity and mortality of penetrating and blunt neck trauma.

Module Learning Objectives 
  1. Review neck anatomy as it relates to penetrating and blunt neck trauma and how injuries are classified based on location.
  2. Explain the various etiologies of neck trauma and how they effect injury pattern and management.
  3. Thoroughly evaluate neck trauma patients in the acute setting.
  4. Recognize the role of imaging in the initial evaluation of patients.
  5. Be comfortable treating neck trauma patients both medically and/or surgically.
  6. Recognize the indications for immediate/delayed surgical vs. non-surgical management.
  7. Describe potential immediate and long-term complications of neck trauma and subsequent treatment.

Embryology

Learning Objectives 

Know the embryologic origin of the major structures in the neck and how various anomalies can affect patient presentation and treatment.

References 
  1. Som, P. M., & Curtin, H. D. (2011). Head and neck imaging. Elsevier Health Sciences.

Anatomy

Learning Objectives 
  1. Identify the boundaries of the three zones of the neck and all of their relevant anatomical structures.
  2. Know the anatomy of the following structures and their relation to other vital structures of the neck.
    1. Pharynx
    2. Larynx
    3. Trachea
    4. Esophagus
    5. Major vascular/lymphatic structures
    6. Major neurologic structures
    7. Bony structures
References 
  1. Asensio, J. A., & Trunkey, D. D. (2016). Current therapy of trauma and surgical critical care. Philadelphia, PA: Elsevier.
  2. Bagheri, S. C., Khan, H. A., & Bell, R. B. Penetrating Neck Injuries. Oral and Maxillofacial Surgery Clinics of North America. 2008 Aug;20(3);393-414. doi:10.1016/j.coms.2008.04.003

Pathogenesis

Learning Objectives 
  1. Be familiar with the properties of various penetrating weapons/ballistics (High-velocity, Low-velocity) and their effect on the injury site.
  2. Understand the different patient presentations based on location and mechanism of injury .
References 
  1. Bagheri, S. C., Khan, H. A., & Bell, R. B. Penetrating Neck Injuries. Oral and Maxillofacial Surgery Clinics of North America. 2008;20(3):393-414. doi:10.1016/j.coms.2008.04.003

Basic Science

Learning Objectives 
  1. Understand the physical principles behind penetrating and blunt forces and how they exert their force on the structures in the neck.
  2. Understand the clotting cascade and its role in acute hemorrhage control.
  3. Understand neuronal injury/degeneration in the trauma setting and its effect on treatment and recovery.
References 
  1. Brennan, J. A., Meyers, A. D., & Jafek, B. W. Penetrating neck trauma: a 5-year review of the literature, 1983 to 1988. American journal of otolaryngology. 1997;11(3):191-197.

Incidence

Learning Objectives 
  1. Know the incidence of neck injuries amongst trauma patients.
  2. Know the leading causes of morbidity/mortality following neck trauma.
References 
  1. Brennan, J. A., Holt, G. R., & Thomas, R. W. (2015). Otolaryngology/head and neck surgery combat casualty care in Operation Iraqi Freedom and Operation Enduring Freedom. Fall Church, VA: Office of the Surgeon General, United States Army.
  2. Pinto, A., Brunese, L., Scaglione, M., Scuderi, M. G., & Romano, L. Gunshot Injuries in the Neck Area: Ballistics Elements and Forensic Issues. Seminars in Ultrasound, CT and MRI. 2009;30(3):215-220. doi:10.1053/j.sult.2009.02.006.
  3. Soliman, A., Ahmad, S. M., & Roy, D. The role of aerodigestive tract endoscopy in penetrating neck trauma. The Laryngoscope. 2014;124(S7):S1-S9.
  4. Zaidi, S. M. H., & Ahmad, R. Penetrating neck trauma: a case for conservative approach. American journal of otolaryngology. 2001;32(6):591-596.

Patient Evaluation

Learning Objectives 
  1. Be familiar with the ATLS guidelines for initial management of a trauma patient
    1. Be familiar with initial airway management in an unstable patient
  2. Identify the hard and soft signs associated with neck injuries
  3. Be familiar with adjunct studies to aid in diagnosing and classifying injuries
References 
  1. Marx, J., Walls, R., & Hockberger, R. (2013). Rosen's emergency medicine-concepts and clinical practice. Elsevier Health Sciences.

Measurement of Functional Status

Learning Objectives 
  1. Know how to objectively evaluate a neck trauma patient based on the following:
    1. ATLS guidelines (primary and secondary survey)
      1. ABCDE’s
      2. Vital signs
      3. GCS
      4. Physical exam
      5. Lab studies
      6. Initial imaging studies
References 
  1. Advanced trauma life support: student course manual. (2012). Chicago, IL: American College of Surgeons.
  2. Horton, C. L., Brown, C. A., & Raja, A. S. Trauma airway management. The Journal of emergency medicine. 2014;46(6):814-820.

Imaging

Learning Objectives 

Be familiar with and know when to obtain the following studies in neck trauma based on physical exam findings and anatomical location:

  1. Multi-slice Helical Computed Tomography (MHCT)
  2. CT-angiography (CT-A)
  3. Duplex ultrasonography
  4. Angiography
  5. Rigid/Flexible esophagoscopy
  6. Esophagography
  7. Direct laryngoscopy(DL)
  8. Fiberoptic laryngoscopy/bronchoscopy (FOB)
  9. Magnetic Resonance Imaging (MRI)
References 
  1. Soliman, A., Ahmad, S. M., & Roy, D. The role of aerodigestive tract endoscopy in penetrating neck trauma. The Laryngoscope. 2014;124(S7):S1-S9.

Treatment

Learning Objectives 
  1. Be familiar with multiple ways to obtain a definitive airway:
    1. Non-surgical
    2. Surgical
  2. Know the treatment algorithm for neck trauma based on physical exam findings and adjunctive imaging studies.
    1. Understand when observation vs. surgical exploration is indicated.
  3. Understand the surgical approaches to the zones of the neck.
  4. Be familiar with endovascular approaches and know when consultation is warranted.
References 
  1. Bagheri, S. C., Khan, H. A., & Bell, R. B. Penetrating Neck Injuries. Oral and Maxillofacial Surgery Clinics of North America. 2008;20(3):393-414. doi:10.1016/j.coms.2008.04.003
  2. Bhatti, N. I. Surgical management of the difficult adult airway. Cummings CW, et al. Cummings Otorhinolaryngology, Head & Neck Surgery. 5th ed. Philadelphia, 121-129.
  3. Meghoo, C. A., Dennis, J. W., Tuman, C., & Fang, R. Diagnosis and management of evacuated casualties with cervical vascular injuries resulting from combat-related explosive blasts. Journal of vascular surgery. 2012;55(5)1329-1337.
  4. Soliman, A., Ahmad, S. M., & Roy, D. The role of aerodigestive tract endoscopy in penetrating neck trauma. The Laryngoscope. 2014;124(S7):S1-S9.
  5. Tisherman, S. A., Bokhari, F., Collier, B., Cumming, J., Ebert, J., Holevar, M., ... & Rhee, P. Clinical practice guideline: penetrating zone II neck trauma. Journal of Trauma and Acute Care Surgery. 2008;64(5):1392-1405.

Medical Therapies

Learning Objectives 

Be familiar with guidelines regarding observation of patients without emergent need for exploration.

References 
  1. Soliman, A., Ahmad, S. M., & Roy, D. The role of aerodigestive tract endoscopy in penetrating neck trauma. The Laryngoscope. 2014;124(S7):S1-S9.
  2. Tisherman, S. A., Bokhari, F., Collier, B., Cumming, J., Ebert, J., Holevar, M., ... & Rhee, P. Clinical practice guideline: penetrating zone II neck trauma. Journal of Trauma and Acute Care Surgery. 2008;64(5):1392-1405.

Pharmacology

Learning Objectives 
  1. Be familiar with the medications used for Rapid Sequence Intubation (RSI) in acute airway setting
  2. Know the properties and mechanisms of the various hemostatic agents available in the setting of acute hemorrhage
References 
  1. Lier, H., Böttiger, B. W., Hinkelbein, J., Krep, H., & Bernhard, M. Coagulation management in multiple trauma: a systematic review. Intensive care medicine. 2011;37(4):572-582.
  2. Stollings, J. L., Diedrich, D. A., Oyen, L. J., & Brown, D. R. Rapid-sequence intubation a review of the process and considerations when choosing medications. Annals of Pharmacotherapy. 2014;48(1):62-76.

Surgical Therapies

Learning Objectives 
  1. Know and understand the surgical interventions for vascular injury
    1. Direct repair
      1. Primary repair/reanastamosis
      2. Interpositional graft
    2. Bypass
      1. Permanent vs temporizing
    3. Ligation
    4. Endovascular repairs
    5. Observation
  2. Know and understand the surgical interventions for esophageal injury
    1. Primary repair
    2. Local muscle flaps
    3. Microvascular free tissue transfer
    4. Delayed repair with esophageal diversion/esophagostomy
  3. Know and understand the surgical interventions for laryngotracheal injury
    1. Diagnostic/Therapeutic Endoscopy
    2. Open repair
      1. Thyrotomy, laryngofissure
  4. Know and understand the surgical interventions for neuronal injury
    1. Primary neurorrhaphy
    2. Interpositional graft neurorrhaphy
    3. Nerve transposition
References 
  1. Bell, R. B., Osborn, T., Dierks, E. J., Potter, B. E., & Long, W. B. Management of penetrating neck injuries: a new paradigm for civilian trauma. Journal of Oral and Maxillofacial Surgery. 2007;65(4):691-705.
  2. Flint, P. W., Haughey, B. H., Lund, V., Niparko, J. K., Robbins, K. T., Thomas, J. R., . . . Cummings, C. W. (2015). Cummings otolaryngology--head & neck surgery. Philadelphia, PA: Elsevier/Saunders.
  3. Ledgerwood, A. M., Mullins, R. J., & Lucas, C. E. Primary repair vs ligation for carotid artery injuries. Archives of Surgery. 1980;115(4):488-493
  4. Martin, R. S., & Meredith, J. W. (2012). Management of acute trauma. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. Philadelphia. Elsevier-Saunders, 430-470.

Staging

Learning Objectives 

Know how to classify and grade neurolymphovascular, laryngotracheal, esophageal, and soft tissue injuries.

References 
  1. Becker, M., Leuchter, I., Platon, A., Becker, C. D., Dulguerov, P., & Varoquaux, A. Imaging of laryngeal trauma. European journal of radiology. 2014;83(1):142-154.
  2. Heizmann, O., Schmid, R., & Oertli, D. Blunt injury to the thyroid gland: proposed classification and treatment algorithm. Journal of Trauma and Acute Care Surgery. 2006;61(4):1012-1015.
  3. Lee, C. C., Tindall, S. C., & Winn, H. R. (2004). Youman's Neurological Surgery.
  4. Martin, M. J., & Long, W. B. Vascular trauma: epidemiology and natural history. Rutherford’s Vascular Surgery, 2, 2422-2437.
  5. Moore, E. E., Jurkovich, G. J., Knudson, M. M., Cogbill, T. H., Malangoni, M. A., Champion, H. R., & Shackford, S. R. (1995). Organ injury scaling VI: Extrahepatic biliary, esophagus, stomach, vulva, vagina, uterus (nonpregnant), uterus (pregnant), fallopian tube, and ovary.

Case Studies

  1. A 13-year-old male presents to the ER following blunt trauma to his neck with a hockey stick. He reports immediate pain but was able to continue playing. Over the ensuing hour, he began to complain of increasing neck pain but denied shortness of breath or mental status changes. He was eventually examined four hours after the initial trauma. Upon evaluation, the patient had moderate neck pain but remained asymptomatic from an airway standpoint, and he appeared to be in no acute distress. Physical exam revealed normal vital signs, without obvious edema or swelling of anterior neck. Besides ecchymosis to area of trauma and mild tenderness, his exam was unremarkable. Flexible fiberoptic laryngoscopy was performed, and findings were all within normal limits. Subsequent CT scan showed evidence of left thyroid lobe rupture without active extravasation of blood.
    1. Patient with evidence of stable blunt injury to Level III of the neck with stable left thyroid lobe rupture
    2. Patient was stable on presentation and remained stable with no physical exam findings or diagnostic studies indicative of injuries requiring surgical intervention
    3. He was observed for a total of 36 hours to ensure stable symptoms and discharged without further complications
    4. This case highlights the importance of a thorough examination, work up, and subsequent observation in neck trauma patients, even if stable initially
  2. A 22-year-old male presents with a gunshot wound to the right neck in level II from a 9-mm handgun. Upon presentation, he is in obvious distress with evidence of an expanding hematoma. His heartrate at the time of initial evaluation was 130 and systolic blood pressure was 70.
    1. ATLS protocol was initiated.
    2. He was taken emergently to the operating room for neck exploration.
    3. Broad exposure was obtained by using an incision along the anterior border of his right sternocleidomastoid muscle. After evacuation of hematoma, exploration of the carotid sheath revealed a 5 mm laceration of his common carotid artery. Once proximal and distal control of the artery was achieved, the artery was repaired with 6-0 Prolene sutures.
    4. This case highlights the importance of emergent neck exploration without imaging for hard signs in an unstable patient.
References 
  1. Brennan, J. A., Holt, G. R., & Thomas, R. W. (2015). Otolaryngology/head and neck surgery combat casualty care in Operation Iraqi Freedom and Operation Enduring Freedom. Fall Church, VA: Office of the Surgeon General, United States Army.
  2. Zawawi, F., Varshney, R., Payne, R. J., & Manoukian, J. J. Thyroid gland rupture: a rare finding after a blunt neck trauma. International journal of pediatric otorhinolaryngology. 2013;77(5):863-865.

Complications

Learning Objectives 

Understand the early and late complications surrounding injury to the following structures:

  1. Neurovascular
  2. Lymphatic
  3. Aerodigestive
References 
  1. Asensio, J. A., & Trunkey, D. D. (2016). Current therapy of trauma and surgical critical care. Philadelphia, PA: Elsevier.

Review

Review Questions 
  • What is the incidence of laryngeal trauma in a civilian setting?
References 
  1. Asensio, J. A., & Trunkey, D. D. (2016). Current therapy of trauma and surgical critical care. Philadelphia, PA: Elsevier.
  2. Cameron, J. L., & Cameron, A. M. (2013). Current surgical therapy. Elsevier Health Sciences.
  3. E. (2014, June 20). Resident Manual of Trauma to the Face, Head, and Neck. Retrieved April 19, 2017, from http://www.entnet.org/content/resident-manual-trauma-face-head-and-neck
  4. Flint, P. W., Haughey, B. H., Lund, V., Niparko, J. K., Robbins, K. T., Thomas, J. R., . . . Cummings, C. W. (2015). Cummings otolaryngology--head & neck surgery. Philadelphia, PA: Elsevier/Saunders.
  5. Marx, J., Walls, R., & Hockberger, R. (2013). Rosen's emergency medicine-concepts and clinical practice. Elsevier Health Sciences.