Farrah Siddiqui, M.D.

Discussion: Francis B. Quinn, Jr., M.D., FACS

University of Texas Medical BranchDepartment of Otolaryngology

Grand Rounds PresentationMarch 31, 2010

http://www.utmb.edu/otoref/grnds/GrndsIndex.html

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Background: History of management of PNI

Anatomy & classification of neck zonesEpidemiologyMorbidity & types of injuryDiagnosisManagementClinical casesConclusions

Background: History 1944: Bailey—early exploration if deep to platysma 1956: Fogelman & Stewart—6% mortality in early exploration vs.

35% if delayed 1979: Roon & Christensen—immediate exploration for middle

zone vs. angiogram for stable high or low zones 81% surgery with 53% negative exploration rate

1980s +: Selective management Clinical Exam Adjunctive tests: Endoscopy, swallow study Arteriography Duplex Ultrasound Computerized tomography angiography (CTA)

With mandatory exploration, mortality decreased from 15-18% pre WWII to 3-7% during WWII.However, negative exploration increased dramatically—40-60%Roon AJ, Christensen N. Evaluation and treatment of penetrating cervical injuries. J Trauma 1979; 19: 391-7.

Background: HistoryMeyer et al 1987: prospective zone II study, n = 120

5.8% immediate exploration 94.2% had endoscopy & arteriography before surgery 6% morbidity, 0.8% mortality

Biffl WL et al 1997: 18 year prospective study showed selective management of PNI safe 1973-1978: mandatory exploration 56% negative 1978-1996: selective 66% observed

1 missed esophageal injury 16% negative exploration 3 % mortality; 10% morbidity

Biffl WL et al. Selective management of penetrating neck trauma based on cervical level of injury; Denver since 1978

Sniper injury to neck from Spanish Civil War left him with vocal cord paralysis

Anatomy: Zones I - IIIZone I: sternal notch

cricothyroid membraneZone II: cricothyroid

membrane angle of mandible

Zone III: angle of mandible skull base

Is this classification outdated?

Zone I is treated like thoracic injuryAnterior neck area classification ant to pos B of SCM; posterior neck not further dividedOften patients have multiple wounds or GSW tract can involve multiple zones, so some question importance of this classificationSuperficial wound does not correspond well to deeper structures injured.

Anatomy: Facial planesHematomas, air tracksBullet, metal tracksCarotid space: Carotid, IJV,

CN XRetropharyngeal space:

behind pharynx, anterior to prevertebral muscles

Perivertebral space: muscles & soft tissue around vertebrae

www.medscape.com

Bleeding that displaces prevertebral muscles anteriorly is associated with vertebral body fractures.Retropharyngeal carotid artery important for presurgical planningEsophageal injury can track air into RP, prevertebral spaceMissed esophageal injuries can present as retropharyngeal abscess, mediastinitis, sepsis

Epidemiology: Adult PNI

1% of all trauma patients in USADemetriades et al 1993 GSW more clinical signs & injuries

(35% vs. 19% for SW)Structures injured: 40% no significant damage

Major vein 15-25% Major artery 10-15% Digestive tract (pharynx, esophagus) 5-15% Respiratory tract (larynx, trachea) 4-12% Major nerves 3-8%

Gun shot (GSW)

Stab (SW) Shotgun

45% 40% 4%

Brywczynski JJ et al. Management of penetrating neck injury in the emergency department: a structured literature review. Emerg Med J 2008; 25: 711-715

metaanalysis of 20 studiesDemetriades prospective study; 97 GSW, 89 SW

Epidemiology: Pediatric PNI40% mortality—zones I & III more common

60% zone I—multiple wounds29% zone II56% zone III—multiple wounds

Mandatory Neck Exploration Selective Neck Exploration

Hoarseness, aphonia, airway Change in neck exam

Shock, continued bleeding Abnormal diagnostic tests

Blood in aerodigestive tract

Subcutaneous air

Neurologic deficits 86% positive exploration

Multiple major injuries

100% positive exploration

Kim MK et al. Penetrating neck trauma in children: An urban hospital’s experience. Otolayngol Head Neck Surg 2000; 123: 439-43.Upenn n = 35 1990-97Firearm injuries second leading cause of mortality in age 15-24.

Morbidity: Vascular injuryMajor Signs

Active bleedingUnstable/hypotensionExpanding hematomaPulsatile swellingBruit, thrillUnilateral CNS deficitPulse deficit

Minor SignsParasthesiasNonexpanding hematomaC spine or skull base

fractures in MVAs

Morbidity: Vascular injuryCarotid artery injury

22% vascular injuries10-20% mortality in

hospitalRepair preferred unless

comatose patientLigate or embolize if

high carotid injuryMinor injury (intimal

flap) endovascular repair, ? Anti-platelet Tx

Anticoagulate blunt injury

Vertebral artery injury10%2/3 major neck trauma,

especially C spine & esophagus

Isolated 1/3 no signsSepsis due to missed

esophageal injuryEndovascular

embolization if bleeding Ligation low riskAnticoagulate blunt

injury

Morbidity: Esophageal InjuryOdynophagia, dysphagia,

hematemesisAirway injury 25% have

esophageal injuryTranscervical trajectorySaliva in wound,

subcutaneous emphysemaPrevertebral air on lateral

neckX ray

Kietdumrongwong P & Hemachudha T 2005

Kietdumrongwong P & Hemachudha T. Pneumomediastinum as initial presentation of paralytic rabies: A case reportBMC Infectious Diseases 2005, 5:92.

Morbidity: Esophageal Injury Most commonly missed Weigelt JA et al 1987: 30% no signs or symptoms Wood J et al 1989: most common cause delayed morbidity Asensio JA et al 2001: 34 center study of 405 patients with

penetrating esophageal injuries 56% cervical esophagus 19% mortality—most common exsanguination 82% primary repair with 16% requiring muscle flaps 11% drainage 3-4% complex: resection/diversion or resection/anastomosis 41% esophageal complication in delayed repair (vs. 19%)

Empyema, abscess, mediastinitis

Weigelt JA et al. Diagnosis of penetrating cervical esophageal injuries. Am J Surg, 1987; 154 (6): 619-22.Asensio JA et al. Penetrating esophageal injuries: multicenter study of the American Association for the Surgery of Trauma. J Trauma-Injury, Infection & Critical Care. 2001; 50(2): 289-96. 34 centers retrospectiveWood J et al. Penetrating neck injuries: recommendations for selective management. J Trauma 1989; 29: 602-5.

Morbidity: Esophageal InjurySrinivasan et al 2000: flexible esophagoscopy safe &

accurateSensitivity = 92.4%, specificity = 100%PPV = 33.3%, NPV = 100% no injuries missedLow PPV because incidence of injury low (3.6%)

ImagingWater soluble contrast (gastrograffin): ½ missed

aspiration pneumonitis: not use if poor gag reflex/cough

Barium: ¼ missed increased mediastinitis

Srinivasan R et al. Role of Flexible Endoscopy in the Evaluation of Possible Esophageal Trauma After Penetrating Injuries. AJG 2000; 95(2): 1725-29.Start with gastrograffin if negative, repeat swallow with barium

Morbidity: Esophagram

Nel L et al 2009

Nel L et al. Imaging the oesophagus after penetrating cervical trauma using water-soluble contrast alone: simple,cost-effective and accurate. Emerg Med J. 2009;26:106–108

Morbidity: Esophageal InjuryTreatment

Observe 24 hrs if high suspicion but studies negative

Pharyngeal injury NPO, IV antibiotics, NGTEsophageal injury primary repair vs.

drainage/ resection/diversion Early diagnosis primary repair Late diagnosis with sepsis/inflammation drainage

Morbidity: Airway Injury More common in blunt trauma 5-15% PNI will have laryngotracheal trauma Hoarseness, stridor, hemoptysis, difficulty breathing, pain Air leak in wound, difficult airway surgery!!! Majority airways managed by rapid sequence intubation (RSI) at scene or ED

Mandavia DP 2000

Retrospective

N = 748 11% emergent intubation -67% RSI with 100% success -33% fiberoptic 91% success -3 fiberoptic failures RSI

Eggen JT 1993

N = 114 60% intubated, 22% EDNo intubation complications

Shearer VE 1993

N = 107 83% RSI with DL 100% success6% surgical airway 100% 7% awake fiberoptic 98% 4% blind nasotracheal 75%

•Eggen JT et al. Airway management, penetrating neck trauma. J Emerg Med 1993: 11: 31-5.•Mandavia DP et al. Emergency airway management in penetrating neck injury. Ann Emerg Med 2000; 35: 221-5.•Shearer VE et al. Airway management for patients with penetrating neck trauma: a retrospective study. Anasth Analg 1993; 77: 1135-8.•Mandavia et al•Shearer et al

Morbidity: Airway InjuryHigh index of suspicion—avoid paralytic agent!Trachea most commonly involved (2/3) vs. larynx

(1/3)25% have esophageal injuryEsophageal injury chances of airway injury doubleUnstable airway Be prepared for surgical airway tracheotomy safest option Stable airway Flexible laryngoscopy,

bronchoscopy CT shows fractures, tracheal injury OR for endoscopy if suspect injury

Steroids, oxygen, IV Abx, humidified air if no fractures, mucosal disruptions or progressive edema/hematoma

Morbidity: Airway InjuryLaryngeal fractures in PNI

Thyroid cartilage most common Should not delay fixation for > 24 hours since increased risk of

scarring

Group Laryngeal Injury Treatment

I Minor endolaryngeal hematoma;No fracture; Good airway

Observe; steroids, PPI, humidity

II Hematoma/edema compromising airway; Laceration without exposed cartilage;Nondisplaced fracture(s)

OR for tracheotomy, DL & esophagoscopy

III Massive edema, exposed cartilage, immobile vocal cord(s), displaced fracture(s)

OR for repair & tracheotomy

IV Group III + more than 2 fracture lines OR for repair & trach

V Laryngotracheal separation OR for repair

Gold SM et al. Blunt laryngeal trauma in children. Arch Otolaryngol Head Neck Surg 1997; 123: 83.

Morbidity: Airway InjuryGroups III- V: OR for repair

Repair anterior commissure, TVC lacerationsCover exposed cartilageRepair fractures with stainless steel wire or

suture Some prefer absorbable (PDS), others prolene Nonabsorbable & absorbable miniplates also used

Stent indicated if unstable larynx after fracture fixation or lacerations involving anterior commissure Remove 10-14 days with endoscopy, remove

granulation with CO2 laser

Morbidity: Airway Injury Baisakhiya N et al 2009

Baisakhiya N et al. Laryngotracheal Trauma . The Internet Journal of Otorhinolaryngology. 2009 Volume 9 Number 1CT shows right thyroid cartilage fracture & air escape suggesting tracheal tear. Extensive subQ air.Patient managed with tracheostomy, reduction of fracture + fixation with 4-0 prolene. Tracheal partially excised with primary repair of trachea.

Morbidity: Airway InjuryOutcomes of penetrating laryngotracheal

injury1/3 delayed diagnosis10% preventable mortalityMany suffer permanent voice & swallowing

problems

Diagnosis: Clinical exam Rivers et al 1988

no vascular injury missed by physical exam

Demetriades et al 1993, n = 335 269 negative exam observed 2 later required intervention for

vascular injury Demetriades et al 1996, n = 223

All patients with negative clinical exam had arteriogram

No vascular injury requiring intervention

NPV of clinical exam 100%

Biffl et al 1997, n = 312 105 positive exam OR

16% negative exploration 207 negative exam observed

1 esophageal perforation Sekharan J et al 2000, n = 145

0.7% vascular injury missed Azuaje R et al 2003

93% sensitive, 97% PPV Inaba K et al 2006, n = 91

100% sensitive, 93.5% specific Tisherman SA et al 2008

Clinical exam protocol up to 95% sensitive injury

Demetriades Br J Surg 1993; World J Surg 1996, all prospectiveBiff et al, Am J Surg 1997, prospectiveTisherman SA et al. Clinical practice guideline; penetrating zone II neck trauma. J Trauma 64: 1392-1405, 2008.Inaba K et al. Prospective evaluation of screening multislice helical computed tomographic angiography in the evaluation of penetrating neck trauma. J Trauma 61: 144-149, 2006. n = 91, prospectiveAzuaje RE et al. Reliability of physical examination as a predictor of vascular injury after penetrating neck trauma. The Am Surg. 2003; 69: 804-7.Sekharan J et al. Continued experience with physical examination alone for evaluation and management of penetrating zone 2 neck injuries: rests of 145 cases. J Vasc Surg 1988; 8: 112-6.

Diagnosis: Clinical Exam Fogelman MJ & Stewart RD 1956: 43% positive explorations were

hemodynamically stable & 70% had no bleeding Carducci et al 1985: 1/3 patients with positive exploration had no

signs/symptoms on clinical exam Scalafani et al 1991: 61% sensitivity for vascular injury Apffelstaedt et al 1994: n = 335 SW; 30% positive explorations

had no clinical signs Eddy VA et al 2000: low sensitivity & NPV with clinical exam but

improved in patients when CXR added to physical exam

Fogelman MJ and Stewart RD, Am J Surg 1956, 91: 581.Carducci et al, Ann Emerg Med 1985 15:208Apffelstaedt World J Surg, 1994, 18: 917Scalafani SJ et al. The role of angiography in penetrating neck trauma. J Trauma 31: 557-62, 1991.Eddy VA et al. Is routine arteriography mandatory for penetrating injuries to zone I of the neck? J Trauma 2000; 48: 208.

Diagnosis: ArteriographyGold standard for vascular injuryDiagnostic & therapeuticZones I & III difficult to assess clinicallyZones I & III often involve complex surgeryEddy VA et al 2000

N = 138, retrospective review vs. mandatory zone I angio

No arterial injuries on arteriogram if normal exam & CXR

Demetriades et al 1993Cost-effective for zones I & IIIDecreased surgery rates to 5% in zone I & 13% in zone III

Diagnosis: ArteriographyModrall JM et al 1995 meta-analysis: Diagnosis of

vascular trauma 23% positive zones I & III2.2 to 28% positive zone II only 1% needs surgery94-100% sensitive90-98% specific54-66% PPV high false positive rate100% NPV no false negatives0-3% complication, mostly minor$66,420 per positive arteriogram due to high FP

Modrall JM et al. Diagnosis of vascular trauma. 9(4) 1995.

Munera F et al 2000

Left carotid artery occlusion seenin angiogram on right as well as parasagittal helical CTA on left

Diagnosis: ArteriographySpecialized teamExpensive0.16-2.0% complication:

hematoma, pseudoaneurysm, spasm, thrombosis, emboli, thrombi, arterial dissection permanent CNS sequelae

Morris C 2008.

Morris C. Vascular and Solid Organ Trauma - Interventional Radiology. www.emedicine.com 2008.Digital subtraction left cervical carotid angiogram demonstrating traumatic injury of the left internal carotid artery, manifested by pseudoaneurysm formation and an intimal dissection

Diagnosis: ArteriographyEndovascular therapy

Covered stent graft: pseudoaneurysm, lacerations, AVF

Embolization or coiling: pseudoaneurysm, AVF

Endovascular occlusion: injured vertebral arteries

Test balloon occlusion prior to ligation

www.medscape.com

Munera F et al 2000 & 2005.

Diagnosis: Arteriography

www.findmeacure.com

Dong Z et al 2006.

Dong Z et al. Endovascular repair for a huge vertebral artery pseudoaneurysm caused by Behcet’s disease. Chinese Medical Journal, 2006, Vol. 119 No. 5 : 435-437

Diagnosis: Duplex U/S Bynoe RP et al 1991, n = 198

95% sensitive, 99% specific

Demetraides D et al 1995 (82) 91% sensitive, 98.6% specific 100% sensitive for clinically significant

injuries

Montalvo BM et al 1996 (52) Detected all serious injuries

Limitations Operator dependent No soft tissue/bony detail Not useful in zone I & III

•Bynoe RP et al. Noninvasive diagnosis of vascular trauma by duplex ultrasonagraphy. J VAsc Surg 14: 346-52, 1991. prospective•Demetraides D et al. Penetrating injuries of the neck in patients in stable condition: Physical examination, angiography or color flow Doppler imaging. Arch Surg 130: 971-75. 1995. prospective•Montalvo BM et al. Collor Doppler sonography in penetrating injuries of the neck. Am J Neuroradiol. 17: 943-951, 1996. prospective•Picture shows Pseudoaneurysm (arrow) of the femoral artery on angiography and on (B) color duplex ultrasound demonstrating communication and flow between the false aneurysm (FA) and the common femoral artery (CFA) via a neck. (C) Characteristic "to-and-fro" Doppler waveform in the neck of the pseudoaneurysm. (D) Absence of flow within the false aneurysm after successful thrombin injection

Diagnosis: CTAMethod:

Nonionic contrast in peripheral IV, care in renal or diabetic Exam takes 1 min., postprocessing takes 15 min.Axial usually enough; add multiplanar + 3D for OR plan

Direct signs Irregular vessel margins, filling defectsContrast extravasation, lack of vascular enhancementVessel caliber changes

Indirect: indistinct perivascular fat plane, bullet/bone fragments within 5 mm of major vessel, hematoma close to vessel

Associated Injuries: C spine, bullet track, aerodigestive

Munera F et al. Penetrating injuries of the neck: use of helical computed tomographic angiography. J Trauma. 2005; 58: 413-18.University of Miami, prospective 2 yr. n = 60

Diagnosis: CTA Munera F et al 2000 (2005) (p)

Sensitivity 90% (100%) Specificity 100% (98.6%) PPV 100% (92.8%) NPV 98% (100%)

Inaba K et al 2006 (p) Sensitivity 100% Specificity 93.5% Nondiagnostic 2.2%

Woo K et al 2005 (r) CTA decreased negative

exploration & adjunct tests

Gonzalez RP et al 2003 (p) Physical exam missed 2 esophageal

injuries seen on CTA Recommend as initial for zone II

Mazolewski PJ et al 2001 (p) 100% sensitive, 91% specific operative findings in zone II

Gracias VH et al 2001 (r) Initial test in zones I – III Decreased overall adjunct studies

MRI/MRA logistics difficult, no bony information

(1st number compared to arteriography; 2nd number compared to actual intervention—surgery or endovascular or observation)Munera F et al. Diagnosis of arterial injuries caused by penetrating trauma to the neck: comparison of helical CT angiography and conventional angiography. Radiology 2000; 216 (2) 356-62.Inaba K et al. Prospective evaluation of screening multislcine helical CTA in the initial evaluation of penetrating neck injuries. J Trauma, Injury, Infection and Critical Care. 2006; 61 (1): 144-56Gracias VH et al. Computed tomography in the evaluation of penetrating neck trauma: a preliminary study. Arch Surg. 2001; 136: 1231-1235.Mazolewski PJ et al. Computed tomographic scan can be used for surgical decision making in zone II penetrating neck injuries. J Trauma. 2001: 51: 315-19.Gonzalez RP et al. Penetrating zone II neck injury: does dynamic computed tomographic scan contribute to the diagnostic sensitivity of physical examination for surgically significant injury? A prospective blinded study. J Trauma 2003; 54: 61-4.

Diagnosis: CTAWoo K et al 2005 Retrospective 1994 – 2004

Patient

n = 130

Surgery

NegativeExploration

Angio-graphy

Esopha-gram

CFDoppler

CTA 34 1(3%)

0 4(12%)

4(12%)

13(39%)

No CTA

96 32(33%)

22% (66%/32)

19(29%)

17(26%)

21(32%)

No CTA 1994-1998: 34% angiogram, 24% esophagram41% CTA 1999-2004: 11% angiogram, 16% esophagram

Woo Karen et al. CT angiography in penetrating neck trauma reduced the need for operative neck exploration. The American Surgeon 2005.

Diagnosis: Cost-effectiveness of CTA

Seamon MJ et al: extremity CTA versus arteriogram saved $12,922 in patient charges & $1,166 hospital cost

Decreased negative exploration rate cuts OR & patient cost

A Prospective Validation of a Current Practice: The Detection of Extremity Vascular Injury With CT Angiography. Original Article

Journal of Trauma-Injury Infection & Critical Care. 67(2):238-244, August 2009. Seamon, Mark J.

Diagnosis: CTA—stab wound

Munera F et al. Multidetector row computed tomography in the management of penetrating neck injuries. Seminals in Ultrasound CT and MRI. 2009.Multiple stab wounds to neck; axial CT (c) shows right skin defect with extension down to jugular vein, no hematoma; B) is maximum intensity projection & A) is color 3D volume rendered image patient taken to OR for debridement & small injury to right IJV repaired

Munera F et al 2009.

Self-inflicted GSW to right neck; axial CTA shows large hematoma with contrast extravasation. MIP & 3D show facial artery branching from ECA & running into hematoma,most likely source of bleeding

Munera F et al 2005

Right common carotid pseudoaneurysm

Munera F et al 2000

Axial CT images from inferior to superior shows progressive narrowing of right ICA; no contrast enhancement seen in superior most (bottom)

Munera F et al 2000

Left common carotid pseudoaneurysm with fistula to IJV: left = proximal axial CT, right = at bifurcation; see increased collection of contrast into left IJV as compared to normal right; sagittal recon shows extravasation of contrast and increased enhancement of left IJV

Munera F et al 2009.Direct injury with thrombosis of right IJV

Munera F et al 2005.

Axial CT shows bullet tract through left neck, close to esophagus; esophagus replaced by large posterior mediastinal hematoma

Diagnosis: CTA—esophageal injury

Rathlev NK et al 2007

Rathlev NK et al. Evaluation and management of neck trauma. Emerg Med Clin N Am 2007; 25: 679-694.Free air adj to esophagus, traumatic perf

Diagnosis: CTALimitations

1.1 – 2.2% nondiagnosticLarge patients: shoulder

obscures neckStreak artifacts from

bullets/metalNormal variants may look

like injuriesSubclavian arteries Large volume contrast:

renal, diabetic patientMunera F et al 2009.

Munera F et al 2009.GSW to neck, bullet fragments in right carotid space cause streak artifact nondiagnostic CTA required angio which showed dissection

Management SummaryUnstable Stable w/ symptoms Stable without

symptoms

Airway injuryHemodynamic instabilityUncontrolled bleedingEvolving CVA

Hematoma, hemoptysis, hematemesis, dysphagia, dysphonia, peripheral neuro deficit, subcutaneous air

Mandatory Exploration CTA in allSelective testing: endoscopy, esophagraphyArteriography I & IIIFoley tamponade? Mandatory exploration

Observe > 12 hrsCTA in allArteriography & Esophagraphy in zone I? exploration

South Africa: Foley catheter balloon tamponade for life-threatening hemorrhage in penetrating neck trauma. Navsaria P et al. World J Surgy 2006 30: 1265-1268

Case 124 M, GSW to right

neckIntubated at sceneVitals currently

stableRight neck swelling,

no bruit/thrillSubQ air CTA done

What next?Woo K et al 2005

Woo K et al 2005. CTA allows visualization of bullet tract; carotids are fine; bullet fragments + air in prevertebral + parapharyngeal space esophagram done, no injury noted

Case 235 M Injury to neck with

working with axe chip flew into midline1 week agoc/o pain, dysphagiaVitals stable, no

dysphoniaNo feverWound between thyroid

& cricoid, no saliva or air Gulia J et al 2009

•J. Gulia, S. Yadav, K. Singh & A. Khaowas : Penetrating Neck Injury: Report Of Two Cases. The Internet Journal of Emergency Medicine. 2009 Volume 6 Number 1•Gulia J et al 2009

Case 3:40 M, stray shot to

neckc/o pain, some

bleedingWound anterior neckNo exit woundNo swellingMild dysphoniaNo airway distressVitals stable

Sari M et al 2007.

Sari M et al 2007. Atypical penetrating laryngeal trauma. European Journal of Emergency Medicine 2007, 14:230–232

Case 3 Sari M et al 2007.

Flexible laryngoscopy showed airway stable, bilat TVC mobile, right supraglottic edema with bullet lodgedOR for DL, bullet removed, no further intervention needed, observed x 24 hrs.

ConclusionsImmediate exploration for patients with hard

signsHemodynamic instabilityUncontrollable bleeding, expanding hematomaWorsening neurological statusAir bubbling in wound, need for surgical airway

Brywczynski JJ et al 2008: meta-analysis shows C spine injury less common in penetrating trauma

Remove C collar to examine neck !!!

Selective management of stable patients

Conclusions: Selective ManagementMethod Logistics

($, ease)Reliability Adjunct

TestsBonus

Physical Exam

CheapQuick

Large trauma centers

X raysEsophagramEndoscopy

No

Duplex Ultrasound

CheapQuick

OperatorZone II only

No

Arteriography

ExpensiveTimeSpecialized

Gold standard vascular injury

Endovascular Treatment

CTA Mid priceQuick

Good Streak artifacts

Lower rate Bony, tissue, aerodigestiveC spine, bullet tract

ConclusionsZone I Zone II Zone III

CTA CTA CTA

Esophagram/flexible esophagoscopy if suspect/see injury on CTFlexible laryngoscopy if suspect/see injury on CTArteriogram if CTA nondiagnostic, need more information for OR or plan endovascular interventionOR if injury needs to be surgically assessed/repaired? Usefulness of whole body CTA in multiple GSW/SW

Neck Zones Obsolete???

ConclusionsZone I-III classification still works for

operative management of vascular injuriesZone II easy to get proximal & distal control

surgeryZone I & III may try endovascular therapy

Difficult proximal control zone I: median sternotomy

Difficult distal control zone III: skull base

Munera F et al.

Munera F et al. Penetrating injuries of the neck: use of helical computed tomographic angiography. J Trauma. 2005; 58: 413-18.University of Miami, prospective 2 yr. n = 60

Discussion: Francis B. Quinn, Jr., MDDoctor Siddiqui has given an excellent and up‐to‐date summary of the diagnosis and treatment of penetrating injuries of the neck, with emphasis on the wide range of approaches made possible by newer imaging techniques. She has pointed out that the earlier "zone" protocol may be soon overwhelmed by the more modern "selective" management strategies.

The question of evaluating various series of cases is made complicated by the several mechanisms of injury as drawn from different cultures and environments. We note that 75% of South African patients present with incised wounds, 50% of U.S. urban patients seek treatment for gunshot wounds, and our military casualties suffer wounds from low‐velocity shell fragments, as well as high velocity small caliber rifle bullets, often accompanied by substantial loss of tissue.

Thus, reports of treatment results should allow us to picture the biomechanics of injury, for as has been shown in a previous Grand Rounds(1,2,3), the high velocity projectile creates instantaneous and extensive tissue expansion with shearing stress leading to delayed devitalizationand unanticipated late complications. Further, even low velocity (800 fps) bullets are known to tumble and fragment, causing tissue injury far from the missile track. In contrast, stabbing or cutting injury causes tissue injury limited to the track of the weapon.

Doctor Siddiqui's presentation has shown us that the newer treatment methods have laid upon faculty of resident training institutions the requirement to distill the reports of these methods into a doctrine suitable for the instruction of those aspiring young surgeons under our direction, a doctrine which takes into account the local weapons culture as well as the technical and imaging support available.

Discussion: Francis B. Quinn, Jr., MDREFERENCES:

1. Dr. Quinn's Online Textbook of Otolaryngology, http://www.utmb.edu/otoref/Grnds/GrndsIndex.html

2. LeBoeuf, Herve J, MD. "Penetrating Neck Trauma". University of Texas Medical Branch, Department of Otolaryngolgy. Online[Available]: http://www.utmb.edu/otoref/Grnds/Pen neck trauma 9901/Pen neck‐ ‐ ‐ ‐ ‐trauma 9901.html‐ . SLIDES: http://www.utmb.edu/otoref/Grnds/Pen neck‐ ‐trauma 9901/Pen neck trauma.pdf. January 27, 1999.‐ ‐ ‐

3. Reddy, Shashidhar S, MD. "Management of Penetrating Neck Trauma". University of Texas Medical Branch, Department of Otolaryngolgy. Online[Available]: http://www.utmb.edu/otoref/Grnds/Penetrat-NeckTrauma-2002-0905/Penetrat-Neck-Trauma-020905..pdf. SLIDES: http://www.utmb.edu/otoref/Grnds/Penetrat NeckTrauma 2002 0905/Penetra‐ ‐ ‐t Neck Trauma 2002 0905 slides.pdf, September 6, 2002.‐ ‐ ‐ ‐ ‐