Neck Trauma: Causes, Symptoms, and Treatment Options

Neck trauma is often associated with road traffic accidents, gunshot wounds, cutthroat injuries, and interpersonal conflicts.

Despite its relative rarity, neck trauma poses a significant risk due to the presence of vital vascular structures.

There has been a distinctive paradigm shift from mandatory exploration towards more selective, conservative management based on clinical evaluation and specialized investigations.

Airway And Cervical Spine Protection In Neck Injury

• Symptoms indicating airway obstruction may present as stridor, the utilization of accessory muscles during respiration, and hypoxia.
• Possible causes of airway compromise encompass obstructions, edema, a foreign body in the airway, or injury to the trachea or larynx.
• The neck should be immobilized using either a cervical collar or sandbags.
• It is essential to rule out cervical spine injury before initiating any movement.
• Even in cases where there is no known cervical spine injury, maintaining immobilization is paramount to prevent potential harm.
• Major facial fractures, particularly mandibular fractures, and large cervical hematomas may compromise the airway.
• Patients with transcervical gunshot wounds (GSWs) may not have airway problems initially, but they must be closely observed.
• A chin lift and jaw thrust procedure should be done to try to overcome the obstruction.
• Patients with Glasgow coma score GCS of ≤8 usually require intubation to protect the airway.
• An endotracheal tube may sometimes be inserted directly into the trachea through a penetrating cervical injury.
• Cricothyroidotomy must be considered if intubation fails.
• It should be converted to a formal tracheostomy within 24 hours to prevent subglottic stenosis.

Breathing in Neck Trauma

• Tension pneumothorax and haemothorax are life-threatening conditions; immediate intervention based on clinical diagnosis is mandated before X-rays are obtained. 
• Tension pneumothorax presents with hypoxia, restlessness, hyper-resonance to percussion, decreased air entry, contralateral tracheal shift, and elevated jugular venous pressure. 
• It is decompressed by needle thoracocentesis, followed by the insertion of a chest drain. 
• A large haemothorax is identified by dullness to percussion and decreased air entry and is also managed with an intercostal drain.

Circulation And Perfusion

• In the management of a shocked patient, it is recommended that two high-flow lines be inserted into the antecubital fossae using a 14-gauge cannula.
• This facilitates the rapid administration of crystalloids and colloids, helping to restore blood volume.
• It is essential to avoid inserting the needle on the same side as the vascular injury to prevent the administered substances from oozing out through the wounds, which could increase blood loss.
• The patient should be positioned in a supine posture during the insertion of the high-flow lines to minimize the risk of air embolism. 
• The initial management starts with the infusion of 2 liters of crystalloid solution.
• If the patient's blood pressure does not improve, the next step is to initiate a transfusion of O-negative blood.
• Simultaneously, blood cross-matching should be arranged to ensure that compatible blood products are readily available for the patient's ongoing treatment. 
• A shocked patient exhibiting warm peripheries may experience neurogenic shock secondary to spinal cord injuries.
• Neurogenic shock can manifest as low blood pressure and bradycardia, which may potentially mask the symptoms of vascular injuries.
• Active bleeding from an open cervical wound may be controlled with compressive dressing or digital pressure.
• Foley’s catheter can be used for neck injuries and epistaxis.

Disability Analysis In Neck Trauma

• The GCS and pupil size and reactivity to light are recorded, and power in the limbs is assessed.

Patient Exposure In Neck Trauma

• All clothing is removed to avoid missing associated injuries.
• The patient is kept warm.

Adjuncts In Primary Survey Of Neck Trauma

• Continuous monitoring with ECG, pulse oximetry, and non-invasive blood pressure monitoring is essential.
• Before inserting a urinary catheter, a rectal examination is performed to exclude urethral injury and avoid exacerbating any existing trauma.
• A comprehensive assessment of the patient's condition involves assessing the hemoglobin level, blood glucose level, and arterial blood gas analysis to detect potential metabolic acidosis or alkalosis that may require management.
• Imagining is essential, and it should include both cross-sectional CT scans and MRIs to evaluate internal injuries and potential complications thoroughly.
• Cervical spine, chest, and pelvic X-rays are conducted to identify any skeletal or thoracic injuries that may be present. 
• Hemothorax and pneumothorax should be excluded.
• When the mediastinal width is more than 8 cm, it indicates the potential for major intrathoracic injuries, and further investigation, such as CT angiography, should be done.
• Cervical spine X-rays are done to assess for potential injuries, such as the presence of air bubbles in the prevertebral soft tissue, to exclude spinal cord injuries and injuries related to the pharynx or esophagus.
• Non-urgent X-rays should only be requested after completing the secondary survey.

Adjuncts In Secondary Survey Of Neck Trauma

• During the secondary survey, a tract is established to identify the injured anatomical structure.
• X-rays (AP and lateral) are taken when there is no exit wound to locate and determine the trajectory of the bullet.
• A cranial nerve examination is conducted if the patient has not been intubated. Horner's syndrome is ruled out in instances of cervical sympathetic chain involvement, which may present with symptoms like ptosis, miosis, and anhidrosis. 
• The patient is examined for a large cervical hematoma, subcutaneous emphysema, jugular venous pressure, and tenderness over the mandible.
• In cases where a nasogastric tube is inserted, blood in the nasogastric tube is checked.
• Distal carotid and superficial temporal artery pulses are examined, and listen for bruits.
• The possibility of a hemothorax or pneumothorax is ruled out, and heart sounds are auscultated.
• The abdomen and pelvis are examined, followed by a full neurological examination, during which trauma to the spinal cord and the brachial plexus is excluded. 
• In cases of hemiplegia or Brown-Sequard syndrome, a thorough examination is conducted to check for hemi-transection of the spinal cord.
• To assess for potential back trauma, the patient is carefully log rolled to examine the entire back for any injuries or signs of trauma.

Clinical History In Case Of Neck Trauma

• Begin the patient assessment by inquiring about symptoms suggestive of esophageal injury, including hemoptysis, hematemesis, dysphagia, and odynophagia.
• Note information about symptoms that may indicate recurrent laryngeal nerve or laryngeal injury, such as dysphonia (hoarseness) or stridor (noisy breathing).
• Document the patient's medical and surgical history.
• Determine the time of the patient's last meal, as this information is crucial in assessing the risk of aspiration and the need for emergency intubation.

Etiological Classification Of Neck Trauma

• Penetrating injuries can be classified into stabs, gunshot wounds (GSW), blast injuries, and blunt injuries.
• Unlike stab wounds and low kinetic energy GSWs, close-range shotgun, rifle, and bomb injuries cause extensive soft tissue trauma.

Mandatory Versus Selective Exploration Of Penetrative Cervical Injuries in Cases of Neck Trauma

Before a few years, Mandatory exploration of the neck whenever the platysma muscle had been breached became common practice.

• Stone questioned the need for mandatory exploration for civilian injuries in 1963.
• The debate continues, with some advocating mandatory exploration for stable patients with low-velocity GSWs and stab wounds that breach the platysma muscle. In contrast,e others support selective exploration based on clinical evaluation and specialized investigations.

Mandatory Exploration In Neck Trauma

• Proponents of mandatory exploration of stable patients with low-velocity GSWs and stab wounds that breach the platysma muscle consider that the risk of missing an unsuspected vascular or aerodigestive tract injury outweighs the morbidity and expense of negative exploration. 
• They point to the unreliability of clinical evaluation. 
• They argue that low morbidity is associated with negative exploration, but additional time and effort are associated with expectant observation.
• Delayed esophageal injury detection and repair can result in significant morbidity and mortality.
• Vascular and esophageal injuries can be missed when the neck is explored without the assistance of pre-operative angiography, esophagography, and esophagoscopy.

Selective Exploration In Neck Trauma

• Protagonists of selective exploration cite the relatively high rate (36-60%) of negative mandatory exploration, highlighting the need to minimize unnecessary procedures.
• They highlight special investigations with good sensitivity and specificity, including angiography, Doppler ultrasound, barium swallow, rigid esophagoscopy, and flexible laryngotracheobronchoscopy.
• The expense of prolonged hospitalization following negative exploration. 
• Many injuries (e.g., thyroid, pharyngeal, and certain venous injuries) detected at mandatory exploration may be treated conservatively.
• They highlight that neck exploration leaves an unsightly scar.
• Negative exploration incentives practicing selective exploration range between 9% and 62%.
• Selective non-operative management of penetrating neck injuries has been validated as effective and safe in several prospective studies.

• In studies showing selective management, 4 studies don’t show endovascular management.
  Mortality and negative explorations are also very low.

Active Observation With Selective Special Investigations

• Some proponents of selective exploration recommend mandatory esophageal and vascular studies due to concerns about relying solely on physical assessment.
• Alternatively, when clinical examination results are equivocal, active observation with special investigations is suggested. 
• A combination of clinical evaluation and selective investigations can offer a specificity of 85% and a sensitivity of 100% in identifying vascular and aerodigestive tract injuries.
• Patients displaying subcutaneous emphysema, hoarseness, dysphagia, or minor hematemesis should be considered for exploration.
• Assessment is performed individually, considering the direction of the injury tract and the severity of clinical signs.
• If the injury tract courses away from critical structures like the larynx, trachea, esophagus, and carotid sheath, further investigations may not be necessary. 
• However, if the trajectory is directed towards the midline, contrast esophagography, and endoscopy are performed.

Specific Injuries In Neck Trauma

1. Pharyngeal Injury
   • Suspected hypopharyngeal injury in Zone II penetrating injuries with symptoms like dysphagia, odynophagia, voice change, hemoptysis, hematemesis, and surgical emphysema.
   • Diagnosis involves using flexible nasopharyngoscopy or direct pharyngoscopy.
   • Upper hypopharyngeal injuries may be managed non-operatively, while lower hypopharyngeal injuries, due to their higher intraluminal pressure and less capacious nature, may require surgery.
2. Esophageal Injury
   • Early recognition and treatment are crucial for a favorable outcome, as missed esophageal injuries have high morbidity and mortality.
   • Delays in intervention beyond 12 hours result in higher mortality. 
   • Management varies from observation to simple repair, with the possibility of drainage of deep neck spaces or primary diversion of salivary flow.
   • Factors influencing management include wound site, size, mechanism of injury, time delay, associated injuries, availability of diagnostic tests (oesophagography, esophagoscopy), and theatre time.
   • Barium swallow was performed on days 5-7 to detect asymptomatic fistulae.
   • Complications of Esophageal Injury
     • Esophagocutaneous fistulae are common with gunshot wounds, and they often close spontaneously. 
     • Esophagotracheal fistulae are repaired with muscle flaps. 
     • More serious complications may include abscess formation, mediastinitis, septicemia, and death.
3. Tracheal Injury
   • Symptoms of tracheal injury include a blowing wound, surgical emphysema, hemoptysis, and hoarseness.
   • Chest X-ray may reveal surgical emphysema and pneumomediastinum. 
   • Securing an airway is a priority.
   • Tracheotomy is appropriate in cases of laryngeal trauma, the inability to safely pass an endotracheal tube, or quadriplegia requiring ventilatory support.
   • Nasotracheal or orotracheal intubation may be cautiously used. 
   • Minor tracheal injuries in patients not requiring cervical exploration can be managed expectantly, and repair involves interrupted sutures with muscle flap reinforcement.
4. Vascular Injury
   • The common carotid artery is the major vessel most frequently injured. 
   • Clinical signs of vascular injury include an expanding hematoma, external hemorrhage, absent or significantly diminished distal pulses, and ischemic neurological deficits or coma.
   • 4 vessel arch angiography with selective catheterization is considered the gold standard for investigation.
   • Helical CT angiography is replacing conventional angiography due to its high sensitivity and specificity.
   • Pre-operative angiography is recommended for suspected vascular injuries in Zone I and III.
   • Color-flow duplex Doppler (CFD) imaging is also utilized for evaluation.

Exploration Of The neck: General Principles

• Airway management: Depending on the situation, consider nasotracheal or orotracheal intubation or resort to cricothyroidotomy/tracheotomy for securing the airway.
• Positioning: Place the patient in a supine position with the neck extended. If there is no cervical spine injury, turn the patient's head to the opposite side.
• Exposure: For Zones I and II injuries, expose the chest and face. For saphenous vein harvesting, access the contralateral groin and lower leg.
• Approach: For localized injuries, use a horizontal skin crease incision. For wider exploration, opt for a long incision along the anterior border of the sternocleidomastoid muscle.
• Additional exposure: To access Zone I, divide the omohyoid muscle. For Zone II, an anterior dislocation of the mandible is performed.
• False aneurysm of the internal carotid artery, with caroticojugular fistula following stab wound at the base of the skull.
• Trapped false aneurysm and fistula with coils by endovascular technique.

Hope you found this blog helpful for your ENT residency head and neck preparation. For more informative and interesting posts like these, keep reading PrepLadder’s blogs.

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