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31 Operative Strategies inPenetrating Trauma totheNeck
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275
suture line to leak in the neck is the esophagus, and the secretions/infection may cause the failure of neighboring suture
lines. A surgical drain is a must.
Trick
Buttress the esophageal repair with a tongue of viable strap or
SCM when associated with other vascular or tracheal injuries.
Always place a drain in the neck following an esophageal
repair. If in 72h, there is no amylase present in the drain, it
is OK to remove to avoid erosion into the repair or other
structures. Should a leak develop, this will allow for creation
of a stula rather than mediastinitis which has a high associated mortality.
31.5.1 Damage Control
1. Use a drain to create a stula rather than risk
mediastinitis.
2. Consider diversion with a cervical esophagostomy when
there is massive destruction of the esophagus. Esophageal
reconstruction or repair can then be planned
post-recovery.
Important Points
• Trick: Always approach a neck hematoma medial to the
SCM.
• Trick: If the pseudoaneurysm is contained in the neck,
dissect either proximally or distally to gain vascular control in more virgin territory.
• Trick: If you enter a pseudoaneurysm and you are unable
to control it more proximally, try replacing your nger
with a Foley catheter and inate the balloon. This will
often tamponade the bleeding in a GSW tract while you
perform your sternotomy.
• Caution: Bilateral IJ ligation has a high mortality associated with it.
• Tricks: (1) Evaluate associated injuries. (2) Avoid searching for the recurrent laryngeal nerves. (3) Separate tracheal and esophageal suture lines utilizing a muscle ap.
(4) Conserve viable trachea to maximize opportunity for
successful primary repair. (5) Avoid tracheostomy through
the repair. (6) Flex the neck postoperatively to reduce
tension.
• Trick: Buttress the esophageal repair with a tongue of
viable strap or SCM.
Suggested Reading
31.6 Bone Bleeding
An uncommon but distressing problem could be bleeding
from a hole in the vertebrae. Usually this type of bleeding in
the neck arises from an injured vertebral artery. Treatment
options include lling the hole with bone wax or packing it
and then proceeding with angioembolization of the vertebral
artery. A Foley catheter can also be used to tamponade bleeding in large bore injuries.
31.7 Conclusion
These are general guidelines and a few tricks of the trade for
surgeons to consider when performing these repairs. This is
by no means an exhaustive list of operative techniques. The
surgeon’s approach to penetrating neck trauma needs to be
considered in the context of the institutional resources. At
times for a tracheal injury, airway control with an endotracheal tube with the cuff below the injury and transfer to a
higher level of care is necessary. If imaging modalities are
limited and follow-up is limited, more liberal exploration of
necks may be necessary. This only serves to provide some
guidance when you are confronted with a neck injury and
you nd yourself in the operating room.
Atteberry LR, Dennis JW, Menawat SS, Frykberg ER. Physical
examination alone is safe and accurate for evaluation of vascular injuries in penetrating zone II neck trauma. J Am Coll Surg.
1994;179:657–62.
Bif WL, Moore EE, Rehse DH, etal. Selective management of pen-
etrating neck trauma based on cervical level of injury. Am J Surg.
1997;174:678–82.
Bishara RA, Pasch AR, Douglas DD, etal. The necessity of manda-
tory exploration of penetrating zone II neck injuries. Surgery.
1986;100:655–60.
Demetriades D, Asensio JA, Velmahos G, etal. Complex problems in
penetrating neck trauma. Surg Clin North Am. 1996;6:661–83.
Demetriades D, Theodorou D, Cornwell E III, Berne TV, Asensio J,
Belzberg H, Velmahos G, Weaver F, Yellin A.Evaluation of penetrating injuries of the neck: prospective study of 223 patients. World
J Surg. 1997;21:41–8.
Elerding SC, Manart FD, Moore EE.A reappraisal of penetrating neck
injury management. J Trauma. 1980;20:695–7.
Golueke PF, Goldstein AS, Sclafani SJ, etal. Routine versus selective
exploration of penetrating neck injuries: a randomized prospective
study. J Trauma. 1984;24:1010–4.
Mathisen DJ, Grillo H. Laryngotracheal trauma. Ann Thorac
Surg. 1987;43(3):254–62. https://doi.org/10.1016/
s0003- 4975(10)60608- x.
Monson DO, Saletta JD, Freeark RJ. Carotid vertebral trauma. J
Trauma. 1969;9:987–99.
Múnera F, Soto JA, Palacio D, Velez SM, Medina E. Diagnosis of
arterial injuries caused by penetrating trauma to the neck: comparison of helical CT angiography and conventional angiography.
Radiology. 2000;216(2):356–62. https://doi.org/10.1148/radiology.
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L. Schroeder and M. de Moya
Nance FC, Cohn I Jr. Surgical judgement in the management of
stab wounds of the abdomen: a retrospective and prospective
analysis based on a study of 600 stabbed patients. Ann Surg.
1969;170:569–645.
Nason RW, Assuras GN, Gray PR, et al. Penetrating neck injuries:
analysis of experience from a Canadian trauma centre. Can J Surg.
2001;44:122–6.
Roon AJ, Christensen N.Evaluation and treatment of penetrating cervi-
cal injuries. J Trauma. 1979;19:391–7.
Saletta JD, Lowe RJ, Lim LT, etal. Penetrating trauma of the neck. J
Trauma. 1976;16:579–87.
Sekharan J, Dennis JW, Veldenz HC, Miranda F, Frykberg ER.Continued
experience with physical examination alone for evaluation and man-
agement of penetrating zone 2 neck injuries: results of 145 cases. J
Vasc Surg. 2000;32(3):483–9.
Shirkey AL, Beall AC Jr, Debakey ME.Surgical management of pen-
etrating wounds of the neck. Arch Surg. 1963;86:955–63.
Shiroff AM, Gale SC, Martin ND, et al. Penetrating neck trauma: a
review of management strategies and discussion of the ‘No Zone’
approach. Am Surg. 2013;79(1):23–9.
Sriussadaporn S, Pak-Art R, Tharavej C, etal. Selective management of
penetrating neck injuries based on clinical presentations is safe and
practical. Int Surg. 2001;86:90–3.
Velmahos GC, Souter I, Degiannis E, etal. Selective surgical manage-
ment in penetrating neck injuries. Can J Surg. 1994;37:487–91.
Access totheNeck inPenetrating
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Trauma
JereyUstin
The neck is an incredibly anatomically complex region of
the body containing vital aerodigestive and neurovascular
structures. Despite this density of structures, you can access
the entire neck by knowing three basic exposures.
Deciding among the incisions requires some knowledge
or assumptions about the trajectory of the wound. Ultimately,
you are trying to decide which zone or zones (Fig.32.1) have
been injured and if the wound is unilateral or transcervical. It
is here that your assessment is critical. What have you learned
about the mechanism of injury? Are there any signs or symptoms that indicate which structures have been injured such as
the classic “hard signs”? Are there any indications that the
trajectory crossed the midline and affected the bilateral
necks? Is there a pneumothorax, hemothorax, pericardial
effusion, or abnormal brachio-brachial index (BBI) indicating a trajectory into the thoracic cavity as well as the neck?
Do you have any imaging studies to guide your decision? It
is usually feasible to obtain a quick chest radiograph and thoracic ultrasound.
Some situations require a denitive maneuver before
formal exploration. Tracheal injuries require denitive airway control. Laryngoscopic or ber-optic endotracheal
intubation is often possible and worth attempting. Large
injuries allow direct intubation through the wound which
is an acceptable temporary airway. Otherwise, emergency
cricothyroidotomy is the quickest approach and may be
left as a denitive airway without conversion to
tracheostomy.
Bleeding is usually controllable with digital pressure.
Subclavian injuries can be difcult to compress. Place a
Foley catheter into the wound, inate it, and pull it against
the clavicle for tamponade.
J. Ustin (*)
Division of Trauma, Emergency Surgery & Surgical Critical Care,
Massachusetts General Hospital, Harvard Medical School,
Boston, MA, USA
e-mail: Jeffrey.Ustin@UHhospitals.org
32
Zone III
Zone II
C6
Cricoid
Zone I
Fig. 32.1 Zones of the neck
Several steps can help optimize the surgical approach.
The cervical collar is removed. It is unnecessary to follow
cervical spine precautions in penetrating neck trauma since
the probability of an unstable cervical spine with a penetrating mechanism is exceedingly small, and suboptimal positioning can seriously impair the ease of access to the neck.
Place a transversely oriented shoulder roll to obtain some
neck extension. Turn the patient’s head away from the side of
the initial exploration. Prep both sides of the neck starting at
the mastoid process. Leave the tips of the pinnae and angles
of the mandible exposed. Prep the sternum into the eld for
possible extension of the neck incision into a sternotomy.
Prep one leg for possible vein graft. Finally, if you are uncertain about the exact trajectory of a missile, consider prepping
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
E. Degiannis et al. (eds.), Penetrating Trauma, https://doi.org/10.1007/978-3-031-47006-6_32
277
278
SCM
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Fig. 32.2 (a, b) Easiest and
most safe access is via the
anterior sternocleidomastoid
incision
J. Ustin
a
Facial vein beneath fascia
Common carotid artery
Internal jugular vein
Metzenbaum scissors
open fascia
the abdomen as well. Make sure to ask to have the following
equipment immediately available: vascular sutures such as
5-0 Prolene, vascular clamps, vascular grafts, and patches; a
variety of balloon embolectomy catheters; and a sternal saw
and sternal retractor. Request the anesthesiologist to place a
large bore nasogastric (NG) tube.
The workhorse access is the anterior sternocleidomastoid
(SCM) incision (Fig.32.2). Make a generous incision along
the anterior border of the sternocleidomastoid. At the angle
of the mandible, curve the incision slightly posteriorly to
remain at least 2cm from the mandible and thus avoid injury
to the marginal mandibular branch of the facial nerve. The
platysma is divided, and the dissection is continued anterior
b
to the SCM.Look for the internal jugular (IJ) vein. The facial
vein crosses the wound and empties into the IJ.Divide the
facial vein or veins. It is also acceptable to divide the IJ as
well if there are other injuries, the patient is doing poorly, or
the vessel is badly injured.
A large hematoma will often distort the planes as you
continue your dissection, advancing the self-retaining retractors deeper into the wound. Before entering a large hematoma, gain proximal control. This may require extending the
incision caudally toward the sternal notch or even performing a median sternotomy. The omohyoid crosses the wound
low in the neck and may need to be divided. Stay in the
adventitial plane on the top of the carotid artery (Fig.32.3).
Digastric m.
Common
Xyphoid
a
Manubrium
32 Access totheNeck inPenetrating Trauma
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Hypoglossal n.
279
Facial v.
Injury
Carotid
Fig. 32.3 Stay in the adventitial plane of top of the carotid
Vagus n.
Jugular v.
As you pass a vessel loop or clamp around the carotid and IJ,
recall the position of the vagus nerve and protect it.
Sometimes this requires surrounding it with a vessel loop
and gently retracting it laterally.
Distal control can be challenging. The incision may need
to be extended toward the mastoid. The hypoglossal nerve
crosses the carotid at approximately the level of the bifurcation and often very near the posterior belly of the digastric
muscle. Protect the hypoglossal, and divide the digastric if
needed. By remaining anterior to the SCM, you should not
encounter the spinal accessory nerve until you are within
several centimeters of the skull base. High carotid injuries
are very hard to reach. Dislocating the jaw is possible but
requires special expertise. Use a handheld retractor on the
mandible itself in these situations. Oftentimes it is easier to
obtain distal control by entering the hematoma and applying
distal pressure, vascular clamps, or a balloon embolectomy
catheter directly to the open end of the vessel.
To access the trachea, divide the omohyoid, sternohyoid,
and sternothyroid as needed. If needed, mobilize the thyroid
by dividing the middle thyroid vein and inferior thyroid
artery. Be mindful of the recurrent laryngeal nerve, although
frequently it is not readily identiable in the trauma
situation.
To access the esophagus, divide the omohyoid, sternohyoid, and sternothyroid (as needed), middle thyroid vein, and
inferior thyroid artery. Retract the carotid sheath posterolaterally. Do not hesitate to open the contralateral neck to fully
examine the esophagus when needed. The previously placed
NG tube helps with esophageal mobilization.
b
Fig. 32.4 (a) Pass a nger deep to the sternum at both ends of the inci-
sion to separate the deep surface of the sternum from the underlying
soft tissues. (b) You can divide the left innominate vein to achieve better
exposure if retraction alone is insufcient
Divide or retract
for access to innominate artery
and left common carotid artery
Bleeding from deep within the posterior neck is coming
from a vertebra or vertebral artery. This is best controlled
with a hemostatic agent and pressure. You can also try placing bone wax to control hemorrhage. Avoid exploring these
injuries as they are very difcult to directly control.
As discussed above, it is sometimes necessary to perform a sternotomy to gain proximal control of the carotid.
This is further described in the chapters on Thoracic
Trauma. Briey, incise the skin over the sternum from the
sternal notch to several centimeters below the xiphoid. Pass
a nger deep to the sternum at both ends of the incision to
separate the deep surface of the sternum from the underlying soft tissues (Fig. 32.4a). Ask the anesthesiologists to
hold respirations and divide the sternum using the saw. Try
to remain in the middle of the sternum. Apply gentle traction on the saw toward the ceiling, keeping the saw guide
against the deep surface of the sternum. Place the sternal
retractor, and divide the thymus between clamps if needed.
Retract the innominate vein to expose the ascending aorta
and great vessels. You can divide the left innominate vein to
achieve better exposure if retraction alone is insufcient
(Fig.32.4b). The right-sided vessels are easily accessible.
The left side is more difcult since the arch extends posteriorly. Identify the vagus and recurrent laryngeal nerves
before clamping.
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For transcervical injuries, perform a “U” incision
(Fig.32.5). Start by making an anterior sternocleidomastoid
incision as described above. At approximately 2 cm above
the sternal notch, curve the incision toward the contralateral
side, and continue by incising the skin along the anterior border of the other sternocleidomastoid. Incise the platysma,
grasp it with several Allis clamps, and raise a superior ap.
Continue to identify the IJ veins, divide the facial veins, and
access the carotid sheaths as described above.
J. Ustin
One finger-width
Fig. 32.5 For transcervical injuries, perform a “U” incision to enable
bilateral exploration
Penetrating Trauma totheLarynx
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andtheCervical Trachea
LisaM.Kodadek, AliciaKieninger, andElliottR.Haut
33
Penetrating neck trauma with laryngotracheal injury carries
high mortality secondary to loss of the airway. While many
patients die from these injuries before reaching the hospital,
improved prehospital care has increased the number of
patients needing surgical evaluation for penetrating neck
trauma. As many as 50% of patients presenting with gunshot
wounds to the neck and 10–20% of patients with stab wounds
to the neck will have signicant injuries requiring intervention. Injuries to multiple structures in the neck are common
given the close proximity of major vascular, aerodigestive,
nervous, and endocrine structures (Fig. 33.1). Important
aspects of initial care include airway control as well as early
and complete diagnosis and management of all injuries.
L. M. Kodadek
Yale School of Medicine, New Haven, CT, USA
e-mail: lisa.kodadek@yale.edu
A. Kieninger
St. Joseph Mercy Oakland, Pontiac, MI, USA
e-mail: alicia.kieninger@stjoeshealth.org
E. R. Haut (*)
Division of Acute Care Surgery, Department of Surgery, The Johns
Hopkins Hospital, The Johns Hopkins University School of
Medicine, Baltimore, MD, USA
e-mail: ehaut1@jhmi.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
E. Degiannis et al. (eds.), Penetrating Trauma, https://doi.org/10.1007/978-3-031-47006-6_33
281
282
Sternohyoid m.
Thyrohyoid m.
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Fig. 33.1 Injuries to multiple
structures in the neck are
common with penetrating
neck trauma given the close
proximity of major vascular,
aerodigestive, nervous, and
endocrine structures
L. M. Kodadek et al.
Hyoid
bone
Thyroid
cartilage
Cricoid
cartilage
SCM
Trachea
33.1 Historical Context
Penetrating trauma to the neck has historically been managed by dividing the neck into three zones based on the 1979
categorization by Roon and Christensen. Zone I extends
from the clavicles to the cricoid cartilage, Zone II spans from
the cricoid cartilage to the angle of the mandible, and Zone
III is between the angle of the mandible and the skull base.
Zone II is more commonly injured than Zone I or III.Based
on military experience during conict, historical management of all Zone II penetrating injuries was mandatory operative exploration and direct repair, given the high incidence
of injuries to vascular and aerodigestive structures.
Mandatory exploration of Zone II injuries as well as mandatory endoscopy and angiography for Zone I and III injuries
remained the standard of care for civilians for several
decades. Over time, surgeons began to question the zonebased approach to management, since civilian injuries were
often sustained from lower velocity weaponry, and anywhere
Omohyoid m.
Thyroid
isthmus
Anterior
jugular m.
from 40% to 89% of operations were nontherapeutic.
Ultimately, the scientic literature demonstrated the safe
management of Zone II neck injuries in civilian populations
without mandatory operative exploration, disproving the surgical dogma of a zone-based selective approach. In current
practice, a “No Zone” approach to management recognizes
that regardless of the location of the injury, all patients with
a penetrating neck injury in violation of the platysma and
without hemodynamic compromise or hard signs of vascular
or aerodigestive injury may be safely evaluated with thorough clinical examination and high-resolution computed
tomography angiography (CTA). This evidence-based
approach, supported by two recent systematic reviews of the
literature, makes use of modern imaging technology and
allows for safe and effective triage of those patients who
require further operative or procedural intervention. With
overall mortality rates as high as 40–50%, penetrating neck
trauma remains a challenging disease process and requires
skillful and timely surgical care.
33 Penetrating Trauma totheLarynx andtheCervical Trachea
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283
33.2 Airway Management
Patients presenting obtunded or in respiratory distress after
penetrating neck trauma require immediate intubation.
Patients with a patent airway and spontaneous breathing may
not require emergent intubation, but a high level of clinical
suspicion for injury is required. Any delay in diagnosis of a
laryngotracheal injury may lead to edema and hematoma formation with subsequent airway obstruction and an urgent
need for a surgical airway. Signs and symptoms of airway
injury may be readily apparent such as massive subcutaneous emphysema, air bubbles in the wound, or inability to
phonate. More subtle signs may include hoarseness, cervical
ecchymoses, voice changes, or odynophagia. Prehospital
cervical collar use in penetrating neck trauma is not routinely
necessary and can delay the management of the airway. If a
cervical collar is present, it should immediately be removed
to fully assess the airway and neck while manual inline cervical stabilization is provided if indicated. Recent guidelines
have recommended against spine immobilization in penetrating trauma as this practice is associated with increased
mortality and does not have a benecial effect on mitigating
neurologic injuries.
A review of patients with penetrating laryngotracheal
injury demonstrated that approximately half of the patients
required immediate airway control, and the majority of these
were accomplished through oral endotracheal intubation. In
an older series of penetrating laryngotracheal injuries, just
over half required immediate airway control, but only 44%
of these were accomplished through oral endotracheal intubation. In both of these series, the most common clinical
manifestations of injury were stridor, respiratory distress,
and crepitus.
Oral endotracheal intubation via direct laryngoscopy or
video laryngoscopy is the preferred route for airway control in patients with laryngotracheal injury. While this
method is expedient and successful in many patients, oropharyngeal swelling or facial fractures may limit visualization under direct or video laryngoscopy. Furthermore,
neuromuscular blockade, commonly used to achieve oral
endotracheal intubation, should be avoided in cases of penetrating neck trauma in order to maintain the patient’s
spontaneous respiratory drive. In cases of signicant laryngotracheal injury, the most experienced individual available should perform the procedure. In some cases, only one
attempt at intubation will be possible. In the event of failure
to orally intubate, other options for airway control must be
readily available.
Controlled awake beroptic nasotracheal intubation with
topical anesthesia is a safe and effective alternative when
performed by an individual skilled in this procedure. Blind
nasotracheal intubation should not be attempted in any
patient with airway injury as this may compound injuries.
Furthermore, nasotracheal intubation should not be attempted
in patients with basilar skull fractures, frontal sinus fractures,
or cribriform plate fractures. Intubation over a gum elastic
bougie may also be utilized as an adjunctive strategy for airway management. Laryngeal mask airway (LMA) may be
considered, but this is not a denitive airway, these typically
do not work well when anatomy is distorted, and placement
may cause additional injury.
Surgical airway equipment should always be readily
available in the event translaryngeal techniques fail.
Cricothyroidotomy is the procedure of choice in the emergent setting and can be accomplished quickly and with
minimal morbidity to surrounding structures. Continuing
education and simulation for this rare, high-risk procedure is
important to ensure that clinicians can perform it when
needed. Both horizontal and vertical incisions are described,
but a vertical incision may be preferable in the setting of tracheolaryngeal injury (Fig.33.2a). A vertical incision allows
exibility to identify the proper level of the airway and
avoids the anterior jugular veins. A tracheostomy tube
(Fig. 33.2b, c) or an endotracheal tube (e.g. endotracheal
tube with 5.0mm or 6.0mm internal diameter) may be used.
Care should be taken to avoid main stem bronchus intubation
if an endotracheal tube is used; this may be accomplished by
ensuring the balloon of the endotracheal tube is inated just
beyond the cricothyroidotomy incision. Emergent
tracheotomy should only be used in cases of suspected complete laryngotracheal separation or when the injury is located
below the cricothyroid membrane. Very rarely, the trachea
has been transected by the initial injury and can be directly
accessed and intubated via the neck.
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a
bc
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Fig. 33.2 (a) A vertical
cricothyroidotomy incision
allows exibility to identify
the proper level of the airway
and avoids the anterior jugular
veins. (b, c) A tracheostomy
tube is used as an airway
device for cricothyroidotomy
Vertical
incision
over cricoid
L. M. Kodadek et al.
Thyroid
cartilage
Cricoid
cartilage
33.3 Injury Classication
Denitive care of laryngotracheal injury requires a comprehensive understanding of the anatomy of the larynx and trachea. Airway injuries are best classied based on their
relation to the vocal cords. Supraglottic injuries are typically
associated with vertical fractures of the thyroid cartilage
with or without fracture of the cricoid cartilage. Glottic injuries may involve the thyroid cartilage, but can also involve
the true vocal cords, thyroarytenoid muscles, and aryepiglottic bands. Subglottic injuries involve the lower thyroid cartilage and cricoid cartilage and are potentially the most
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