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Introduc  

tion
This
chapter
aims to
discuss
the
manage
ment of
soft
tissue
neck
injuries.
It is
specifical
ly
directed
away
from the
manage
ment of
the
cervical
spine
and
spinal
injury in
trauma
patients.

We
mainly
refer to
penetrati
ng neck
injuries,
however
the
assessm
ent and
manage
ment of
any neck
soft
tissue
injury
should
follow a
common
pathway
in our
opinion.
Specific
consider
ation of
skin
involvem
ent in
these
injuries is
also left
to other
texts.

Soft
tissue
injuries
in the
neck are
difficult
to
assess
and
manage.
This
compact,
important
anatomic
al area
contains
a dense
concentr
ation of
vital
vascular,
aero-
digestive
and
nervous
system
structure
s; many
of which
are not
accessibl
e to
physical
examinat
ion and
surgical
exposure
is a
challeng
e. There
has been
a shift
away
from
early
aggressi
ve
operative
manage
ment to a
more
selective
and
conserva
tive
approach
,
however
controver
sy still
exists.
(Demetri
ades et
al. 1996)

A
thorough
review of
current
literature
has been
made to
give the
best
available
evidence
base; the
referenc
es are
included
at the
end of
the
chapter.

General Points about soft tissue injuries of the neck


• Difficult to assess

• Difficult to manage

  • Surgical exposure is a challenge  

• Controversy regarding mandatory exploration or selective


conservatism

  History  

• First documented treatment of vascular injury in the neck – Ambrose


Pare 1510-1590

• 1803, Fleming ligated lacerated common carotid artery

• 2nd world war, 851 cases of neck injury were reported with a 7%
mortality, in Vietnam this rose to 15% (Thal 1988)

• 1944, Bailey proposed early exploration of all cervical haematomas


on the basis of wartime experience (Bailey 1944)

• 1956, Fogelman and Stewart (Fogelmann & Stewart 1956) reported


a series of 100 patients showing a mortality of 6% in patients
undergoing early neck exploration versus 35% for those whose
exploration is delayed. They advocated mandatory, early exploration
of any wound penetrating the platysma.

• Subsequently the rate of negative neck explorations increased and


the operative mortality fell leading to a selective approach to
management challenging this older dictum (Asensio et al. 1991)

Neck anatomy
The anatomy of the neck is unique as it contains many vital structures
representing the most important body systems. Traditionally an anatomical
scheme to look at the neck uses triangles, each triangle containing different
vital structures and coated by muscle, fascia and skin. Classically the neck is
divided into anterior and posterior triangles by the sternocleidomastoid
muscle.
The anatomical structures in the neck structures are invested by two fascial
layers:

1. The superficial fascia lies just beneath the skin and encompasses
the body of platysma (a thin superficial muscle that originates over
the upper part of the thorax and passes over the clavicles across the
neck and blends with the superficial musculo-aponeurotic system
(SMAS) of the face).

2. The deep cervical fascia can be subdivided into investing, pre-


tracheal and pre-vertebral layers.

• The investing fascia encompasses the sternocleidomastoid,


omohyoid and trapezius muscles as it encircles the neck.

• The pre-tracheal fascia attaches to the thyroid and cricoid cartilages


and blends with the pericardium in the thorax. It encloses the major
neck viscera (thyroid gland, trachea & oesophagus)

• The pre-vertebral fascia encompasses the pre-vertebral muscles


and blends with the axillary sheath, which houses the subclavian
vessels.

• The carotid sheath is formed by all 3 components of the deep fascia.


Anatomy
Neck contains structures representing different systems:
• Cardiovascular 

  • Respiratory   

• Digestive 

• Endocrine 

• Central nervous system
Such tight fascial compartmentalisation of the neck structures limits external
bleeding from vascular structures (Fig. 1). This beneficial effect is countered
   
by the dangers of bleeding within these closed spaces, which can
compromise the airway.

   

  Figure 1: Cross sectional view of cervical fascial planes (from Gray SW,  
Skandalis JE, McClusky DA: Atlas of Surgical Anatomy. Baltimore, Williams &
Wilkins, 1985, p15, with permission).

Penetrating neck injury is most commonly referred to in terms of zone of


injury (Fig. 2), rather than triangles. This is because this allows knowledge of
the possible structures involved, the need for additional specialised
investigations, surgery and prognosis.

   

Figure 2: Anatomic zones of the neck (from Feliciano, Moore & Mattox:
  Trauma 3rd edition. Appleton & Lange 1996, p330, with permission).  

Anatomic zones of injury


  Zone Boundaries Structures at risk  
Proximal Common
Carotid, Vertebral and
Subclavian Arteries
I
Clavicles inferiorly to
the inferior aspect of the Major vessels of the
Cricoid cartilage Superior Mediastinum,
Apices of the lungs

Oesophagus, Trachea and


Thoracic Duct

Carotid and Vertebral


Arteries and Internal
Jugular Vein
II
Cricoid cartilage
inferiorly up to the Larynx, Trachea &
angle of the mandible Oesophagus

Vagus nerve, Recurrent


(Note - Some authors use the inferior border of the mandible as the upper
boundary of zone 2) (Demetriades et al. 1997)

Mechanisms of injury
Classification of neck injury can be accomplished in different ways. The
   
anatomical site of injury and the related structures are vital, however the
history, mechanism and pattern of injury also give us important information
and clinicians should get as much history as possible from the pre-hospital
carers / ambulance personnel.

   

   Epidemiology  

• The typical victim sustaining a penetrating neck wound is male in his


late 20’s (Miller & Duplechain 1991)Male: Female =5:1 (Markey, Jr.,
Hines, & Nance 1975)

• Although one might expect that the number of firearm injuries to


have increased over the last 30 years, both firearm and stab wounds
have increased at a comparable rate (Markey, Jr., Hines, & Nance
1975;Noyes, McSwain, Jr., & Markowitz 1986;Saletta et al. 1976)

• The most common site of injury is the anterior triangle of the neck

Initial management
An “ABC” approach to all trauma patients has now become standard thanks
to the teaching of Advanced Trauma Life Support (ATLS). As part of this
teaching, the assessment and immediate management of life threatening
problems go hand in hand in a stepwise progression. The presence of a
bleeding neck wound shouldn’t detract from an airway injury, respiratory
distress, stridor and altered level of consciousness mandating emergency
airway management. (Walls, Wolfe, & Rosen 1993) The importance of this
process cannot be emphasised too much; approximately 10% of patients with
penetrating neck injuries present with airway compromise. (Pate 1989) 25-
40% have a vascular injury (10% carotid artery), 10% have a respiratory tract
injury.
Expeditious pre-hospital transfer without intervention in the urban
environment, gives the patient with life threatening soft tissue neck injury the
best chance of survival. Airway and respiratory care are paramount and early
endotracheal intubation should be considered if patients present with
symptoms of respiratory obstruction:

• Restlessness
• Stridor
• Air hunger
• Hoarseness
• Tracheal tug
• Retraction of supraclavicular, intercostals or epigastric areas
• Cyanosis
• Inability to swallow and drooling

Prophylactic intubation is preferred in as controlled a fashion as possible


rather than emergency intubation, cricothyroidotomy or tracheostomy.

Patients should be assessed and initially treated in a Trendelenburg position


in order to minimise the chances of air embolism.

Direct pressure is used to control external haemorrhage. Vascular access


should be attained, ideally on the contra-lateral side to the injury and blood is
taken for cross-match of 6 units of packed red blood cells. If bleeding cannot
be controlled by direct pressure, balloon-tamponade may be attempted
(Gilroy et al. 1992), however blind / non-selective clamping of vessels should
be avoided to prevent further injury to structures.

The insertion of a nasogastric tube at this early stage should be avoided to


keep patient agitation to a minimum and to prevent bleeding which had
previously been controlled.

Demetriades (Demetriades, Asensio, Velmahos, & Thal 1996) suggests an


algorhythmn for evaluation of penetrating neck injuries (Figure 3)

   

  Figure 3: Algorithm for neck injury evaluation (with permission)  

There are other schemes based on findings in zones of the neck, (Klyachkin
et al. 1997;Velmahos et al. 1994). The basic aim is to have a fast and
effective method of assessment, so that injuries are not missed and over
treatment avoided.

A chart to aid the examination and recording of this type of injury has been
proposed by Demetriades et al (Figure 4). Some authors feel that
examination alone is sufficient in the assessment of Zone 2 neck injuries
whilst others feel that it is reliable in all Zones (Demetriades et al.
1995;Demetriades, Theodorou, Cornwell, Berne, Asensio, Belzberg,
Velmahos, Weaver, & Yellin 1997;Jarvik et al. 1995;Kendall, Anglin, &
Demetriades 1998;Velmahos, Souter, Degiannis, Mokoena, & Saadia 1994).

We feel that this chart allows a methodical examination of the structures


involved in penetrating neck injury and serves as a template for notes and
research. Its universal adoption would allow better communication (Atta &
Walker 1998).

Emergency Treatment

• ABC approach

• Direct pressure to control bleeding


  • Immediate transfer to hospital  

• Thorough clinical examination

• Operate or investigate
   

  Figure 4: From Demetriades D, Asensio JA, Velmahos G et al; Surgical  


Clinics of North America 76:664, 1996 (with permission)
Investigations
Investigations available Indications
Plain lateral cervical spine X- All patients
Ray

CT Stable patients with foreign


body, laryngotracheal or
oesophageal injury suspected
Angiography Injury to all Zones I-III in
haemodynamically stable pts*

  Colour flow Doppler 4 QUOTE


"(Demetriades, Theodorou,
Cornwell, III, Weaver, Yellin,
Velmahos, & Berne
1995;Demetriades, Theodorou,
Cornwell, Berne, Asensio,
Belzberg, Velmahos, Weaver, &
Yellin 1997;Ginzburg et al.
1996;Peter Corr, ATO Abdool
Carrim, & John Robbs 1999)"

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