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

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

Anne Conlin, BA&Sc, MD

PGY-2, Otolaryngology

  • 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
  • Treated at local ED w/ irrigation and antibiotics; penrose drain placed
  • Transferred to TOH
  • 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?”
  • Case presentation
  • Approach to penetrating neck wounds
  • To look or not to look? The controversy.
    • Adult population
    • Pediatric population
  • Summary
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


Internal, external & common carotid arteries

Vertebral & subclavian arteries

Internal & external jugular veins



External hemorrhage



Present in: 25%

Mortality: 50%

Systems at Risk
systems at risk1

Symptoms & Signs:

Dysphagia & odynophagia

Hemoptysis & hematemesis

Subcutaneous emphysema

Air bubbling at wound (w̸ cough)

Often difficult to detect

Potential consequences:



Present in: 5%

Systems at Risk
systems at risk2





Subcutaneous emphysema

Present in: 10%

Mortality: 20%

Systems at Risk
systems at risk3
Nervous system

Cranial nerves:



Recurrent laryngeal



Spinal cord

Brachial plexus:

Median n – fist

Radial n – wrist ext

Ulnar n – finger abd

MCC n – elbow flex

Axillary n – arm abd


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
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
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
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)


22 patients, all normal


149 patients w/ Sx or proximity injury

25 abnormal (VC dyskinesia, edema, blood)

5 required surgery

Results: Aerodigestive Assessment
  • 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
  • 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
  • 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
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
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

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
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 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)
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


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



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)
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
  • Thanks.