Penetrating neck injury: case report and evaluation of management

Greater urban violence has resulted in an increased incidence of penetrating neck trauma. Penetrating neck wounds can present difficult diagnostic and therapeutic dilemmas. The evaluation and management of such injuries, however, remains controversial. There is no universally accepted specific approach to the management of patients with penetrating neck injuries, with some surgeons advocating mandatory neck exploration whilst others believe in selective surgical intervention. We believe that an equal willingness for both conservative and surgical intervention as dictated by serial bedside evaluation with adequate radiological and endoscopic support can provide the clinician a safe and effective means of managing a potentially complex and lethal problem.     

Penetrating neck injuries

The incidence of penetrating and lacerated neck injuries has been rising in recent decades largely because of urban violence. Injury to the neck frequently results in multiple regional injuries and in addition poses serious threat to vital structures in the neck. From 1999 to 2005, forty-two cases of penetrating neck injuries which were treated in our hospital were included in this study. Thirty one (73.8%) injuries were due to homicide, six cases (14.2%) were due to suicide attempt and five (11.9%) were accidental injuries. Surgical management included tracheostomy neck exploration and wound repair. All the patients were followed up for a minimum period of six months. Six patients (14.2%) had unilateral vocal cord paralysis. Two patients (4.7%) developed tracheal stenosis. A proper evaluation, rapid air way intervention and proper surgical repair are essential for a successful outcome.     

Case report: acute management of external laryngeal trauma

External laryngeal trauma is rare, accounting for less than 1% of all trauma cases seen at major centers. We report the case of a man who experienced multiple injuries, including an external laryngeal trauma. The primary signs and symptoms of his laryngeal trauma were hoarseness, hemoptysis, the loss of his laryngeal prominence (Adam's apple), neck tenderness, traumatic emphysema in the neck, and a small penetrating wound to the right of the laryngeal prominence. The patient underwent immediate tracheostomy and surgical exploration. On long-term followup, his voice quality and airway patency improved. This case illustrates the importance of rapid identification and early management of laryngotracheal trauma in a patient with multiple injuries.     

Metallic foreign body in the neck: case report

Penetrating neck injuries constitute 5-10% of all trauma cases. Such injuries are dangerous because of the high risk of injury to the vital structures in the neck and hence demand an immediate surgical exploration. We present a case of a penetrating injury of the neck caused by the broken metallic fragment of a saw.     

Pediatric penetrating head and neck trauma

Penetrating head and neck trauma in children causes uncommon and potentially life-threatening injuries. We reviewed the charts of 21 patients who sustained penetrating injuries to the face or upper neck. Seventeen males and 4 females, aged 32 weeks' gestation to 19 years (mean = 10.2 years) comprised the study population. There were 15 gun-shot wounds, 1 shotgun injury, and 5 stab wounds. Significant problems included 7 vascular injuries, 6 central nervous system injuries, 5 ocular injuries, 3 airway compromises, 2 facial nerve injuries, 1 cervical esophageal penetration, and 2 cases of pneumothorax. Three deaths occurred, but the majority of the patients survived and sustained minimal permanent disability. Included in this review is a unique case of an intrauterine gunshot wound to the face at approximately 32 weeks' gestation. The treatment protocol, differences from adult patients, and management highlights are reviewed.     

颈部穿透伤的选择性处理

对颈部穿透伤的处理尚有争议。一些作者提出对所有穿透伤一律手术探查，另一些作者主张选择性处理。本文分析选择性处理颈部穿透伤３６例，认为：（１）病情危急者，需即刻手术探查；（２）病情稳定，疑有重要器官和结构受损者，可辅助检查后进一步处理，血管造影和内窥镜检查是重要的诊断措施；（３）喉部损伤，除个别局限性轻度损伤可严密观察与保守治疗外，均应积极处理，防止喉阻塞和严重喉狭窄。     

Penetrating wounds of the neck

The management of penetrating wounds of the neck provides several decision-making steps that remain controversial. The two basic concepts of management include the idea that all wounds deep to the platysma should be explored and (the more conservative concept) that selective neck exploration should be based on a battery of tests to identify traumatic injuries. The areas of agreement within these two schools of thought include exploration of wounds with obvious injury, exploration of wounds in which patients cannot be stabilized satisfactorily for further testing, and the idea that all patients with wounds deep to the platysma should be admitted to the hospital. The remaining issues, including the need for angiography, barium swallow, or endoscopy, still are contested. Mandatory exploration of neck wounds became popular during World War II. The weapons used, the lack of accurate testing, and delays in treatment caused by transport problems played significant roles in the development of this policy. Proponents of mandatory exploration of neck wounds contend that delays in treatment result in increased mortality rates. Also delays caused by lengthy diagnostic testing have resulted in rapid exsanguination of patients who might otherwise have been surgically salvageable. These factors, along with the potential for undetected injuries and the associated complications (including false aneurysms and mediastinitis) favor mandatory exploration. Advocates of routine neck explorations also note the low morbidity rates associated with a neck exploration. Reported rates of negative exploration are high, however, approaching 45%, and mortality rates vary from 2% to 9%. Selective neck exploration has gained popularity in some centers because of the lower negative exploration rates associated with this treatment, while comparable mortality rates are achieved. May found a negative exploration rate of 12% in his series of selective neck explorations and a mortality rate of approximately 3%. Furthermore, Noyes found that the hospital stay for patients with selective observation management not requiring a neck exploration was 2.8 days, compared with 4.2 days for patients with mandatory but negative neck explorations. A summary of diagnostic techniques and their indications in selecting patients with penetrating neck wounds for surgery is presented in Table 5. It has become apparent that both selective and mandatory explorations of neck wounds play important roles in treatment.(ABSTRACT TRUNCATED AT 400 WORDS)     

Management of war-related neck injuries during the war in Croatia, 1991–1992

From 1 September 1991 to 31 December 1992, a total of 7,043 wounded patients were treated in the War Hospital in Slavonski Brod. Seven hundred and twenty eight patients with head and neck injuries were treated in the Department of Otorhinolaryngology and Cervicofacial Surgery. Of this number, 187 had neck injuries. Ninety-two (49.2%) of them were treated in outpatient facilities and 95 (50.8%) as inpatients. Immediate exploration was done in 84 patients with penetrating neck injuries. Vital structures were involved in 49 patients: major blood vessels (40 cases), larynx (17 cases), pharynx (8 cases), trachea (5 cases), thyroid gland (3 cases) and esophagus (2 cases). Definitive treatment was given to all of these injuries. Primary wound closure was performed upon exploration in 74 patients who were treated within the first 6 h after trauma. Secondary wound closure was performed in 10 patients with neck exploration performed more than 6 h after injury, and in those with extensive defects of tissue requiring the use of larger local flaps or free flaps. The mortality among patients with neck injuries was 2.1 %.     

Multidisciplinary surgical management of an unusual penetrating foreign body of the face

IntroductionFacial injuries by penetrating foreign body are unusual and require specific multidisciplinary surgical management.Case reportThis case report concerns a 20-year-old man who experienced a penetrating injury by a piece of wood to the face and describes the surgical approach to remove the wood and repair the injury. The foreign body had penetrated the infratemporal fossa, with an entry wound situated below the right eye and an exit wound in the neck, in contact with the left internal carotid artery. An adapted surgical strategy was necessary in view of the site of the foreign body. The internal carotid artery was controlled in order to follow the foreign body as far as its entry into the base of the skull. The proximity of the eye and carotid and jugular vessels and the deep penetration of the foreign body required the participation of interventional radiologists, head and neck and vascular surgeons and ophthalmologists.DiscussionThe site of the foreign body, precisely determined preoperatively, justified management by a multidisciplinary team to ensure rapid extraction, while limiting the risk of additional lesions. With a follow-up of 6 months, the patient did not present any sequelae of his facial injury.     

An unusual case of a ballpoint pen migrating into the parapharyngeal space and middle mediastinum

Foreign bodies that penetrate the esophagus and migrate extraluminally are unusual. If they are left untreated, serious complications arise from mediastinitis, and damage to the major structures in the neck can occur. We report a case of a patient who presented with chest pain on inspiration that was found to be caused by a foreign body in the parapharyngeal space and middle mediastinum. Preoperative imaging is critical in obtaining landmarks for safe surgical exploration and is essential to the successful management of penetrating and migrating foreign bodies. This case highlights the importance of localizing the foreign body preoperatively to aid in its surgical removal via a transcervical approach.     

Management of traumatic hypopharyngeal injuries

Violation of the hypopharynx by external penetrating trauma is an uncommon occurrence that may lead to life-threatening infectious complications if not recognized promptly and treated appropriately. A retrospective review of 48 such injuries seen during a 10-year period showed that flexible fiberoptic endoscopic examination is the best screening tool for recognition of a possible hypopharyngeal mucosal violation. Direct laryngopharyngoscopy is the best method of definitively diagnosing the injury. Size of the visualized mucosal violation alone is not sufficient information on which to base the decision for medical management versus surgical intervention (i.e., immediate exploration and drainage). Rather, the size, exact site of injury, and mechanism of the injury must be considered to have equal importance. Associated vertebral body fractures may negatively influence acute outcome if diagnosis and treatment of the hypopharyngeal injury are delayed by the cervical spine injury.     

Management of penetrating wounds of the neck

Summary Management policies for penetrating wounds of the neck vary from mandatory surgical exploration to selective surgical exploration following extensive or minimal imaging investigation. In order to review the treatment protocol at Sheba Medical Center, Tel Hashomer, Israel, we retrospectively studied 21 patients who were treated between the years 1984 and 1989. Thirteen had gunshot injuries and eight had stab wounds. Eight patients had undergone immediate exploration of the neck. Four patients had died, but all of these latter patients had evidence for significant bleeding that could have been detected within a short time of admission. On the basis of our findings and previous studies, we conclude that: presenting features of neck injuries should be differentiated into two basic categories: immediately lifet-hreatening and not immediately life-threatening. Immediately life-threatening features include overt massive bleeding, expanding hematoma, non-expanding hematoma in the presence of hemodynamic instability, hemomediastinum, hemothorax, and hypovolemic shock. In all of these cases, immediate surgical exploration is mandatory. Non-life-threatening features include any signs of vascular complication in a hemodynamically stable patient, signs of upper aerodigestive tract lesions (when initial treatment has already relieved respiratory distress) and periphral neurological deficits. These patients should undergo thorough imaging investigations on the basis of which the need for and the nature of possible surgical intervention can be determined.     

An evidence based review of the assessment and management of penetrating neck trauma

Clin. Otolaryngol. 2012, 37 , 44–52 Background: Although relatively uncommon, penetrating neck trauma has the potential for serious morbidity and an estimated mortality of up to 6%. The assessment and management of patients who have sustained a penetrating neck injury has historically been an issue surrounded by significant controversy. Objectivesof review: To assess recent evidence relating to the assessment and management of penetrating neck trauma, highlighting areas of controversy with an overall aim of formulating clinical guidelines according to a care pathway format. Type of review: Structured, non‐systematic review of recent medical literature. Search strategy: An electronic literature search was performed in May 2011. The Medline database was searched using the Medical Subject Headings terms ‘neck injuries’ and ‘wounds, penetrating’ in conjunction with the terms ‘assessment’ or ‘management’. Embase was searched with the terms ‘penetrating trauma’ and ‘neck injury’, also in conjunction with the terms ‘assessment’ and ‘management’. Results were limited to articles published in English from 1990 to the present day. Evaluation method: Abstracts were reviewed by the first three authors to select full‐text articles for further critical appraisal. The references and citation links of these articles were hand‐searched to identify further articles of relevance. Results: 147 relevant articles were identified by the electronic literature search, comprising case series, case reports and reviews. 33 were initially selected for further evaluation. Conclusions: Although controversy continues to surround the management of penetrating neck trauma, the role of selective non‐operative management and the utility of CT angiography to investigate potential vascular injuries appears to be increasingly accepted.     

Surgical Management of Complex Maxillofacial Fractures

The surgical treatment of severe and complex maxillofacial injuries requires sophisticated modalities. Personal surgical principles of maxillofacial trauma management are delineated. Exploration of all fracture sites with direct reduction and fixation is the most satisfactory technique for best cosmetic and functional results. The maxillary buccal vestibule incision is stressed for routine use in midfacial fractures. A plea is made for utilization of this incision for exploration of the lateral wall of the maxilla, the nasal aperture, the zygomatic buttress, maxillary tuberosity and pterygoid area, the maxillary antrum and roof (or orbital floor), and the infraorbital rim. The extent of the injury can be ascertained and direct reduction and fixation obtained. Two case presentations illustrate the complex management of such injuries. Postoperative follow-up demonstrates the cosmetic results and rehabilitation of properly managed cases.     

External laryngotracheal trauma in children.

External laryngotracheal trauma in the paediatric population, although rare, presents a diagnostic and therapeutic dilemma for the attending surgeon. The purpose of this study was to evaluate the clinical profile, treatment and outcome and to establish a simple, effective management protocol in this emergency. A retrospective case series was studied. There were 12 patients aged 2-14 years in this series, eight of them (67%) having closed injuries. Their clinical presentation was correlated to conservative management, tracheostomy and surgical intervention. In the open injury group all the patients (100%) underwent tracheostomy, upper endoscopy and neck exploration. One patient (25%) in this group developed subglottic stenosis. In the closed injury group, seven patients (88%) had tracheostomy with upper endoscopy, and two of them (25%) had neck exploration in addition. One patient (13%), however, developed glottic stenosis. The patients with stenosis underwent multiple surgical interventions prior to final decannulation. There was no mortality. Breathing difficulty/stridor were the commonest clinical presentations in children with acute external laryngotracheal trauma. Tracheostomy and early surgical intervention appeared to be the treatment of choice. A protocol with major and minor criteria of clinical presentation is suggested for effective management.     

Endoscopic examination of corrosive injuries of the upper gastrointestinal tract.

The authors present the case histories of five patients who have sustained corrosive injuries of the upper gastrointestinal tract. Flexible endoscopic examination was successfully carried out in each patient to assess the extent of the injury and anticipate further therapeutic needs. Three patients sustained major gastric lesions, i.e., strictures or bleeding following the ingestion of alkali, acids, or phenol, and one instance of esophageal stricture was recognized. The endoscopic observation of antral gangrene was inexorably followed by antral stricture requiring surgical management. One fatality followed rigid esophagoscopic examination which resulted in esophageal perforation.     

Penetrating neck trauma: a 5-year review of the literature, 1983 to 1988

Penetrating neck trauma remains controversial: some trauma centers continue to pursue a policy of mandatory exploration while others advocate selective exploration. The literature regarding penetrating neck trauma published during the past 5 years is reviewed in this report. The majority of reports support selective exploration, and most civilian centers report a mortality of 3% to 6% regardless of the type of exploration performed. To clarify the rationale behind the selective management of penetrating neck wounds, current data on ballistics, ancillary diagnostic studies, and comparative costs are reviewed. Emergency room management and surgical follow-up, which vary according to the type of missile and the zone of the neck penetrated, are discussed.     

Surgical and nonsurgical treatment of penetrating injuries to the cervical esophagus

We presented two patients with gunshot wounds and one patient with a stab wound of the cervical esophagus, managed conservatively, which resulted in no deaths. Results of eight studies of cervical esophageal injuries are reviewed and presented in Table I. One must consider both the surgical and conservative methods of management in planning treatment for the given patient.     

Rehabilitation of the face following traumatic injury to the facial nerve

Etiology, diagnosis, and surgical management of facial paralysis due to traumatic injury of the VIIth cranial nerve are discussed. Sixty patients are reviewed who underwent some type of surgical procedure for the repair of the facial nerve. These cases are categorized according to etiology, which includes temporal bone fractures, iatrogenic injuries, and penetrating wounds of the head and neck. The results of a poll of eight leading otologists on their approaches to several aspects of the surgical management of these injuries are presented in the Discussion section. The diagnostic and prognostic studies associated with facial paralysis, as well as the more common surgical procedures available for repair of the facial nerve, are briefly reviewed.     

Neck crepitance: evaluation and management of suspected upper aerodigestive tract injury

OBJECTIVE: To determine safe criteria for the management of patients with crepitance of the neck. HYPOTHESIS: Upper aerodigestive tract injury may lead to significant morbidity and mortality. Historically, this kind of injury has been managed by immediate surgical exploration, repair, and drainage. More recently, a nonoperative approach has been advocated. STUDY DESIGN: Retrospective chart review of patients admitted to the University of Louisville Trauma Center with suspected upper aerodigestive tract injury. METHODS: We reviewed the charts of 236 patients admitted to the trauma service from 1995 to 1999 with the diagnosis of aerodigestive tract injury or subcutaneous emphysema. RESULTS: Nineteen patients were identified with cervical emphysema or cervical crepitance, or both, thought to be caused by an upper aerodigestive tract injury. The average patient age was 38.5 years; 68% of patients were men. The mechanisms of injury were motor vehicle accident (43%), gunshot wound (37%), assault (10%), blunt neck trauma (5%), and stabbing (5%). Each patient presented with cervical emphysema shown by radiograph or crepitance, or both; 21% had dysphagia and 63% were hoarse or had stridor. Location of the injury was tracheal or laryngeal in 37%, hypopharyngeal in 27%, oral pharynx in 16%, esophageal in 5%, and unidentified in 15% of patients. Because of suspected aerodigestive tract injury, 79% of patients were taken to the operating room for direct laryngoscopy and esophagoscopy, and abnormalities were found in 80%. The diameter of the average laceration of the upper aerodigestive tract was 1.6 cm. Associated injuries included mandible fractures in 37% of patients. Broad-spectrum antibiotics were given to 95% of the patients. The initial management involved immediate surgical exploration in 55% of the total number of patients, with 83% of the surgically explored patients undergoing tracheotomy. The remaining 45% of patients were managed without surgery. Complications occurred only in operative patients, with aspiration occurring in 10%, bilateral hypoglossal nerve paralysis in 5%, and vocal cord paralysis in 5%. None of the patients developed postinjury or operative abscess. CONCLUSION: The findings show that suspected upper aerodigestive tract injury can be managed without surgery but that a high index of suspicion for airway compromise and associated facial injuries must be considered.