To look or not to look controversies in surgical exploration of penetrating neck trauma
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To Look or Not to Look: Controversies in Surgical Exploration of Penetrating Neck Trauma. Anne Conlin, BA&Sc, MD PGY-2, Otolaryngology. Case. 46 year old male working in abattoir Was butchering beef when a live steer broke through gate, knocking him over

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To Look or Not to Look: Controversies in Surgical Exploration of Penetrating Neck Trauma

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To look or not to look controversies in surgical exploration of penetrating neck trauma

To Look or Not to Look:Controversies in Surgical Exploration of Penetrating Neck Trauma

Anne Conlin, BA&Sc, MD

PGY-2, Otolaryngology


To look or not to look controversies in surgical exploration of penetrating neck trauma

Case

  • 46 year old male working in abattoir

  • Was butchering beef when a live steer broke through gate, knocking him over

  • Sustained penetrating trauma to the neck w/ a meat hook


To look or not to look controversies in surgical exploration of penetrating neck trauma

Case

  • Treated at local ED w/ irrigation and antibiotics; penrose drain placed

  • Transferred to TOH


To look or not to look controversies in surgical exploration of penetrating neck trauma

Case

  • Hx

    • Pt. unsure of mechanism of injury

    • Complained of pain in the neck

  • Px

    • VSS, O2 sats >92%

    • General: moderate discomfort

    • Neck: 2 cm wound inferior to R body of mandible, penetrating platysma; pain on palpation; neck otherwise unremarkable


What should we do

What should we do?

  • Day call ENT staff: booked patient as P3

  • Night call ENT staff: “Why are we here?”


Objectives

Objectives

  • Case presentation

  • Approach to penetrating neck wounds

  • To look or not to look? The controversy.

    • Adult population

    • Pediatric population

  • Summary


An approach to penetrating neck trauma

An Approach to Penetrating Neck Trauma


Penetrating neck trauma

Penetrating Neck Trauma

  • 5-10% of all trauma admissions

  • Low overall mortality 0-11%

  • 30% of cases involve multi-system injury


Approach to penetrating neck trauma

Approach to Penetrating Neck Trauma

  • Zone I

    • Sternal notch to cricoid cartilage

  • Zone II

    • Cricoid cartilage to angle of mandible

  • Zone III

    • Angle of mandible to base of skull


Zone i

Zone I

  • High risk of serious injury

  • Difficult region for exposure and control

  • Vital structures

    • Proximal carotid, vertebral & subclavian a

    • Major BV of upper mediastinum

    • Lung apices

    • Esophagus

    • Trachea

    • Thoracic duct


Zone ii

Zone II

  • Easier access and control

  • Vital structures:

    • Carotid sheath: carotid a, jugular v, vagus n

    • Vertebral a

    • Esophagus

    • Trachea

    • Larynx

    • Recurrent laryngeal n

    • Spinal cord


Zone iii

Zone III

  • Difficult region for exposure & control

  • Vital structures:

    • Distal carotid a

    • Vertebral a

    • Parotid & other salivary glands

    • Pharynx

    • CN IX, X, XI, XII

    • Spinal cord


Systems at risk

Vascular

Including:

Internal, external & common carotid arteries

Vertebral & subclavian arteries

Internal & external jugular veins

Signs:

ABCs

External hemorrhage

Hematoma

Shock

Present in: 25%

Mortality: 50%

Systems at Risk


Systems at risk1

Pharyngo-esophageal

Symptoms & Signs:

Dysphagia & odynophagia

Hemoptysis & hematemesis

Subcutaneous emphysema

Air bubbling at wound (w̸ cough)

Often difficult to detect

Potential consequences:

Mediastinitis

Sepsis

Present in: 5%

Systems at Risk


Systems at risk2

Laryngotracheal

Signs:

Dyspnea

Hoarseness

Stridor

Subcutaneous emphysema

Present in: 10%

Mortality: 20%

Systems at Risk


Systems at risk3

Nervous system

Cranial nerves:

Facial

Glossopharyngeal

Recurrent laryngeal

Accessory

Hypoglossal

Spinal cord

Brachial plexus:

Median n – fist

Radial n – wrist ext

Ulnar n – finger abd

MCC n – elbow flex

Axillary n – arm abd

GCS

Uncommon injury

Common missed injury

Systems at Risk


Mechanism of injury

Mechanism of Injury

  • Stab wounds

    • depth & direction difficult to determine on exam

  • Bullets & projectiles

    • entry ± exit sites provide little information on amount of tissue injured


Management of penetrating neck trauma historical approach

Management of Penetrating Neck Trauma:Historical Approach


Classic approach to penetrating neck wounds

Classic Approach to Penetrating Neck Wounds

  • Until 1950s:

    • Seen almost exclusively by military surgeons

    • Recommended mandatory exploration for all wounds penetrating the platysma

    • Rationale: high morbidity & mortality from missed injuries


Controversy arises

Controversy Arises

  • Mandatory surgical exploration was challenged in the 1970s & 1980s

    • Arteriography available

    • Health economics

    • Risk vs. benefit


Annals of surgery 1985

Annals of Surgery, 1985

  • Retrospective study

  • 257 patients w/ injury penetrating platysma

  • Group I (1975-1981): mandatory exploration

  • Group II (1981-1984): selective neck exploration

    • Indications: hypotension, shock, profuse external bleed, expanding hematoma, dysphagia, neurological deficit, diminished carotid pulse, subQ emphysema, hemoptysis, hemetemesis, spitting blood, respiratory distress


Annals of surgery 19851

Annals of Surgery, 1985

  • Group I: 69% of pt w/ mandatory exploration had no injury

  • Group II: 22% of pt w/ selective exploration had no injury; none of the observed pt required subsequent exploration

  • Group II: 2 mortalities in observed pt (MI; spinal cord transection)

  • Remainder of mortalities in explored patients


The importance of the zones

The Importance of the Zones

  • Annals of Surgery study did not subgroup patients by zone of injury

  • Considerable variation in surgical access and structures at risk by zone of injury


Investigations

Investigations


World journal of surgery 1997

World Journal of Surgery, 1997

  • Demetriades et al, 1997

  • Prospective study, n=223

  • Objective: to asses role of clinical examination, angiography, colour flow Doppler


World journal of surgery 19971

World Journal of Surgery, 1997

  • Clinical examination

  • Emergency surgery:

    • Severe active bleeding

    • Refractory shock

    • Air bubbling at wound

    • Dyspnea

  • All other patients underwent investigations according to protocol


World journal of surgery

World Journal of Surgery


World journal of surgery1

World Journal of Surgery


Emergency operations

Emergency Operations

  • 38 patients (17%) subjected to emergency operation

  • Only therapeutic in 30 (13.5% of all cases)

    • 6 had negative exploration

    • 2 had non-therapeutic surgery: thrombosed vertebral artery

  • One missed esophageal perforation during exploration

  • Deaths: 6 total; 5 due to non-neck injuries; unclear if deaths in surgery or non-surgery grp


Results vascular assessment

Results: Vascular Assessment

  • Angiography

    • 176 patients

    • 34 abnormalities (19.3%)

    • 14 required surgery (8%)

    • Most common:

      • vertebral artery occlusion (5%)

    • Others:

      • VA tear, ICA occlusion, CCA aneurysm/tear; unnamed vessel thrombosis


Results vascular

Results: Vascular

  • Angiography + Colour Flow Doppler

    • 99 patients

    • w/ angiography as gold standard, CFD had:

      • Sensitivity = 91.7%

      • Specificity = 100%

      • PPV = 100%

      • NPV = 99%

      • 100% all-around if only injuries requiring surgery were considered


Results vascular1

Angiography complications

Femoral hematoma in 5 patients (2.2%)

Clinical Exam for Vascular Injury

w/ angiography or surgical exploration as gold standard:

NPV = 91.7%

100% if only injuries requiring surgery were considered

Results: Vascular


Results aerodigestive assessment

216 patients clinically evaluated

64 had +SSx

10 required surgical repair

0 asymptomatic patients required operation

Contrast swallow study

98 patients w/ Sx or proximity injury

2% esophageal injury (+Sx)

Esophagoscopy

22 patients, all normal

Laryngoscopy

149 patients w/ Sx or proximity injury

25 abnormal (VC dyskinesia, edema, blood)

5 required surgery

Results: Aerodigestive Assessment


Discussion

Discussion

  • If policy of mandatory surgical exploration:

    • Non-therapeutic in 86.5%

  • Angiography has low yield and does not change management

    • 7.8% of asymptomatic patients had +ve AG

    • 0% asymptomatic patients had +ve AG finding requiring surgery


Discussion1

Discussion

  • Esophageal studies

    • Selective contrast swallow study yield: 2%

    • Esophagoscopy yield: 0%

  • Overall

    • Clinical exam has 100% NPV for vascular and aerodigestive injuries requiring surgery

    • Clinical exam: 38.1% sensitivity for vascular and aerodigestive injuries requiring surgery

  • CFD is a reliable and inexpensive alternative to angiography


Discussion2

Discussion

  • Developed algorithm

  • If this had been followed:

    • Total cost would be $30,500 vs. actual cost $444,500

    • If CFD done instead of AG: $250,000 savings


The canadian experience

The Canadian Experience


Canadian journal of surgery 2001

Canadian Journal of Surgery, 2001

  • Retrospective chart review

  • 130 consecutive pt. w/ neck wounds penetrating platysma

  • Surgical exploration vs. observation


Cjs 2001

CJS 2001

  • Location:

    • Zone I: 15%

    • Zone II: 81%

    • Zone III: 4%

  • Mechanism:

    • Knife/broken bottle: 73%

    • GSW: 5%


Cjs 20011

CJS, 2001

  • Management

    • Observation: 50/130 (38%)

    • Surgery: 80/130 (62%)


Important findings

Important Findings

  • Zone II:

  • All zone II major vascular injuries were symptomatic on presentation

  • Neck exploration was negative in all asymptomatic zone II injured patients


Asymptomatic patients

Asymptomatic Patients

  • 76% of all injuries were symptomatic on presentation

  • Mean hospital stay for asymptomatic patients treated w/ observation & surgical exploration was similar (3.5; 4.3; p=0.575)


Missed injuries

Missed Injuries

  • 1 pharyngeal injury missed in a pt who underwent surgical exploration

  • 1 pt developed pharyngocutaneous fistula after exploration & repair of lacerated trachea

  • Follow-up visits

    • 1 brachial plexus injury

    • 1 accessory nerve injury


Long term disability

Long-term Disability

  • All neurologic

  • 3 pt managed by observation + 6 pt managed by surgery:

    • Phrenic (1)

    • Recurrent laryngeal (1)

    • Accessory (3)

    • Brachial plexus (4)


Canadian study overall

Canadian Study Overall

  • Majority of patients were asymptomatic

  • Optimal management of asymptomatic Zone II injured patient is not known

  • Neck exploration does not rule-out the possibility for missed injury

  • Bottom-line: risk of death from missed esophageal injury, therefore, consider NPO x24 hrs, close observation x48 hrs, & low threshold for rigid esophagoscopy


The pediatric experience

The Pediatric Experience


Abujamra et al 2003

Retrospective chart review

Age ≤16

N=31

84% in Zone II

Abujamra et al, 2003


Abujamra et al 20031

Surgical exploration

8 patients (25.8%)

All penetrated platysma

None revealed injury

Barium swallow

4 patients

3 based on location & mechanism (GSW)

1 based on physical (hematoma)

All normal

0 angiograms

Dependent on staff

Abujamra et al, 2003


Abujamra et al 20032

Laryngoscopy

3 patients

2 had minor physical findings

(non-expanding neck hematoma; SC air on neck XR)

1 laceration ant. to larynx

All normal

48% w/ other injuries

Most were facial lacerations

3 patients died

All had major physical findings

2 had GCS 3, pulseless

1 had GCS 8, shock

No evidence of complications

Abujamra et al, 2003


Abujamra et al 20033

Abujamra et al, 2003

  • Concluded

    • Penetrating neck injuries a rare in pediatric pt

    • Management varies

    • Observation in a stable patient is appropriate


Luqman et al 2005

Luqman et al, 2005

  • Case series (n=3)

  • 1 patient w/ PNT secondary to attack by fighting rooster

    • Initially assessed; puncture wounds to face & neck; D/C’d

    • RTER 24 hr later w/ fever, neck swelling, & respiratory distress

    • Neck: crepitus; inflammation; induration

    • CXR: pneumomediastinum


Luqman et al 20051

ICU w/ amp, gent & clinda

Endoscopic EUA: 0.5 cm perforation of lateral wall of pharynx

Neck explored through lateral incision  pus drained

NG feeds  N contrast study POD#10

D/C HD#14 on N diet

Luqman et al, 2005


A zone specific approach to management of penetrating neck trauma

A Zone-Specific Approach to Management of Penetrating Neck Trauma


Zones i iii

Zones I & III

  • Very difficult surgical access

  • Angiography indicated in all but the most unstable patients

  • Unstable  O.R.

    • large expanding hematoma, severe active or pulsatile bleeding, shock unresponsive to fluids, signs of cerebral infarction, presence of a bruit or thrill, and diminished distal pulses

  • Otherwise: angio & observe


Zone ii management

Zone II Management

  • Remains most controversial


Insull 2007

Insull, 2007

  • Retrospective review of 63 pt. w/ only Zone II penetrating neck trauma in New Zealand

  • Hard signs:

    • Active external bleeding, neck bruit, or thrill

    • Expansive, pulsatile hematoma

    • Dysphagia

    • Hoarseness

    • Subcutaneous emphysema

    • Sucking neck wound

    • Neurological deficit


Insull 20071

Insull, 2007


Insull 20072

Insull, 2007

  • Multivariable regression analysis

    • Hard signs were predictive of positive neck exploration

    • No other variables were significant predictors

  • Bayesian parameters re. hard signs

    • Sensitivity 93%

    • Specificity 96%

    • Positive predictive value 87%

    • Negative predictive value 98%


Insull 20073

Insull, 2007

  • No complications of neck exploration

  • No missed injuries

  • If patients had been managed solely on basis Px without investigations, 1 injury would have been missed (foreign body)


Which c t

Which C T ?


Contrast ct

14 pt w/ Zone II injury, prospective

Surgical findings compared to high and low probability CT findings

3 patients had 5 surgical findings

4 of 5 were diagnosed by CT

Sens: 100% Spec: 91%

PPV: 75% NPV: 100%

Contrast CT

Clinical Exam

Contrast CT

Surgeon reads CT

Surgery


Dynamic ct

Prospective blinded study, DCT vs. Px

42 patients not requiring emergent surgery

250 cc contrast, 0.5 cm cuts

Result: minimal contribution to clinical exam & esophagoscopy, no change in surgical intervention

Dynamic CT

Clinical Exam

Dynamic CT

Esophagoscopy

Surgery


Ct angiography

CT Angiography

  • Retrospective review

  • N=130, zone II

  • 34 patients had CTA, 96 did not

  • Significantly fewer neck explorations among pt w/ CTA

  • (No comparison to clinical exam or conventional angiography; no reports on sens, spec, PPV, NPV)


Ct angiography with 3 d reconstruction

CT Angiography with 3-D Reconstruction


Case revisited

Case Revisited

  • Contrast CT: penrose drain; no vascular, aerodigestive, or nerve injury identified

  • Neck exploration: negative

  • Course in Hospital: observed x48 hours then D/C’d home on oral Abx


Take home messages

Take Home Messages

  • Management of penetrating neck trauma is controversial

  • Selective surgical management is common practice

  • Variety of investigations available

  • Physical exam alone is very useful and may be sufficient

  • Adoption of unified, evidence-based approach to management of PNT is elusive

  • Limited literature in pediatric population


Discussion3

Discussion

  • Thanks.


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