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33 Penetrating Trauma totheLarynx andtheCervical Trachea

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dangerous injuries. Complete loss of the airway may result from subglottic stenosis related to cricotracheal separation and emergent tracheostomy is required in this setting. Glottic and supraglottic injuries are more difcult to repair, especially with respect to voice quality. Early multidisciplinary management with the engagement of a head and neck surgeon is important in these cases once the airway has been secured.

33.4 Injury Evaluation andManagement

Indications for immediate surgical exploration in patients with penetrating neck trauma include classic “hard signs” such as expanding hematoma, exsanguinating pulsatile hemorrhage, hemodynamic instability/hemorrhagic shock, bruit or thrill, bubbling of air from the wound, massive subcutaneous emphysema, neurologic decit/signs of stroke, or respiratory distress/airway compromise including stridor or hoarseness. One single institution 13-year review identied 22 patients specically with penetrating cervical or thoracic tracheal injury and 86% required emergent neck exploration. Patients without immediate surgical indications should undergo multi-detector high-resolution CTA.

If there is evidence for injury or clinical suspicion of injury based on the trajectory observed on CTA, further directed evaluation with endoscopy and/or angiography should be pursued. Direct or indirect laryngoscopy, beroptic bronchoscopy, and/or esophagoscopy may be used to evaluate for injury to the aerodigestive structures. Contrast esophagography modalities may also be used in addition to or instead of esophagoscopy. Once all injuries have been identied, denitive surgical care may include operative exploration and repair or non-operative management. Many patients with small glottic, supraglottic, or pharyngeal lacerations or hematomas may be managed non-operatively with NPO status, antibiotics, and speech and language therapy. Follow-up contrast esophagography may be necessary to identify any persistent pharyngeal or esophageal leak before resuming an oral diet.

33.5 Operative Approach

The patient is placed supine on the operating table with a shoulder roll in place to facilitate neck extension; the table is exed at its midpoint. The patient is prepped from the angle of the mandible to the umbilicus and a lower extremity/groin is also prepped in the event of a vascular injury requiring a vein graft. The neck may be explored via a lateral oblique incision anterior to the sternocleidomastoid (as often used for carotid endarterectomy) or via a cervical collar incision

(as often used for thyroidectomy). The lateral incision is useful to retract the sternocleidomastoid and expose the vascular structures of the carotid sheath as well as the esophagus and cervical trachea.

The cervical collar incision is placed two nger-breadths above the sternal notch or higher, depending on the location of the injury. Subplatysmal aps are raised superiorly and inferiorly, and the strap muscles are divided vertically in the midline. This exposure allows excellent access to the cervical trachea and the central neck structures. The incision may be extended laterally along the anterior borders of the sternocleidomastoids or with a vertical extension down towards the sternal notch.

33.6 Laryngeal Repair

The larynx is approached via a high cervical collar incision and entrance through the cricoid membrane. Flexible laryngoscopy should be employed to fully evaluate the extent of injury including injury to the posterior wall and the vocal cords. Repair of laryngeal lacerations must ensure adequate mucosal coverage of exposed cartilage to avoid granulation tissue formation and chondritis; grafting and rotational aps may be used in some cases to achieve coverage. Cartilage fractures and mucosa are repaired with absorbable sutures such as 4-0 PDS.Rigid internal xation and stents may also be used. Early involvement of a head and neck surgeon is important to ensure the best functional outcome.

33.7 Tracheal Repair

The trachea is approached via a lateral neck incision or a cervical collar incision. Fiberoptic bronchoscopy is necessary to fully evaluate for injury including any posterior wall defects. Simple tracheal lacerations are repaired primarily with absorbable sutures such as 4-0 PDS.For larger tracheal defects, the distal trachea may be mobilized cephalad via the use of a tracheal hook or more extensive soft tissue dissection when necessary. Dissection should be completed in the anterior/posterior planes to avoid injury to the recurrent laryngeal nerves, which are located just lateral to the trachea in the tracheoesophageal grooves. Tracheal resection is not commonly required, but up to half the length of the trachea may be resected using mobilization techniques such as laryngeal release. Tracheal repairs should be buttressed with a vascularized muscle ap such as the sternocleidomastoid or omohyoid, particularly if the esophagus or other structures in the neck also require surgical repair. For trauma surgeons who do this infrequently, consultation with an experienced thoracic surgeon is appropriate.

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L. M. Kodadek et al.

33.8 Associated Injuries

Operative exploration for penetrating injury to the larynx or trachea requires a thorough intraoperative assessment of all associated structures including the contents of the carotid sheath and the cervical esophagus. Injuries should be addressed with appropriate repair, ligation, or reconstruction. Injuries to the cervical trachea may commonly injure the recurrent laryngeal nerves. If injury is suspected at the time of exploration, direct repair of the recurrent laryngeal nerve is not recommended. The function may improve with time and observation. If repair is indicated, better outcomes may be achieved with delayed repair in an elective setting.

33.9 Postoperative Airway Management

Historical accounts suggest that a tracheostomy is necessary as a protective measure for the postoperative airway management of patients with laryngotracheal injuries. The use of “protective tracheostomy” has fallen out of favor because good outcomes have been reported with direct suture repair of the trachea. More recently, immediate extubation after repair of tracheal injuries has been advocated as a safe airway management strategy in these patients. A retrospective multi-site study identied 103 patients who underwent operative repair of cervical tracheal injury and evaluated outcomes based on postoperative airway management strategy. Almost 40% of patients were extubated within 24h of cervical trachea repair. Immediate or early extubation was common and safe, although these patients tended to have less severe injuries. Patients with more severe injuries who underwent immediate tracheostomy had a higher risk of surgical site infection, while those who underwent prolonged intubation had a higher risk of pneumonia and mortality. Patients with large tracheal injuries or other injuries that may limit the patient’s ability to protect the airway may require early tracheostomy. For large tracheal injuries requiring an emergent airway, the tracheostomy may be placed directly through the anterior tracheal wound. For smaller injuries, the tracheostomy balloon cuff is placed distal to the injury.

33.10 Complications

Complications of laryngotracheal penetrating injury may include tracheal stenosis, stula, difculty with phonation, hoarseness, and abscess. Complications are more common when multiple structures are injured. In a series of patients with penetrating cervical or thoracic tracheal injury, 55% of patients had additional injuries including injury to the esophagus in most (83%) of these patients. Nearly 54% of patients

with multiple injured structures suffered any complication, but only 11% of the patients with isolated tracheal injury suffered any complication. An older series identied a 5% rate of stenosis and a 17.5% rate of voice change/hoarseness among patients who required operative management of penetrating laryngotracheal injury. While mortality for patients who survive to seek surgical care for penetrating laryngotracheal injury is less than 5% in series, morbidity may be signicant. Careful attention to operative technique and early diagnosis of all associated injuries is critical to ensure the best outcomes in penetrating injuries to the larynx and trachea.

Important Points

• Airway control is the most important aspect of early man-

agement of laryngotracheal penetrating injury.

• Oral endotracheal intubation is the preferred approach for

establishing a denitive airway.

• Cricothyroidotomy is the emergency surgical airway of

choice.

• Early diagnosis of all aerodigestive and vascular injuries

is critical.

• A “No Zone” approach to penetrating neck trauma cou-

ples thorough clinical exam and computed tomography

angiography (CTA) for patients who are stable without

hard signs of vascular and/or aerodigestive injuries.

• Endoscopy and contrast esophagography may be utilized

to fully evaluate the aerodigestive tract for injury if CTA

identies or raises concern for injury.

• The trachea is primarily repaired with an absorbable

suture (4-0 PDS).

• A vascularized muscle ap such as the sternocleidomas-

toid or omohyoid is used to buttress the tracheal repair,

especially if other cervical structures (e.g. esophagus)

require repair.

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Penetrating Injury tothePharynx

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andCervical Esophagus

JessicaA.Keeley andAngelaL.Neville

34.1 Anatomic Basics

The pharynx originates at the base of the skull and extends to the level of the cricoid cartilage. Its constrictor muscles propel food into the esophagus. The lowermost constrictor comprises the upper esophageal sphincter and sits anatomically at the level of the cricoid and C6 vertebra (Fig.34.1). The cervical esophagus descends from there to the thoracic inlet. Thus, the pharynx is the portion of the digestive tube injured in a ‘classic’ Zone 2 or 3 injury, and the cervical esophagus is injured in a Zone 1 injury. The use of “Zones” to dictate the surgical management of penetrating neck injury is less relevant in the era of computed tomography angiography (CTA) but is included here as a clinically useful descriptor.

The pharynx and cervical esophagus lie deep in the neck and are protected posteriorly by the cervical vertebrae. They are abutted anteriorly by the larynx and trachea. Consequently, the only way to get to the pharyngoesophageal region is via a lateral approach, most commonly utilizing the anterior sternocleidomastoid incision. Concomitant (and more deadly) injury to the trachea or vascular structures should be addressed before embarking on a pharyngoesophageal repair.

Zone III

Zone II

Cricoid

Fig. 34.1 Anatomic landmarks of the pharyngoesophageal region

Zone I

J. A. Keeley · A. L. Neville (*) Division of Trauma, Acute Care Surgery, and Surgical Critical Care, David Geffen School of Medicine at UCLA, Harbor-UCLA Medical Center, Torrance, CA, USA e-mail: jkeeley@dhs.lacounty.gov; aneville@dhs.lacounty.gov

34.2 Surgical Indications

There are essentially two scenarios in penetrating neck trauma. The rst scenario is a patient with an obvious “hard sign” (expanding hematoma, active bleeding, shock, airway compromise, massive subcutaneous emphysema) of vascular or tracheal injury who needs to be in the operating room immediately. Once these injuries are identied and repaired, the pharyngoesophagus should be evaluated. Trace the trajectory of the bullet. Perform maneuvers to see if there is a hole in the esophagus (on table endoscopy, air in the nasogastric tube, etc.), and repair it. If the patient is too unstable for further exploration, then leave a drain and get out.

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Fig. 34.2 Nondiagnostic CTA images for exclusion of pharyngoesophageal injury. The air near the pharynx and esophagus will require further evaluation if there are no other indications for surgical exploration

J. A. Keeley and A. L. Neville

The second, more common scenario is a patient who is hemodynamically stable and requires evaluation to exclude an injury that should be xed in the operating room expeditiously. Several retrospective studies found worse esophagealspecic outcomes in patients who had a preoperative evaluation before the esophageal repair compared with those who did not. The implication is that delay in repair (while studies are being performed) leads to a worse outcome. The retrospective nature of these studies makes the interpretation difcult, and no specic time frame has been established, but the take-home message is to identify and treat esophageal injury as soon as possible.

There are no hard signs of pharyngoesophageal injury, but subcutaneous emphysema or hematemesis are clinical ndings concerning a potential pharyngoesophageal injury. Further, in the evaluable patient, symptoms of odynophagia or dysphagia warrant further evaluation. In a large multicenter study of 453 patients with penetrating neck wounds there were no missed injuries in the group of asymptomatic patients. Still, the potential morbidity associated with a missed injury has led to the recommendation that surgeons have a low threshold for obtaining imaging studies in evaluating penetrating injuries to the neck.

CTA is the single imaging modality with the greatest potential to rule out esophageal as well as tracheal and vascular injuries. It is now recommended that asymptomatic stable patients with any suspicion of injury undergo CTA of the neck. A missile trajectory away from the esophagus (or other vital structures) obviates the need for exploration or additional invasive studies. Beyond this, CTA is not a standalone study for diagnosing or excluding pharyngoesophageal injury. In 2003, Gonzales evaluated 42 patients with CTA followed by mandatory esophagogram and operative exploration. Two very small stab wound injuries (<5mm) were missed both by CTA and swallow study, suggesting that CTA was no better than an esophagogram. Inaba subsequently found that CTA “overdiagnosed” aerodigestive injury in four patients with subcutaneous air as the common, nonspecic

sign. Two patients had the injuries ruled out by negative contrast swallows and endoscopy. The other two patients underwent negative exploration. Most centers are using physical examination along with CTA to evaluate for a possible aerodigestive injury. Finding air near the pharyngoesophagus prompts the need for further study, surgical exploration, or both (Fig.34.2).

The current recommended workup of pharyngoesophageal injury is by contrast esophagography or esophagoscopy. There is no consensus that one study is preferable to the other, and most study protocols seem driven by surgeon preference or institutional availability. If a contrast swallow study is chosen, a majority of authors favor water-soluble esophagogram initially, with thin barium to follow. The sensitivity of esophagography to detect pharyngoesophageal injury varies widely and is reported between 60% and 100%. Rigid or exible endoscopy has proven equally, if not more efcacious to esophagogram. Two early studies utilizing rigid esophagoscopy suggested improved sensitivity compared with an esophagogram. Since then, exible endoscopy has been studied with a reported 100% sensitivity (92% and 95% specicity). As exible endoscopy does not require general anesthesia or manipulation of the cervical spine, it is the scoping modality that we prefer.

Of importance, multiple authors report successful conservative (nonoperative) management of patients with penetrating pharyngoesophageal injury. In these studies, patients are kept nothing per oral (NPO), given intravenous antibiotics, and maintained on surgical nutrition (enteral or parenteral). Stanley made a compelling argument that penetrating injuries of the upper hypopharynx (above the arytenoids) be managed nonoperatively. He suggested that the anatomy of this area favored spontaneous healing yet further demonstrated increased complications to the lower pharynx or cervical esophagus if these areas were not surgically repaired. Nel and Yugeros also reported retrospective success of nonoperative management of the pharynx (but did not specify upper or lower). Madiba successfully managed patients with

34 Penetrating Injury tothePharynx andCervical Esophagus

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penetrating injury to the cervical esophagus nonoperatively if their water-soluble contrast study showed contained extravasation (not trickling widely or into the mediastinum). To date, there are no prospective, randomized studies comparing the role of surgical and nonoperative management for penetrating pharyngoesophageal injury. Based on retrospective data, a nonoperative approach seems feasible in a patient with a contained pharyngeal injury who has no other indications for neck exploration.

To summarize, we recommend physical examination and CTA in stable patients with penetrating injuries to the neck. If the examination is negative and the trajectory of the injury is away from the pharyngoesophageal area, no further workup is performed. If there is still potential for pharyngoesophageal injury, we recommend an expeditious esophagogram. A small, contained pharyngeal leak can be managed nonoperatively, with plans to repeat the swallow study in 3–5 days. A patient with a larger, non-contained injury should be taken immediately to the operating room for primary repair. Flexible endoscopy is our preferred diagnostic modality in a patient who is already in the operating room, who is intubated (making the logistics of a swallow evaluation difcult), or whose swallow evaluation is “negative,” but whose physical examination or CTA is highly suggestive of a pharyngoesophageal injury.

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34.3 Surgical Technique

If the patient indicates surgery, positioning the patient for a complete neck exploration is the rst key to success. Place a shoulder roll and tilt the patient’s head away from the injury—unless of course, there is concern of a cervical spine injury, in which case the head should be kept midline. Start your neck exploration on the side that is injured. If the injury is bilateral or you are not sure where the injury originates, start your approach to the esophagus from the patient’s left side. The esophagus deviates slightly to the left in the neck, and there is a lesser chance of injury to the recurrent laryngeal nerve on this side.

Have the anesthesiologist gently place a nasogastric (NG) tube. The NG tube often proves critical in nding your injury. Prep and drape both sides of the neck (from the mastoid down), and include the entire chest if mediastinal exploration is warranted. It is also prudent to prepare both groins in case vascular access or saphenous vein harvesting is required.

Start with a generous incision along the anterior border of the sternocleidomastoid (SCM) muscle (Fig.34.3). If better exposure is required, the incision can be extended all the way up to the mastoid superiorly. Curve posteriorly as you approach the angle of the mandible to avoid injuring the marginal mandibular branch of the facial nerve and the complication of smiling asymmetry. Inferiorly, the incision can be

Fig. 34.3 Incision along the anterior border of the sternocleidomastoid muscle

carried down to the sternal notch (and even further if a median sternotomy is needed).

Divide the platysma muscle and identify the SCM.Divide the brous tissue (supercial cervical fascia) along the anterior border of the SCM to allow for adequate retraction (Fig.34.4). Use a retractor to pull the SCM laterally so you can fully extend the exposure in either direction. This gives you direct access to the carotid sheath. Following exposure of the carotid sheath, place self-retaining retractors, such as blunt-tip Weitlaners. Make sure that the Weitlaner retractors prongs sit below the SCM.

You are about to begin your search for the pharyngoesophagus. In order to get to the esophagus, visualize the mantra—“carotid sheath down and thyroid gland up.” To safely and effectively perform this retraction, you will need to open the carotid sheath and ligate several key structures. Tackle any encountered vascular injuries rst. Open the carotid sheath laterally over the big blue internal jugular vein (Fig. 34.5). Stay on the anterior surface of the vein and extend in both directions. As you move superiorly, look for the large facial vein that courses just over the carotid bifurcation. The facial vein is a critical landmark in any neck exploration; once identied, it needs to be ligated and divided. This provides direct access to the carotid bifurcation and also

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Superficial

Omohyoid m.

Esophagus

Carotid sheath

(below fascia)

laryngeal n.

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Fig. 34.4 Approach to the cervical esophagus

J. A. Keeley and A. L. Neville

cervical fascia

Thyroid

gland

Strap m.

Trachea

Facial v.

Common carotid

Internal jugular v.

Recurrent

Thyroid

gland

SCM

Internal jugular v.

Jugular v. Facial v.

Carotid a. Middle thyroid v.

Esophagus

Inferior thyroid a.

Cut omohyoid m.

Fig. 34.5 Open the carotid sheath over the internal jugular vein and identify the facial vein

releases the internal jugular for lateral retraction. With the facial vein ligated, you may replace your blunt Weitlaner retractors below the medial aspect of the internal jugular to increase exposure.

Begin to march from superior to inferior along the inter-

nal jugular vein to release the thyroid gland and retract it

Fig. 34.6 Optimizing exposure of the cervical esophagus

“up” (anteromedially), so you can access the pharyngoesophagus. In your approach, you will sequentially encounter and divide three structures—the middle thyroid vein, the inferior thyroid artery, and the omohyoid muscle (Fig.34.6). The middle thyroid vein comes directly off the internal jugular and goes into the thyroid gland. Once this is divided, the

Esophagus

tube

Jugular

34 Penetrating Injury tothePharynx andCervical Esophagus

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293

thyroid gland can be pulled more medially. Next, gently retract the carotid sheath “down” (posterolaterally), and you will see the inferior thyroid artery, a branch of the thyrocervical trunk (from the subclavian artery), coursing horizontally posterior to the carotid and entering the posterolateral aspect of the thyroid. Divide this. Note: The inferior thyroid artery is another crucial landmark as it leads you to the recurrent laryngeal nerve. Use this opportunity to look for the nerve in the tracheoesophageal groove, and avoid it. Finally, carry on inferiorly and divide the superior belly of the omohyoid muscle. You now have maximal exposure to the pharyngoesophagus.

With the thyroid gland retracted “up” and the carotid sheath “down,” open the deep cervical fascia. Be gentle as the fascia can be thin. You are looking for the longitudinal muscle bers of the pharyngoesophagus. Technically, the cervical esophagus starts anatomically at the level of the cricoid. Whether your injury is to the pharynx or the cervical esophagus is inconsequential; nding the injury is what matters.

Start with gross inspection. Identifying an injury in the pharyngoesophagus can be difcult. Given its lack of a shiny serosal layer, you may not see a subtle hole in the muscle lying (particularly from a stab wound). Here is where the NG tube comes in. The NG tube provides a rm structure to feel for in an area that may have distorted tissue planes. Use your nger to feel for the NG tube. Use careful digital dissection posteriorly in the areolar tissue plane between the esophagus and the spine (Fig.34.7). Remember the recurrent laryngeal nerve lies anterior to the esophagus in the tracheoesophageal groove, so it is safer to work posteriorly. Keep your eye on the nerve and avoid it. You can hook your nger around the

entire esophagus with this blunt maneuver. To avoid injury to the recurrent laryngeal nerves and the membranous trachea, dissect very carefully along the anterior aspect of the esophagus.

Next, utilize air via the NG tube to look for the injury. Have the anesthesiologist pull back the NG tube so that you can feel the tip. Bathe the area with saline, and gently push air into the NG tube. The area that bubbles is injured. If you still cannot nd the hole, then we recommend intraoperative endoscopy to look for the injury from the inside. While rigid esophagoscopy was traditionally used, we have found exible endoscopy (a more familiar technique) to be extremely efcacious. Methylene blue insertion in the NG tube is another option but can color the eld and make further work more difcult; we are less keen on this option and only utilize it after direct visual inspection and exible endoscopy if suspicion for injury is exceedingly high. Be diligent in your search for an injury, and consider the possibility of a contralateral through and through injury. Make sure you have the entire trajectory accounted for before you leave the operating room.

With the injury identied, you are ready for repair. Debride esophageal wound edges completely, and reapproximate only the well-vascularized, healthy tissue. Repair the injury in one or two layers—equally efcacious. In a trauma situation, where time is important and there is often an element of tissue loss, we prefer a solid one-layer closure. Fullthickness, interrupted bites using a 3.0 absorbable monolament suture is our preference. The submucosa is the strength layer, and good mucosal apposition is critical. A second layer can be performed, but take care to avoid narrowing the lumen. We try and perform the repair over a 40 French bougie to prevent this complication.

Fig. 34.7 Careful digital dissection posterior to the esophagus to aid in identifying injury

Thyroid

gland

SCM

Trachea

vein

Recurrent laryngeal n.

Nasogastric

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J. A. Keeley and A. L. Neville

For simple injuries, sutures sufce. If the patient has any other injury to the surrounding area (laryngotracheal or vascular) or if you are concerned about the repair (tissue viability, tension, etc.), buttress it with a muscle ap. We strongly recommend placing the muscle between combined esophageal and airway injuries to avoid tracheoesophageal stula. Use whatever muscle you can easily mobilize—omohyoid, another strap muscle, or sternal portion of the SCM—to ensure that it overlies the esophageal suture line.

Draining your repair is the nal crucial step. If you do get a leak, you have it controlled. Leave a closed suction drain (we like the at-uted Jackson-Pratt) adjacent to your repair. Bring it out away from the carotid sheath. Conrm hemostasis to avoid an urgent trip back to the operating room for a neck hematoma. Irrigate and close.

Note: This operation becomes very disconcerting when you just cannot do the repair. This may be because the patient is too hemodynamically compromised or because the pharyngoesophagus is too mangled. Your bailout option for a smaller pharyngoesophageal injury is to leave a drain. Remarkably, some of these stulas will heal on their own, or additional procedures may be required once the patient has stabilized. The bailout for a highly destructive pharyngoesophageal injury is to staple across the distal cervical esophagus and construct an esophagostomy (spit stula). Divide the esophagus as low as possible, and bring your distal esophageal stump to a small skin incision. Be sure to leave a drain. It isn’t pretty, but your goal is to prevent mediastinitis and save the patient.

34.4 Postoperative Care andWhat toDo If

theRepair Falls Apart

There is no gold standard algorithm for the postoperative care of a pharyngoesophageal repair. Our preference is to leave the NG tube in place and keep the patient NPO for 3–5days. At this point, we obtain a swallow study to evaluate the integrity of the repair and rule out a subclinical leak. If the repair is intact, we remove the NG tube and start clear liquids with advancement to a soft, dysphagia diet as tolerated.

We favor leaving the NG tube in place early on to provide enteral nutrition usually starting around postoperative day 2. Some authors prefer total parenteral nutrition (TPN) in the perioperative period. We have not found TPN necessary, or had an increase in complications when feeding via a properly positioned NG tube. Broad-spectrum antibiotics are used empirically until the patient has no clinical signs of infection (afebrile, normal white cell count) and the leak has been excluded by swallow study.

We feel the most critical aspect of postoperative care is the drain. The drain should be well secured and maintained until the swallow study conrms no leak and the dysphagia diet is tolerated for 1–2days.

Perioperative complications of penetrating pharyngoesophageal injury include neck abscess (and in the worst case, a descending infection leading to mediastinitis), salivary stula, tracheoesophageal stula, and swallowing dysfunction.

Neck infection is a complication occurring in both operative and nonoperative management and requires prompt open drainage to prevent descending progression. Madiba reported a single case of local sepsis (6% incidence) in 17 patients with contained cervical esophageal injury who were managed nonoperatively. A multicenter study found the incidence of neck abscess to be 3.3%, esophageal stula 3.8%, and tracheoesophageal stula 1.9% in 211 patients with cervical esophageal injuries.

Winter and Weigelt reported cervical esophageal stulas occurring in 9% of 46 penetrating cervical esophageal injuries. In this study, all of the stulas healed with nonoperative management. This study gave support to the widely practiced dictum that the vast majority of esophageal stulas will heal on their own. Importantly, this is contingent upon control of local sepsis (which may necessitate opening of the surgical wound) and no distal obstruction. Of note, a much higher incidence of complications has been reported by Stanley who found that 22% of patients with a hypopharyngeal injury and 39% of patients with cervical esophageal injury developed either a neck infection that required drainage or a postsurgical salivary stula. This group did not discuss their management of these problems but did report that one of two tracheoesophageal stulas healed spontaneously at 3 weeks, and the other required a sternocleidomastoid muscle interposition ap.

The consensus is that a majority of esophageal stulas (to the skin or even to the trachea) will heal spontaneously, but this may require a period of prolonged restricted oral intake. In recent years, endoscopically positioned self-expanding stents have been used to expeditiously manage esophageal stulas and iatrogenic esophageal perforations. The stent excludes the injury while the body repairs itself. It is extracted in approximately 1 month and the patient restudied. Esophageal stenting has also found its way into contemporary management of primary esophageal injury, but the outcomes are less favorable than operative repair. A caveat is that the stent usually needs to be positioned inferiorly to the upper esophageal sphincter to avoid patient discomfort. At this point, stenting remains an option at some centers and can be considered, particularly in the setting of post-operative complications.

34 Penetrating Injury tothePharynx andCervical Esophagus

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34.5 Conclusions

While it may not be the most familiar or hospitable place for a penetrating injury, expeditious diagnosis and management of a pharyngoesophageal injury is generally very satisfying as the surgeon knows he/she has (hopefully) staved off a future, lethal mediastinitis. Familiarity with neck exploration as we have described here can aid in success. With the knowledge that this area can be forgiving as long as postoperative management is vigilant, we hope that you breathe easier the next time this injury rolls through the door.

Important Points

• Initial assessment of penetrating pharyngoesophageal trauma involves history, physical examination, and CTA. A swallow study or endoscopy should conrm or exclude an injury in the stable patient with concerning, yet inconclusive, clinical, or CTA ndings.

• Small, contained pharyngeal injuries can be managed nonoperatively.

• Patient positioning is key—unless there is a concern for an unstable cervical spine, place a shoulder roll and turn the head away from the side of the injury. If it is unclear which side is more involved, approach the esophagus through the left neck.

• Stay along the anterior border of the sternocleidomastoid muscle, and retract it laterally to gain exposure to the neck.

• Open the carotid sheath along the internal jugular vein, and ligate the facial vein.

• Retract the carotid sheath down and the thyroid gland up to nd the esophagus. You will divide the middle thyroid vein, the inferior thyroid artery, and the omohyoid muscle to maximize this exposure.

• Place an NG tube to facilitate nding the pharyngoesophagus by feel. Find the injury by looking for bubbles. Be vigilant to avoid a missed injury.

• Debride injury to healthy edges and repair it in one or two layers—without tension, over a bougie if you can.

• Mobilize a muscle ap and interpose this tissue anytime you create two suture lines or are concerned about a repair.

• Leave a drain until the swallow study conrms no leak and the patient is tolerating a diet.

• If the repair fails, the vast majority of stulas will heal spontaneously (or consider the use of a temporary stent).