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 PowerPoint PPT Presentation


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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

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

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


Case

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

  • Transferred to TOH


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?

  • Day call ENT staff: booked patient as P3

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


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


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

  • 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

  • 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

  • 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

  • Difficult region for exposure & control

  • Vital structures:

    • Distal carotid a

    • Vertebral a

    • Parotid & other salivary glands

    • Pharynx

    • CN IX, X, XI, XII

    • Spinal cord


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


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


Laryngotracheal

Signs:

Dyspnea

Hoarseness

Stridor

Subcutaneous emphysema

Present in: 10%

Mortality: 20%

Systems at Risk


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

  • 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


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

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

    • Arteriography available

    • Health economics

    • Risk vs. benefit


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, 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

  • 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


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, 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


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

  • 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

  • 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


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


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

  • 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


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


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


Canadian Journal of Surgery, 2001

  • Retrospective chart review

  • 130 consecutive pt. w/ neck wounds penetrating platysma

  • Surgical exploration vs. observation


CJS 2001

  • Location:

    • Zone I: 15%

    • Zone II: 81%

    • Zone III: 4%

  • Mechanism:

    • Knife/broken bottle: 73%

    • GSW: 5%


CJS, 2001

  • Management

    • Observation: 50/130 (38%)

    • Surgery: 80/130 (62%)


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

  • 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

  • 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

  • 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

  • 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


Retrospective chart review

Age ≤16

N=31

84% in Zone II

Abujamra et al, 2003


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


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, 2003

  • Concluded

    • Penetrating neck injuries a rare in pediatric pt

    • Management varies

    • Observation in a stable patient is appropriate


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


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


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

  • Remains most controversial


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, 2007


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, 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 ?


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


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

  • 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


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

  • 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


Discussion

  • Thanks.


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