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

slide2
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
slide3
Case
  • Treated at local ED w/ irrigation and antibiotics; penrose drain placed
  • Transferred to TOH
slide4
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
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
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)

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
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
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
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

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)
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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