Combined laryngotracheal separation and esophageal injury following blunt neck trauma

In this article we describe the first case of combined laryngotracheal and esophageal injury following blunt neck trauma in the otolaryngology literature and delineate appropriate management considerations. Successful reconstruction requires appropriate airway management, restoration of esophageal and laryngeal mucosal integrity, and reduction of tracheal and laryngeal fractures with appropriate stenting. Laryngotracheal separation following blunt neck trauma is rare and can be initially overlooked. After the airway is secure, injury severity dictates repair and postoperative care. Immediate reconstruction with restoration of the laryngotracheal framework and mucosal integrity enables patients to recover a patent airway, functional voice, and normal swallow.     

Selective management of penetrating neck trauma

Of 110 patients with penetrating injuries of the neck, 58 were selectively observed and 52 underwent prompt surgical exploration according to defined criteria. In the group initially selected for observation, none required subsequent surgical intervention, and there was no mortality. Among those patients operated upon primarily, the negative exploration rate was 17 percent, and two patients died, both as a result of their injuries (mortality rate, 4%). We conclude that selective management of patients with penetrating neck injuries, when guided by repeated and careful examinations, is appropriate, does not increase the risk to patients, and avoids unnecessary surgical procedures.     

Blind nasotracheal intubation for patients with penetrating neck trauma

BACKGROUND: Early airway management is advocated for patients with penetrating neck trauma who have any signs of airway compromise. This study examined the clinical course of patients with penetrating neck trauma who received prehospital blind nasotracheal intubation, including successful intubation rates, and outcomes. METHODS: A retrospective review of patients admitted to the emergency department for penetrating neck trauma was conducted from January 1, 1993 to July 1, 2001 at the Denver Health Medical Center. Patients were identified from the trauma registry, and data were collected using standardized inclusion and exclusion criteria. RESULTS: The study identified 240 patients with penetrating neck trauma. Overall mortality was 8.3%. Among the 240 patients, 89 (37%) required airway management, and 40 (17%) underwent prehospital management with blind nasotracheal intubation. The success rate for prehospital intubation using the blind nasotracheal method was 90%. The mean number of attempts was 1.16 (range, 1-4), and the mortality in this group was 5%. CONCLUSION: The patients managed with blind nasotracheal intubation did not experience complications related to the choice of airway management. Despite prior warnings in the literature, the results of this study suggest that blind nasotracheal intubation may well be a valuable tool for the management of patients with penetrating neck trauma.     

Delayed evaluation of combat-related penetrating neck trauma

OBJECTIVE: The approach to penetrating trauma of the head and neck has undergone significant evolution and offers unique challenges during wartime. Military munitions produce complex injury patterns that challenge conventional diagnosis and management. Mass casualties may not allow for routine exploration of all stable cervical blast injuries. The objective of this study was to review the delayed evaluation of combat-related penetrating neck trauma in patients after evacuation to the United States. METHOD: From February 2003 through April 2005, a series of patients with military-associated penetrating cervical trauma were evacuated to a single institution, prospectively entered into a database, and retrospectively reviewed. RESULTS: Suspected vascular injury from penetrating neck trauma occurred in 63 patients. Injuries were to zone II in 33%, zone III in 33%, and zone I in 11%. The remaining injuries involved multiple zones, including the lower face or posterior neck. Explosive devices wounded 50 patients (79%), 13 (21%) had high-velocity gunshot wounds, and 19 (30%) had associated intracranial or cervical spine injury. Of the 39 patients (62%) who underwent emergent neck exploration in Iraq or Afghanistan, 21 had 24 injuries requiring ligation (18), vein interposition or primary repair (4), polytetrafluoroethylene (PTFE) graft interposition (1), or patch angioplasty (1). Injuries occurred to the carotid, vertebral, or innominate arteries, or the jugular vein. After evacuation to the United States, all patients underwent radiologic evaluation of the head and neck vasculature. Computed tomography angiography was performed in 45 patients (71%), including six zone II injuries without prior exploration. Forty (63%) underwent diagnostic arteriography that detected pseudoaneurysms (5) or occlusions (8) of the carotid and vertebral arteries. No occult venous injuries were noted. Delayed evaluation resulted in the detection of 12 additional occult injuries and one graft thrombosis in 11 patients. Management included observation (5), vein or PTFE graft repair (3), coil embolization (2), or ligation (1). CONCLUSIONS: Penetrating multiple fragment injury to the head and neck is common during wartime. Computed tomography angiography is useful in the delayed evaluation of stable patients, but retained fragments produce suboptimal imaging in the zone of injury. Arteriography remains the imaging study of choice to evaluate for cervical vascular trauma, and its use should be liberalized for combat injuries. Stable injuries may not require immediate neck exploration; however, the high prevalence of occult injuries discovered in this review underscores the need for a complete re-evaluation upon return to the United States.     

Reliability of physical examination as a predictor of vascular injury after penetrating neck trauma

The policy of routine angiography (ANG) for all penetrating neck wounds results in a high rate of negative studies. The medical records of all patients who presented to Wishard Memorial Hospital and Methodist Hospital of Indiana with penetrating injuries to the neck from January 1992 to April 2001 were reviewed. All patients who were hemodynamically stable underwent four-vessel ANG to evaluate for vascular injury irrespective of findings on physical examination (PE). A total of 216 patients sustained penetrating neck injuries. Patients were divided according to positive or negative PE findings and the results of ANG. Of the 63 patients with a positive PE, 40 (68%) also had a positive ANG finding. Of the 89 patients with negative PE, only 3 had a positive ANG and none of these injuries required operative repair. PE therefore had a 93 per cent sensitivity (SEN) and a 97 per cent negative predictive value (NPV) for predicting the results of ANG. The SEN and NPV of PE for detecting vascular injuries requiring operative repair were both 100 per cent. In this series, no patient with a negative PE had a vascular injury that required operative repair, irrespective of zone of injury. Routine ANG may therefore be unnecessary for patients with penetrating neck injuries and a negative PE.     

Aortocardiac fistula with aortic valve injury from penetrating trauma

A patient with a delayed aorto-right ventricular fistula and aortic valve injury after penetrating trauma is reported, and 17 similar additional cases from the literature reviewed. By examining the aortic root of adults with normal cardiac anatomy at autopsy, we defined the target area for these injuries as a 2 X 2 cm contact surface between the aorta above the right coronary cusp and the right ventricular outflow tract below the pulmonary valve. Five of the 18 patients required emergency exploration due to hemodynamic instability. Life-threatening sequelae (hemorrhage and cardiac tamponade) result from the external injury rather than the intracardiac component. Intracardiac damage is most commonly manifested as the delayed recognition of a cardiac murmur and some degree of congestive heart failure, and when these appear one must suspect intracardiac trauma. We recommend cardiac catheterization and elective repair, maintaining control of both ends of the intracardiac fistula with bolstered suture. Aortic valve injury can often be primarily repaired. Patients with combination aortic valve and aortocardiac fistula injuries, more so than those with a single intracardiac lesion, fail with nonoperative management. Of the 18 patients, 17 underwent surgery. One of these died: the others did well during short-term followup (less than 1 year).     

Brainstem injury by penetrating head trauma with a knife

Abstract The authors describe a rare case about a traumatic lesion of brain and brain stem with a knife. In this case the patient had good clinical condition, diagnosed with TBI by infectious complications. We have highlighted the unusual diagnosis, proximity of vascular structures, the technique used in the treatment and the good outcome of the injury.     

Management of penetrating laryngotracheal injuries

Background. Penetrating Iaryngotracheal injuries are uncommon; however, these injuries are associated with significant morbidity and mortality. In an attempt to define the management of penetrating laryngotracheal injuries, we reviewed our experience with these injuries. Methods. We retrospectively analyzed the records of all patients admitted to a Level I trauma center who required operative management for penetrating laryngotracheal injuries. During the period of this study all patients with penetrating neck injuries were managed according to a protocol of selective exploration. Results. Of fifty-seven patients with penetrating laryngotracheal injury 32 patients sustained gunshot wounds and 25 had stab wounds. The injuries were to the larynx in 24 (42%) and trachea in 33 (58%). Forty-six (81%) had isolated airway injuries and 11 (19%) had combined airway and digestive-tract injuries. Emergent airway management in 32 (56%) patients included: tracheostomy (15), endotracheal intubation (14), and cricothyroidotomy (3). Respiratory distress and subcutaneous crepitus were the commonest clinical findings. Diagnostic evaluation included: Iaryngoscopy/tracheoscopy (17), esophagoscopy (12), contrast esophagography (9), angiography (8), and bronchoscopy (3). Repair of laryngotracheal and esophageal injury was performed in the majority of patients. Selected patients with milder Iaryngotracheal injury did not have tracheostomy performed, with no increase in morbidity or mortality. There were 2 (3.5%) early deaths from associated major vascular injury. Conclusion. Mortality can be minimized by aggressive airway control. Endotracheal intubation can be accomplished safely in selected patients with penetrating laryngotracheal injuries. Digestive-tract injuries can often clinically occult and contribute significantly to morbidity and mortality; therefore, early evaluation of the esophagus is vital. Simple repair of Iaryngotracheal and digestive-tract injuries can be performed safely with good results. In patients with minor injuries, tracheostomy does not appear to be mandatory. © 1995 Jons Wiley & Sons, Inc.     

Results of mandatory exploration for penetrating neck trauma

Management of penetrating wounds to the neck remains controversial despite decades of discussion in the literature. We assessed 393 consecutive stab wounds penetrating the platysma operated at our trauma service between January 14, 1991 and September 30, 1992 to evaluate our policy of mandatory neck exploration (NE). Injury to the common (n=19 cases), external (n=7), internal carotid (n=5), innominate (n=2), subclavian (n=20), vertebral (n=12), facial (n=2), and intercostal (n=2) arteries; the external (n=36), internal (n=65), subclavian (n=20), and innominate (n=4) veins; the pharynx/esophagus (n=21); and the trachea (n=28) was considered a positive NE (n=167). 226 NEs were negative. Except for hemiparesis and bruit, the presence of clinical signs (shock, active hemorrhage, hematoma, surgical emphysema, dysphagia, blowing wound) did not predict a positive NE. Clinical signs were absent in 30% of positive NEs and in 58% of negative NEs. Complications of positive NE included wound infection (n=7 cases), chyle drainage (n=6), cerebellar stroke (n=1), pneumonitis (n=8), reoperation for recurrent hemorrhage (n=1), subclavian artery graft occlusion (n=1), bronchopleural fistula (n=1), and cerebrospinal fluid leak (n=1). Negative NEs were complicated by a wound infection in four cases and pneumonitis in one case. The mean hospital stay was 4.3 days for those with a positive NE and 1.5 days for those with a negative NE. Clinical signs are of no help in determining whether a stab wound to the neck has led to potentially life-threatening injury. Mandatory NE saves unnecessary invasive diagnostic studies, is associated with negligible morbidity, and incurs only a short hospital stay.

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Resumen Luego de decenios de discusión, persite la controversia sobre el manejo de las heridas penetrantes del cuello. Hemos analizado 393 heridas cortopunzates penetrantes del músculo platisma o cutáneo del cuello operadas en nuestro servicio de trauma entre enero 14 de 1991 y septiembre 30 de 1992, con el fin de valorar nuestra política de exploración cervical obligatoria (EC). Se consideró como EC positiva (167 casos) cuando la herida afectaba las arterias carótida primitiva (19 casos), externa (7), interna (5), innominada (2), subclavia (20), vertebral (12), facial (2) e intercostales (2), las venas yugular externa (36), interna (65), subclavia (20) e inominada (4), la faringe/esófago (21) y la tráquea (28); 226 ECs fueron negativas. Excepto por hemiparesia y soplos, la presencia de signos clínicos (shock, hemorragia activa, hematoma, enfisema quirúrgico, disfagia, herida sopladora) no constituyó un factor positivo de predicción de la EC. Los signos clínicos estuvieron ausentes en 30% de las ECs positivas y en 58% de las negativas. Las complicaciones de las ECs positivas incluyeron infección de la herida (7 casos), drenaje quiloso (6), accidente cerebelar (1), neumonitis (8), reoperación por hemorragia recurrente (1), oclusión de un injerto arterial subclavio (1) fistula brocopleural (1) y fistula de líquido cefalorraquídeo (1). Las ECs negativas se complicaron por infección de la herida en 4 casos y neumonitis en 1 caso. El promedio de la estancia hospitalaria fue de 4.3 días para las ECs positivas y de 1.5 días para las ECs negativas. Los signos clínicos no son de ayuda en cuanto a establecer si una herida corto-punzante del cuello ha dado lugar a una lesión potencialmente letal. La exploración cervical obligatoria ahorra estudios diagnósticos invasivos innecesarios e implica una morbilidad insignificante y una corta estancia hospitalaria.

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Résumé Le traitement de plaies pénétrantes du cou reste controversé malgré des décennies de discussion dans la littérature. Nous avons évalué les résultats de notre politique d'exploration systématique (ES) dans 393 plaics du cou ayant franchi le muscle peaucier traités dans notre unité de soins entre le 14 Janvier 1991 et le 30 Septembre 1992. Ont été considérée comme une ES «positive» (n=167) les plaies des artères carotide commune (n=19), externe (n=7), interne (n=5), sous-clavière (n=20), vertébrale (n=12), faciale (n=2) et intercostales (n=2), du tronc brachiocéphalique (n=2), des plaies des veines jugulaire interne (n=65), externe (n=36), sous-elavière (n=20) et innominée (n=4), des plaies du pharynx/oesophage (n=21) et de la trachée (n=28). Deux cent vingt six ES ont été considéré comme «négatives». Exceptés l'hémiparésie et le souffle carotidien, la présence de signes cliniques (choc, hémorragie active, hématome, emphysème, dysphagie, une plaie soufflante) n'était pas prédictive d'une ES positive. Ces signes étaient absents dans 30% des ES positives et présents dans 42% des ES négatives. Les complications de l'ES positive ont été une infection de la plaie (n=7), une lymphorrhée (n=6), un accident vasculaire cérébral (n=1), une infection pulmonaire (n=8), une réopération pour hémorragie récidivante (n=1), une occlusion de greffe de la sous-clavière (n=1), une fistule bronchopleurale (n=1), et une fuite de liquide céphalo-rachídien (n=1). L'ES négative a été compliquée d'infection (n=4) et d'une infection pulmonaire (n=1). La durée moyenne de séjour hospitalier a été de 4.3 jours en cas d'ES positive, et de 1.5 jours pour une ES négative. En conclusion, lors d'une plaie pénétrante du cou, les signes cliniques ne permettent pas de déterminer s'il y a des lésions potentiellement létales. Une ES est associée avec une économie d'investigations souvent inutiles, une morbidité réduite et une durée d'hospitalisation plus courte.

     

Emergency parotidectomy for penetrating zone III neck trauma

Penetrating trauma to the face and upper zone III of the neck may present unique challenges when the parotid gland and associated neurovascular structures are involved. We report a case of massive hemorrhage from penetrating neck trauma that necessitated emergency parotidectomy for vascular exposure. Facial nerve repair was also necessary, underscoring the importance of this approach not only for successful vascular control but also for preservation of nearby vital structures. The management of penetrating trauma to the parotid region,and relevant anatomy, are discussed.     

Limited role of arteriography in penetrating neck trauma

Of the patients with penetrating neck wounds treated between 1979 and 1986, 61 patients with 65 injuries had arteriography during their evaluation. Twenty-seven patients had stab wounds and 34 had gunshot wounds, with a relatively equal distribution between the zones of injury. Fifty-seven arteriograms were normal and six were abnormal. Of the six arteriographic defects, three were thought to be spurious on subsequent review, two were clinically insignificant, and one required surgery. No significant arterial injuries were identified by arteriography in the absence of suggestive physical findings. No major arterial injuries were discovered during neck surgery that were missed preoperatively. Neither abnormal nor normal angiograms significantly altered the course of management, including the approach to neck exploration. These data suggest that arteriography for penetrating neck trauma is usually unnecessary for observation of patients in stable condition without suggestive physical findings. Thorough neck exploration with dissection of the carotid sheath in patients with physical diagnostic criteria for surgery eliminates the need for angiography in most cases and avoids the consequences of a possible false-negative study.     

The role of angiography in penetrating neck trauma

Seventy-two consecutive patients who underwent neck arteriography were reviewed to assess recent suggestions that angiography is not indicated in asymptomatic patients with penetrating neck trauma. Proximity to major neck vessels without signs or symptoms of vascular trauma was the reason for angiography in ten of 26 patients with proven arterial injuries. Physical examination had a specificity of 80% and a sensitivity of 61% in this series. There was no correlation between mechanism or location of penetration and the likelihood of clinically significant injury. We conclude that recent recommendations suggesting that arteriography is unnecessary in asymptomatic patients with penetrating neck trauma are premature. Further investigations of larger patient samples are necessary to determine if "proximity" should be abandoned as an indication for arteriography. We advocate that, until additional data are accumulated, urgent arteriography and esophagography or operative exploration are indicated in stable asymptomatic patients with neck wounds which violate the platysma.     

Airway management in laryngotracheal injuries from blunt neck trauma in children

Pediatric laryngotracheal injuries from blunt neck trauma are extremely rare, but can be potentially catastrophic. Early diagnosis and skillful airway management is critical in avoiding significant morbidity and mortality associated with these cases. We present a case of a patient who suffered a complete tracheal transection and cervical spine fracture following a clothesline injury to the anterior neck. A review of the mechanisms of injury, clinical presentation, initial airway management, and anesthetic considerations in laryngotracheal injuries from blunt neck trauma in children are presented.     

Occult aortic injury after penetrating abdominal trauma

Although pseudoaneurysms after penetrating extremity trauma are well described, we describe an unusual case of residual occult aortic injury after an initial attempt at repair that was recognized on postoperative imaging. Reoperation with primary resection and end-to-end repair was accomplished successfully. Because this entity is so unusual, we review strategies to avoid and recognize its occurrence. Early imaging allows early identification of aortic pseudoaneurysms should they occur, and will preclude delayed manifestation of complications, including death. Our case illustrates the utility of such postoperative scanning. Other alternatives to primary repair or interposition grafting in management of penetrating abdominal aortic trauma, such as interventional stent grafting, are discussed.     

Acute treatment of penetrating popliteal artery trauma: The importance of soft tissue injury

During a 20-year period from 1973 to 1992, 109 patients underwent early operation for acute popliteal artery trauma. Clinical variables were analyzed for their association with amputation. Gunshot wounds accounted for the majority of injuries (73%), followed by shotgun wounds (18%), stab wounds (6%), iatrogenic injuries (2%), and lacerations (1%). Fasciotomies were performed selectively in 41% of patients. Seven patients (6%) lost the injured extremity despite arterial repair. The mean time from injury to arterial repair was not significantly different for patients with or without subsequent amputation (8.6±3.6 and 9.7±7.4 hours, respectively;p=0.69). Delay in diagnosis longer than 6 or 12 hours after the injury did not increase the risk of amputation. Other factors not associated with limb loss were preoperative ischemic neurologic deficit or compartmental hypertension, concomitant fracture, and popliteal vein injury. Severe soft tissue injury (p<0.0001) or postoperative wound sepsis (p<0.0001) substantially increased the risk of amputation. Delayed fasciotomies were uncommon (4%) but were associated with a significantly increased risk of amputation (p<0.0001). Vein grafting for arterial repair (p=0.0017) and shotgun injuries (p<0.0001) were associated with amputation to the extent that they were related to severe soft tissue injury. The degree of soft tissue trauma and subsequent infection of devitalized tissue limits the success of popliteal arterial repair. Changes in the mechanism of trauma, liberal use of four-compartment fasciotomies, and aggressive management of soft tissue injury resulted in a significant decline in the amputation rate from 21% (4/19) in the first 5 years to 0% (0/39) in the last 5 years of the study.Presented at the Twelfth Annual Meeting of the Southern California Vascular Surgical Society, Coronado, Calif, September 17–19, 1993.     

Blunt trauma with flail chest and penetrating aortic injury.

Blunt chest trauma with flail chest is common. The mortality attributes initially to the associated pulmonary contusion, massive hemothorax and later to the occurrence of adult respiratory distress syndrome. We report a case of flail chest with segmental fractures near the costovertebral junction and delayed hemothorax attacked 14 h later. The final diagnosis of the penetrating aortic injury by detached rib fragment was appreciated by aortogram. Unfortunately, active aortic hemorrhage made prompt thoracotomy in vain for life salvage.     

Neurosurgical intervention in penetrating spinal trauma with associated visceral injury

Associated injuries to the neck, chest, or abdomen are found in approximately one-quarter of all civilians with penetrating spinal cord or cauda equina injuries. While the value of and indications for general surgical exploration and repair of these injuries are fairly self-evident, the value of neurosurgical intervention in terms of neurological outcome and infection prophylaxis remains the subject of debate. To study this issue, 160 civilian patients with penetrating spinal injuries and neurological deficits were retrospectively reviewed. Associated injuries of the esophagus, trachea, bronchi, or bowel were seen in 107 individuals (67%); 33 (31%) of these patients had abdominal injuries, 25 (23%) had neck injuries, 23 (21%) had thoracic injuries, and 26 (24%) had injuries occurring at multiple sites. Of these 107 patients, 67 (63%) had complete neurological injuries and the remaining 40 (37%) demonstrated incomplete deficits. All 107 patients underwent surgical exploration and repair of their visceral injuries; in 19 of them a neurosurgical procedure was also performed for decompression of the neural elements and/or debridement of the wound. Regardless of the presence of associated visceral injuries, the mechanism of injury, and the extent of the neurological deficit, no statistically significant difference in neurological outcome was found in patients with or without neurosurgical intervention. Complications associated with neurological injury were reported in 17 (11%) of the total group of 160 patients. Four (21%) of the 19 patients who had neurosurgical intervention suffered a related complication, compared to only six (7%) of the 88 patients who were managed conservatively (p less than 0.05). Within the limitations of a retrospective review, the results of this study do not clearly support the value of routine neurosurgical intervention as an adjunct to general surgical repair in cases of spinal injury associated with penetrating visceral trauma.