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Hamilton JM, Chan TG, Moore CE. Penetrating Head and Neck Trauma: A Narrative Review of Evidence-Based Evaluation and Treatment Protocols. Otolaryngol Clin North Am 2023; 56:1013-1025. [PMID: 37353366 DOI: 10.1016/j.otc.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/25/2023]
Abstract
Penetrating injury to the head and neck accounts for a minority of trauma but significant morbidity in the US civilian population. The 3-zone anatomical framework has historically guided evaluation and management; however, the most current evidence-based protocols favor a no-zone, systems-based approach. In stable patients, a thorough physical examination and noninvasive imaging should be prioritized, with surgical exploration of the head and neck reserved for certain circumstances. Diagnostic and management decisions should be tailored to the mechanism of injury, history, physical examination, experience of personnel, availability of equipment, and clinical judgment.
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Affiliation(s)
- James M Hamilton
- Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Grady Memorial Hospital, Atlanta, GA, USA.
| | - Tyler G Chan
- Emory University School of Medicine, Atlanta, GA, USA
| | - Charles E Moore
- Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Grady Memorial Hospital, Atlanta, GA, USA
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2
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Sachdeva K, Vatsyayan R. A Prospective Study of Management of Neck Trauma and its Complications : An Institutional Approach. Indian J Otolaryngol Head Neck Surg 2023; 75:895-901. [PMID: 37275081 PMCID: PMC10234975 DOI: 10.1007/s12070-023-03533-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 01/24/2023] [Indexed: 02/15/2023] Open
Abstract
Background: Assessment and immediate surgical management of laryngotracheal injuries is essential to minimize the risk of perioperative and long term complications [1]. The present study was conducted at tertiary care centre to assess the proportions of complications following neck injuries. Methodology: The study was conducted as a prospective study on 19 patients presenting with laryngotracheal injuries at Emergency department in NSCB Medical College, Jabalpur, India during the study period of 2 years. History was obtained in detail and depending upon the extent and nature of injury, patients were managed. Patients were followed up till discharge for assessment of any postoperative complications. Results: A total of 19 cases with neck trauma were enrolled during our study period with mean age of 27.37±8.88 years. Tracheal breach was noted in 78.9% cases. The most common site of airway injury was tracheal wall (47.3%), followed by Laryngeal trauma with unilateral or bilateral thyroid cartilage (15.8%). Major vessels injury was noted in 26.3% cases and injury to minor blood vessels was observed in 68.4% cases. Wound exploration followed by wound repair was done in 36.8% of the cases whereas emergency tracheostomy along with wound repair was done in 31.6% of the cases. During surgery, brachial plexus injury and surgical site infection were the surgical complications in 1 case each. However, anemia psychiatric tendency and symptoms due to alcohol withdrawal were the complications in 1 case each. Among postoperative complications, persistence of psychiatric symptoms, recurrent laryngeal nerve palsy, withdrawal symptoms, and complications due to brachial plexus injury persisted. Conclusion: Neck injuries and laryngotracheal injuries are rare but life threatening injuries, timely management of which is essentially important to avoid the occurrence of complications. Management often requires multidisciplinary approach due to associated complications. The complications may be immediate or remote which can be prevented if patients are managed timely. Supplementary Information The online version contains supplementary material available at 10.1007/s12070-023-03533-7.
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Affiliation(s)
- Kavita Sachdeva
- Netaji Subhash Chandra Bose Medical College and Hospital, Jabalpur, Madhya Pradesh India
| | - Richa Vatsyayan
- Netaji Subhash Chandra Bose Medical College and Hospital, Jabalpur, Madhya Pradesh India
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3
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Aljohani K, Alsaud A, Aldarsouni FG, Alruwaite H, Alsubaie NM. Penetrating Neck Injury: Double Jeopardy of a Complex Aerodigestive Dilemma. Cureus 2023; 15:e39533. [PMID: 37366441 PMCID: PMC10290894 DOI: 10.7759/cureus.39533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2023] [Indexed: 06/28/2023] Open
Abstract
The neck is a critical region containing many essential structures. Before surgical intervention, it is crucial to assess the adequacy of the airway and circulation, as well as the presence of any skeletal or neurological damage. Here, we present a case of a 33-year-old male with a background of amphetamine abuse who presented to our emergency department with a penetrating neck injury just below the mandible at the hypopharynx level, resulting in an upper zone II neck injury with complete separation of the airway. The patient was taken immediately to the operating room for exploration. Airways were managed by direct intubation, hemostasis was maintained, and the open laryngeal injury was repaired. After the surgery, this patient was transferred to the intensive care unit for two days and discharged after a satisfactory full recovery. Penetrating neck injuries are rare but often fatal. Advanced trauma life support guidelines emphasize the importance of managing the airway as the first action. Providing multidisciplinary care before, during, and after trauma can help prevent and treat such incidents.
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Affiliation(s)
- Khaled Aljohani
- Department of Surgery, King Saud University Medical City, Riyadh, SAU
| | - Ahad Alsaud
- Department of Emergency Medicine, College of Medicine, King Saud University Medical City, Riyadh, SAU
| | | | - Hosam Alruwaite
- Department of Surgery, King Saud University Medical City, Riyadh, SAU
| | - Norah M Alsubaie
- Department of Surgery, King Saud University Medical City, Riyadh, SAU
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4
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Di Scenza G, Mason K, Oikonomou G. Analysis of penetrating neck injuries at a South London Trauma Centre before and after the first national lockdown of the coronavirus pandemic. Clin Otolaryngol 2023; 48:259-263. [PMID: 36539942 DOI: 10.1111/coa.14024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 11/19/2022] [Accepted: 12/10/2022] [Indexed: 12/24/2022]
Affiliation(s)
| | - Katrina Mason
- Ear, Nose and Throat (ENT) Surgery Department, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Georgios Oikonomou
- Ear, Nose and Throat (ENT) Surgery Department, St George's University Hospitals NHS Foundation Trust, London, UK
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5
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Alves DG, Sousa J, Ferreira V, Almeida Pinto J, Teixeira N. Anterior Penetrating Neck Injury: A Path to the Cervical Spine. Cureus 2023; 15:e35370. [PMID: 36994302 PMCID: PMC10042214 DOI: 10.7759/cureus.35370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2023] [Indexed: 02/25/2023] Open
Abstract
While rare in incidence, penetrating neck injuries are often life-threatening. When a patient's physiological status is appropriate, the first step in treatment should be a detailed preoperative imaging assessment. Formulating a treatment plan that includes computed tomography (CT) imaging and discussing the surgical approach with a multidisciplinary team before operating allows for a successful selective surgical approach. The authors report the case of a Zone II penetrating injury with a right laterocervical entry wound in which an impaled blade with an inferomedial oblique path pierced deeply into the cervical spine. The blade missed multiple vital structures in the neck, such as the common carotid artery, jugular vein, trachea, and esophagus. The patient underwent a formal neck exploration, and controlled extraction of the blade under direct vision was achieved. Therefore, the author's recommendation for implementing any management algorithm for penetrating neck injuries should rely primarily on a multidisciplinary selective approach.
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6
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Jones D, Muthirevula A, Chaudhuri N. Letter to the editor: an isolated midline zone 1 neck injury, with a tracheooesophageal fistula. Indian J Thorac Cardiovasc Surg 2022; 38:683-685. [PMID: 36258826 PMCID: PMC9569269 DOI: 10.1007/s12055-022-01410-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 08/18/2022] [Accepted: 08/23/2022] [Indexed: 11/28/2022] Open
Affiliation(s)
- Daniel Jones
- Department of Thoracic Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Arvind Muthirevula
- Department of Thoracic Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Nilanjan Chaudhuri
- Department of Thoracic Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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7
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Kong V, Cheung C, Ko J, Xu W, Bruce J, Liang G, Manchev V, Clarke D. The Management of Penetrating Neck Injury With Retained Knife: 15-Year Experience From a Major Trauma Center in South Africa. Am Surg 2021; 88:2703-2709. [PMID: 34965158 DOI: 10.1177/00031348211065127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND This study reviews our cumulative experience with the management of patients presenting with a retained knife following a penetrating neck injury (PNI). METHODS A retrospective cohort study was conducted at a major trauma center in South Africa over a 15-year period from July 2006 to December 2020. All patients who presented with a retained knife in the neck following a stab wound (SW) were included. RESULTS Twenty-two cases were included: 20 males (91%), mean age: 29 years. 77% (17/22) were retained knives and 23% (5/22) were retained blades. Eighteen (82%) were in the anterior neck, and the remaining 4 cases were in the posterior neck. Plain radiography was performed in 95% (21/22) of cases, and computed tomography (CT) was performed in 91% (20/22). Ninety-five percent (21/22) had the knife or blade extracted in the operating room (OR). Formal neck exploration (FNE) was undertaken in 45% (10/22) of cases, and the remaining 55% (12/22) underwent simple extraction (SE) only. Formal neck exploration was more commonly performed for anterior neck retained knives than the posterior neck, although not statistically significant [56% (10/18) vs 0% (0/18), P = .096]. There were no significant differences in the need for intensive care admission, length of hospital stay, morbidities, or mortalities between anterior and posterior neck retained knives. DISCUSSION Uncontrolled extraction of a retained knife in the neck outside of the operating room may be dangerous. Retained knives in the anterior neck commonly required formal neck exploration but not for posterior neck retained knives.
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Affiliation(s)
- Victor Kong
- Department of Surgery, 37707University of the Witwatersrand, Johannesburg, South Africa
| | - Cynthia Cheung
- Department of Surgery, 118838Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| | - Jonathan Ko
- Department of Surgery, 1415University of Auckland, Auckland, New Zealand
| | - William Xu
- Department of Surgery, 1415University of Auckland, Auckland, New Zealand
| | - John Bruce
- Department of Surgery, 56394University of KwaZulu Natal, Durban, South Africa
| | - Grant Liang
- Department of Surgery, 56394University of KwaZulu Natal, Durban, South Africa
| | - Vasil Manchev
- Department of Surgery, 56394University of KwaZulu Natal, Durban, South Africa
| | - Damian Clarke
- Department of Surgery, 37707University of the Witwatersrand, Johannesburg, South Africa.,Department of Surgery, 56394University of KwaZulu Natal, Durban, South Africa
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8
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Ichibayashi R, Suzuki G, Nakamichi Y, Yamamoto S, Serizawa H, Watanabe M, Harada M, Harada N, Honda M. Penetrating vertebral artery injury treated by combining the "zone" approach and imaging tests: A case report. Clin Case Rep 2021; 9:e05134. [PMID: 34849232 PMCID: PMC8609188 DOI: 10.1002/ccr3.5134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 11/08/2021] [Accepted: 11/09/2021] [Indexed: 11/18/2022] Open
Abstract
Patients with vertebral artery injury from penetrating neck trauma may not present with signs of vascular injury because of anatomical characteristics and concomitant conditions, such as hypothermia and shock. If patients are hemodynamically stable, imaging tests should be performed to examine the posterior components, including the vertebral artery.
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Affiliation(s)
- Ryo Ichibayashi
- Department of Critical Care CenterToho University Medical Center Omori HospitalOta‐kuJapan
| | - Ginga Suzuki
- Department of Critical Care CenterToho University Medical Center Omori HospitalOta‐kuJapan
| | - Yoshimi Nakamichi
- Department of Critical Care CenterToho University Medical Center Omori HospitalOta‐kuJapan
| | - Saki Yamamoto
- Department of Critical Care CenterToho University Medical Center Omori HospitalOta‐kuJapan
| | - Hibiki Serizawa
- Department of Critical Care CenterToho University Medical Center Omori HospitalOta‐kuJapan
| | - Masayuki Watanabe
- Department of Critical Care CenterToho University Medical Center Omori HospitalOta‐kuJapan
| | - Masashi Harada
- Department of NeurosurgeryToho University Medical Center Omori HospitalOta‐kuJapan
| | - Naoyuki Harada
- Department of NeurosurgeryToho University Medical Center Omori HospitalOta‐kuJapan
| | - Mitsuru Honda
- Department of Critical Care CenterToho University Medical Center Omori HospitalOta‐kuJapan
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9
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Paladino L, Baron BJ, Shan G, Sinert R. Computed tomography angiography for aerodigestive injuries in penetrating neck trauma: A systematic review. Acad Emerg Med 2021; 28:1160-1172. [PMID: 34021515 DOI: 10.1111/acem.14298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 05/10/2021] [Accepted: 05/11/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Management of hemodynamically stable patients with penetrating neck trauma (PNT) has evolved in recent years with improvements in imaging technology. Computed tomography angiography (CTA) encompassing all zones of the neck has become part of the standard diagnostic algorithm for PNT patients who do not require immediate surgical intervention for vascular or aerodigestive injuries (ADI). Several studies have demonstrated favorable operating characteristics for CTA at excluding arterial injuries; however, consensus as to CTA's ability to detect ADI is lacking. We conducted a systematic review (PROSPERO registration number CRD42019133509) to answer the question Is CTA sufficient to rule out ADI in hemodynamically stable PNT patients without hard signs? METHODS Investigators independently searched PubMed, EMBASE, and Web of Science from their inception to August 2020 for the search terms "penetrating neck injuries" and "CT scan." To be included, studies required sufficient data to construct a 2×2 table of CTA for ADI. The operating characteristics of CTA for detecting ADIs are reported as sensitivity, specificity, and likelihood ratios (LRs), with 95% confidence intervals (95% CIs). Bias in our studies was quantified by QUADAS-2. RESULTS Our search identified 1,242 citations with seven studies with moderate to high risk of bias meeting our inclusion/exclusion criteria and encompassing 877 subjects with an ADI prevalence of 13.4%. CTA for ADI had sensitivity of 92% (95% CI = 85% to 97%), specificity of 88% (95% CI = 85% to 90%), positive likelihood ratio of 12.2 (95% CI = 4.6 to 32), and negative LR of 0.14 (95% CI = 0.05 to 0.37). Of the 26 identified esophageal injuries across our studies that were diagnosed by either swallow studies or surgical exploration, five (19%, 95% CI = 8.1% to 38.3%) were initially missed by CTA. CONCLUSION CTA alone is not sufficient to exclude esophageal injuries in PNT. Because delayed diagnosis is associated with increased morbidity, additional diagnostic interventions should be undertaken if there is remaining concern for esophageal injury.
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Affiliation(s)
- Lorenzo Paladino
- Department of Emergency Medicine State University of New York Downstate Health Sciences University and NYC Health Hospitals Kings County Brooklyn New York USA
| | - Bonny J. Baron
- Department of Emergency Medicine State University of New York Downstate Health Sciences University and NYC Health Hospitals Kings County Brooklyn New York USA
| | - Gururaj Shan
- Department of Emergency Medicine State University of New York Downstate Health Sciences University and NYC Health Hospitals Kings County Brooklyn New York USA
| | - Richard Sinert
- Department of Emergency Medicine State University of New York Downstate Health Sciences University and NYC Health Hospitals Kings County Brooklyn New York USA
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10
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Zakaria B, Muzaffar J, Borsetto D, Fussey J, Kumar R, Evans K, Pickering C, Reid C, Coulson C, Orr L, Pracy P, Nankivell P, Sharma N. Civilian Penetrating Neck Trauma at a Level I Trauma Centre: A Five-Year Retrospective Case Note Review. Clin Otolaryngol 2021; 47:44-51. [PMID: 34323008 DOI: 10.1111/coa.13841] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 06/21/2021] [Accepted: 07/17/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To report the experience of civilian penetrating neck trauma (PNT) at a UK level I trauma centre, propose an initial management algorithm and assess the degree of correlation between clinical signs of injury, operative findings, and radiological reports. DESIGN Retrospective case note review SETTING: UK level I trauma centre April 2012-November 2017 PARTICIPANTS: 310 cases of PNT were drawn from electronic patient records. Data was extracted on hard and soft signs of vascular or aerodigestive tract injury, clinical management, radiological imaging and patient outcomes. MAIN OUTCOME MEASURES Patient demographics, mechanism of injury, morbidity and mortality. The correlation between clinical signs, and radiological reports to internal injury on surgical exploration. RESULTS 271 (87.4%) male and 39 (13.6%) female patients with a mean age 36 years (16 - 87) were identified. The most common causes of injury were assault 171 (55.2%) and deliberate self-harm 118 (38%). A knife was the most common instrument 240 (77.4%). Past psychiatric history was noted in 119 (38.4%) and 60 (19.4%) were intoxicated. 50% were definitively managed in theatre with a negative exploration rate of 38%, and 50% were managed in ED. Pre-operative radiological reports correlated with operative reports in 62% of cases with venous injury the most common positive and negative finding. Multivariate correlation was r=0.89, p=0.045 between hard signs plus positive radiology findings and internal injury on neck exploration. CONCLUSIONS Management of PNT by clinical and radiological signs is safe and effective, and can be streamlined by a decision-making algorithm as proposed here.
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Affiliation(s)
- Benjamin Zakaria
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,Department of Ear, Nose and Throat Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jameel Muzaffar
- Department of Ear, Nose and Throat Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, UK
| | - Daniele Borsetto
- Department of Ear, Nose and Throat Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jonathan Fussey
- Department of Ear, Nose and Throat Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Raghu Kumar
- Department of Ear, Nose and Throat Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Kate Evans
- Department of Ear, Nose and Throat Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Christopher Pickering
- Department of Ear, Nose and Throat Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Conor Reid
- Department of Ear, Nose and Throat Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Christopher Coulson
- Department of Ear, Nose and Throat Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Linda Orr
- Department of Ear, Nose and Throat Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, UK
| | - Paul Pracy
- Department of Ear, Nose and Throat Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Paul Nankivell
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,Department of Ear, Nose and Throat Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Neil Sharma
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,Department of Ear, Nose and Throat Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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A 10-year study of penetrating head and neck injury by assault in the North East of England. Oral Maxillofac Surg 2021; 26:213-222. [PMID: 34152514 PMCID: PMC8215095 DOI: 10.1007/s10006-021-00980-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 06/07/2021] [Indexed: 11/13/2022]
Abstract
Introduction Assaults inflicting penetrating head and neck trauma have potential for serious morbidity or mortality. This paper studies in-depth all cases treated at a level one trauma centre in the North East of England over 10 years. Methods All patients assaulted with sharp implements to the head and neck treated from 2010 to 2019 were identified using clinical codes. Results Retrospective data collection were as follows: 214 patients identified (189 male, 25 female). Average age was 31.5 years (range 3–80). The majority presented between 20:00 and 05:00. Knives were the commonest weapon. Fifty-two had scalp, 137 face and 69 neck injuries. Forty-eight percent had additional non-head and neck injuries. Eighty-six percent required admission, 16.6% to intensive care. Oral and maxillofacial and plastic surgeons provided most treatment. One hundred two required treatment under general and 96 local anaesthetic. Sixteen patients had significant vascular injury, 1 brachial plexus injury, 4 facial nerve injuries (of which 3 repaired) and one required parotid duct repair. Mean length of stay was 3.7 days. No mortality was recorded. Incidence significantly increased from 2010 to 2019. Conclusions Head and neck penetrating injuries occur frequently, often with other injuries and mainly in young males. Incidence of significant vascular or nerve injury was low. This study provides important data for those planning trauma services.
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12
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Ko JW, Gong SC, Kim MJ, Chung JS, Choi YU, Lee JH, Jung PY. The efficacy of the "no zone" approach for the assessment of traumatic neck injury: a case-control study. Ann Surg Treat Res 2020; 99:352-361. [PMID: 33304863 PMCID: PMC7704270 DOI: 10.4174/astr.2020.99.6.352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 08/11/2020] [Accepted: 10/09/2020] [Indexed: 12/20/2022] Open
Abstract
Purpose Recently, several studies have demonstrated symptom-based, non-zonal algorithms for approaching penetrating neck injuries. The purpose of this study was to confirm the effectiveness of the “no zone” approach in traumatic neck injuries. Methods Medical charts of patients with traumatic neck injuries who presented at the Regional Trauma Center in South Korea between January 2014 and December 2018 were retrospectively reviewed. Negative final neck findings (FNFs) were compared with positive FNFs (which include major vascular, aerodigestive, nerve, endocrine gland, cartilage, or hyoid bone injuries) using multivariate logistic regression analysis including values of the “zone” and/or no zone approach. Results Out of 168 trauma patients, 70 patients with a minor injury and 7 patients under the age of 18 years were excluded. Of the remaining 91 patients, 74 (81.3%) had penetrating neck injuries and 17 (18.7%) had blunt neck injuries. Initial diagnosis most frequently revealed external wounds in zone II (84.6%). Twenty (22.0%) and 36 (39.5%) patients had hard and soft signs, respectively, using the no zone approach. Further, there was a significant difference between the negative and positive FNFs in patients with hard signs (11.6% vs. 54.5%; P < 0.01, respectively). According to the multivariate logistic regression analysis, the hard signs were associated with an odds ratio (OR) for FNFs (OR, 18.92; 95% confidence interval, 3.55–157.60). Conclusion Traumatic neck injuries classified as having hard signs based on the no zone approach may be correlated with internal organ injuries of the neck.
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Affiliation(s)
- Ji Wool Ko
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea.,Regional Trauma Center, Wonju Severance Christian Hospital, Wonju, Korea
| | - Seong Chan Gong
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea.,Regional Trauma Center, Wonju Severance Christian Hospital, Wonju, Korea
| | - Myung Jun Kim
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea.,Regional Trauma Center, Wonju Severance Christian Hospital, Wonju, Korea
| | - Jae Sik Chung
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea.,Regional Trauma Center, Wonju Severance Christian Hospital, Wonju, Korea
| | - Young Un Choi
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea.,Regional Trauma Center, Wonju Severance Christian Hospital, Wonju, Korea
| | - Jun Hyuk Lee
- Department of Biostatistics, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Pil Young Jung
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea.,Regional Trauma Center, Wonju Severance Christian Hospital, Wonju, Korea
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13
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Staniszewska A, Anwar M, Hamady M, Nott D. Hybrid repair of proximal subclavian artery transection. TRAUMA-ENGLAND 2020. [DOI: 10.1177/1460408620934364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Although rare, subclavian artery injuries are associated with significant mortality and morbidity, with almost two-thirds of patients dying before reaching hospital. Recent advances in technology have resulted in increasing use of endovascular therapy in management of these injuries. In this report, we present a case of a successful hybrid repair of traumatic left proximal subclavian artery transection. The employment of an Amplatzer Vascular Plug to control a short proximal subclavian artery stump and subsequent ligation of the distal segment of subclavian artery with its anastomosis to the carotid artery resulted in excellent clinical outcome without performing a sternotomy in a young patient.
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Affiliation(s)
- Aleksandra Staniszewska
- Department of Vascular Surgery, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Muzaffar Anwar
- Department of Vascular Surgery, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Mohamad Hamady
- Department of Interventional Radiology, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - David Nott
- Department of Vascular Surgery, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK
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14
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Isaza-Restrepo A, Quintero-Contreras JA, Escobar-DiazGranados J, Ruiz-Sternberg ÁM. Value of clinical examination in the assessment of penetrating neck injuries: a retrospective study of diagnostic accuracy test. BMC Emerg Med 2020; 20:17. [PMID: 32151240 PMCID: PMC7063736 DOI: 10.1186/s12873-020-00311-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 02/14/2020] [Indexed: 12/04/2022] Open
Abstract
Background There are many high-volume trauma centers in limited resource environments where a thorough clinical examination of patients may contribute to a more economical, accurate, and widely applicable method of determining the proper management of patients with penetrating neck injuries. The purpose of this study was to validate thorough physical examination as a reliable diagnostic tool in these patients. Methods We performed an observational retrospective study of a diagnostic accuracy test where we compared clinical findings (symptoms and soft signs on admission of the patient) with the definitive findings according to the gold standard test for each particular situation (selective studies, clinical observation and surgical exploration). The study was conducted at Hospital Occidente Kennedy (HOK) between August 2009 and June 2010. Results The sample consisted of the clinical records of 207 (n = 207) patients who went to the emergency room for penetrating neck wounds at Hospital Occidente Kennedy (HOK). Of the total sample, 36.2% (n = 75) of patients were considered “asymptomatic” as they didn’t present with any soft signs of injury. Vascular soft signs were present in 57% (n = 118) of the patients, soft signs of the airway and the upper gastrointestinal tract were present in 15.9% (n = 33) and 21.3% (n = 44) of the patients respectively. The sensitivity and negative predictive value (NPV) of any soft sign to determine injuries which require surgical repair was 97.4% [CI] [86.5–99.5%] and 98.7% [CI] [92.8–99.8%] respectively, with a range of confidence [CI] of 95%. Conclusions Our study’s main findings suggest that patients with neck injuries and no vascular, airway, or gastrointestinal soft sign can be safely managed with a conservative approach. It is important to emphasize the value of the clinical examination since there are many contexts in the modern world where a considerable amount of the population is afflicted by neck trauma and treated under conditions where technological resources are limited.
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Affiliation(s)
- Andrés Isaza-Restrepo
- Escuela de Medicina y Ciencias de la Salud. Grupo de Investigación Clínica, Universidad del Rosario, Carrera 24 No 63C-69 Barrio Siete de Agosto, Bogotá, DC, Colombia. .,Méderi Hospital Universitario Mayor, Bogotá, DC, Colombia.
| | | | - Jorge Escobar-DiazGranados
- Escuela de Medicina y Ciencias de la Salud. Grupo de Investigación Clínica, Universidad del Rosario, Carrera 24 No 63C-69 Barrio Siete de Agosto, Bogotá, DC, Colombia
| | - Ángela María Ruiz-Sternberg
- Escuela de Medicina y Ciencias de la Salud. Grupo de Investigación Clínica, Universidad del Rosario, Carrera 24 No 63C-69 Barrio Siete de Agosto, Bogotá, DC, Colombia
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Petrone P, Velaz-Pardo L, Gendy A, Velcu L, Brathwaite CEM, Joseph DK. Diagnosis, management and treatment of neck trauma. Cir Esp 2019; 97:489-500. [PMID: 31358299 DOI: 10.1016/j.ciresp.2019.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 04/27/2019] [Accepted: 06/02/2019] [Indexed: 11/15/2022]
Abstract
Trauma injuries to the neck account for 5-10% of all trauma injuries and carry a high rate of morbidity and mortality, as several vital structures can be damaged. Currently, there are several treatment approaches based on initial management by zones, initial management not based on zones and conservative management of selected patients. The objective of this systematic review is to describe the management of neck trauma.
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Affiliation(s)
- Patrizio Petrone
- Department of Surgery, NYU Winthrop Hospital, NYU Long Island School of Medicine, Mineola, Nueva YorkEE. UU..
| | - Leyre Velaz-Pardo
- Department of Surgery, NYU Winthrop Hospital, NYU Long Island School of Medicine, Mineola, Nueva YorkEE. UU
| | - Amir Gendy
- Department of Surgery, NYU Winthrop Hospital, NYU Long Island School of Medicine, Mineola, Nueva YorkEE. UU
| | - Laura Velcu
- Department of Surgery, NYU Winthrop Hospital, NYU Long Island School of Medicine, Mineola, Nueva YorkEE. UU
| | - Collin E M Brathwaite
- Department of Surgery, NYU Winthrop Hospital, NYU Long Island School of Medicine, Mineola, Nueva YorkEE. UU
| | - D'Andrea K Joseph
- Department of Surgery, NYU Winthrop Hospital, NYU Long Island School of Medicine, Mineola, Nueva YorkEE. UU
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16
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Penetrating neck trauma: radiological predictors of vascular injury. Eur Arch Otorhinolaryngol 2019; 276:2541-2547. [PMID: 31218447 DOI: 10.1007/s00405-019-05517-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 06/13/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Vascular injury in penetrating neck trauma predicts a poorer outcome and usually requires surgical neck exploration. Multi-detector computed tomography (MDCT) angiography is a readily available non-invasive diagnostic tool that can identify direct and indirect signs of vascular injury in stable patients. This study aims to investigate the diagnostic accuracy of radiological signs of vascular injury on MDCT, and their implications on patient management in the setting of penetrating neck trauma. METHODS A retrospective cohort study of penetrating neck injuries (PNI) between 2012 and 2018 in a UK major trauma centre was performed. Clinical data and operative findings were compared with radiological findings on MDCT performed at the time of admission. RESULTS 157 patients were identified with PNI in the study period, with 67 meeting inclusion criteria. The predictive value of indirect radiological signs of vascular injury alone was low, with only 12.1% of these patients having significant vascular injury found at neck exploration. However, the combined use of direct radiological signs with clinical signs resulted in a specificity of 97.7% for vascular injury. CONCLUSIONS The use of direct and indirect radiological signs of vascular injury can increase the accuracy of diagnosis when used in conjunction with clinical signs. Combining clinical assessment and radiological investigation, specifically contrast-enhanced MDCT, improves the specificity in pre-operative assessment of potential vascular injury in PNI. MDCT is recommended in stable patients with clinical signs of vascular injury to reduce the rate of negative neck exploration.
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17
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Nowicki JL, Stew B, Ooi E. Penetrating neck injuries: a guide to evaluation and management. Ann R Coll Surg Engl 2017. [PMID: 29046084 DOI: 10.1308/rcsann.2017.0191] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Introduction Penetrating neck injury is a relatively uncommon trauma presentation with the potential for significant morbidity and possible mortality. There are no international consensus guidelines on penetrating neck injury management and published reviews tend to focus on traditional zonal approaches. Recent improvements in imaging modalities have altered the way in which penetrating neck injuries are now best approached with a more conservative stance. A literature review was completed to provide clinicians with a current practice guideline for evaluation and management of penetrating neck injuries. Methods A comprehensive MEDLINE (PubMed) literature search was conducted using the search terms 'penetrating neck injury', 'penetrating neck trauma', 'management', 'guidelines' and approach. All articles in English were considered. Articles with only limited relevance to the review were subsequently discarded. All other articles which had clear relevance concerning the epidemiology, clinical features and surgical management of penetrating neck injuries were included. Results After initial resuscitation with Advanced Trauma Life Support principles, penetrating neck injury management depends on whether the patient is stable or unstable on clinical evaluation. Patients whose condition is unstable should undergo immediate operative exploration. Patients whose condition is stable who lack hard signs should undergo multidetector helical computed tomography with angiography for evaluation of the injury, regardless of the zone of injury. Conclusions The 'no zonal approach' to penetrating neck trauma is a selective approach with superior patient outcomes in comparison with traditional management principles. We present an evidence-based, algorithmic and practical guide for clinicians to use when assessing and managing penetrating neck injury.
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Affiliation(s)
- J L Nowicki
- ENT Head and Neck Surgery, Flinders Medical Centre and Flinders University , South Australia , Australia
| | - B Stew
- ENT Head and Neck Surgery, Flinders Medical Centre and Flinders University , South Australia , Australia
| | - E Ooi
- ENT Head and Neck Surgery, Flinders Medical Centre and Flinders University , South Australia , Australia.,Department of Surgery, Flinders University , South Australia , Australia
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18
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Casal D, Pelliccia G, Pais D, Carrola-Gomes D, Angélica-Almeida M, Videira-Castro J, Goyri-O'Neill J. Stab injury to the preauricular region with laceration of the external carotid artery without involvement of the facial nerve: a case report. J Med Case Rep 2017; 11:205. [PMID: 28754171 PMCID: PMC5534056 DOI: 10.1186/s13256-017-1361-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 06/22/2017] [Indexed: 12/03/2022] Open
Abstract
Background Open injuries to the face involving the external carotid artery are uncommon. These injuries are normally associated with laceration of the facial nerve because this nerve is more superficial than the external carotid artery. Hence, external carotid artery lesions are usually associated with facial nerve dysfunction. We present an unusual case report in which the patient had an injury to this artery with no facial nerve compromise. Case presentation A 25-year-old Portuguese man sustained a stab wound injury to his right preauricular region with a broken glass. Immediate profuse bleeding ensued. Provisory tamponade of the wound was achieved at the place of aggression by two off-duty doctors. He was initially transferred to a district hospital, where a large arterial bleeding was observed and a temporary compressive dressing was applied. Subsequently, the patient was transferred to a tertiary hospital. At admission in the emergency room, he presented a pulsating lesion in the right preauricular region and slight weakness in the territory of the inferior buccal branch of the facial nerve. The physical examination suggested an arterial lesion superficial to the facial nerve. However, in the operating theater, a section of the posterior and lateral flanks of the external carotid artery inside the parotid gland was identified. No lesion of the facial nerve was observed, and the external carotid artery was repaired. To better understand the anatomical rationale of this uncommon clinical case, we dissected the preauricular region of six cadavers previously injected with colored latex solutions in the vascular system. A small triangular space between the two main branches of division of the facial nerve in which the external carotid artery was not covered by the facial nerve was observed bilaterally in all cases. Conclusions This clinical case illustrates that, in a preauricular wound, the external carotid artery can be injured without facial nerve damage. However, no similar description was found in the reviewed literature, which suggests that this must be a very rare occurrence. According to the dissection study performed, this is due to the existence of a triangular space between the cervicofacial and temporofacial nerve trunks in which the external carotid artery is not covered by the facial nerve or its branches.
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Affiliation(s)
- Diogo Casal
- Plastic and Reconstructive Surgery Department and Burn Unit, Centro Hospitalar de Lisboa Central, Lisbon, Portugal. .,Anatomy Department, NOVA Medical School, Universidade NOVA de Lisboa, Campo dos Mártires da Pátria, 130, 1169-056, Lisbon, Portugal.
| | - Giovanni Pelliccia
- Plastic and Reconstructive Surgery Department and Burn Unit, Centro Hospitalar de Lisboa Central, Lisbon, Portugal.,Anatomy Department, NOVA Medical School, Universidade NOVA de Lisboa, Campo dos Mártires da Pátria, 130, 1169-056, Lisbon, Portugal
| | - Diogo Pais
- Plastic and Reconstructive Surgery Department and Burn Unit, Centro Hospitalar de Lisboa Central, Lisbon, Portugal.,Anatomy Department, NOVA Medical School, Universidade NOVA de Lisboa, Campo dos Mártires da Pátria, 130, 1169-056, Lisbon, Portugal
| | - Diogo Carrola-Gomes
- General Surgery Department, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - Maria Angélica-Almeida
- Plastic and Reconstructive Surgery Department and Burn Unit, Centro Hospitalar de Lisboa Central, Lisbon, Portugal.,Anatomy Department, NOVA Medical School, Universidade NOVA de Lisboa, Campo dos Mártires da Pátria, 130, 1169-056, Lisbon, Portugal
| | - José Videira-Castro
- Plastic and Reconstructive Surgery Department and Burn Unit, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - João Goyri-O'Neill
- Anatomy Department, NOVA Medical School, Universidade NOVA de Lisboa, Campo dos Mártires da Pátria, 130, 1169-056, Lisbon, Portugal
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Penetrating neck trauma and the need for surgical exploration: six-year experience within a regional trauma centre. The Journal of Laryngology & Otology 2016; 131:8-12. [PMID: 27916016 DOI: 10.1017/s0022215116009506] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND There has been a shift towards conservative management of penetrating neck trauma in selected patients. METHODS A retrospective case note review of the management of penetrating neck trauma (2007-2013) was undertaken at our large teaching hospital and compared against best-evidenced practice. RESULTS Sixty-three patients were admitted over six years. The incidence of penetrating neck trauma is reducing, contrary to our belief. Most cases were knife inflicted (33 out of 63), and of these most were attempted suicide. There was a high rate of negative findings for neck explorations under general anaesthesia (18 out of 22). Only nine cases had justification for general anaesthesia exploration according to best practice. CONCLUSION The rate of neck explorations under general anaesthesia has dramatically fallen, in line with best practice. The need for operative intervention in patients with penetration of the aerodigestive tract or a major vascular injury should be based on clinical features, and these have been shown to be reliable indicators prior to open exploration.
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Voelker A, von der Hoeh NH, Gulow J, Heyde CE. Cervical spondylodiscitis with epidural abscess after knife stab wounds to the neck: A case report. Injury 2015; 46:1684-8. [PMID: 26052055 DOI: 10.1016/j.injury.2015.05.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 03/31/2015] [Accepted: 05/16/2015] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Cervical spondylodiscitis is usually caused by pyogenic infections, associated with retropharyngeal abscesses, or due to the swallowing of foreign bodies. No cases of cervical spondylodiscitis caused by a penetrating neck injury have been published in the literature. We describe a case of cervical spondylodiscitis after multiple knife stab wounds to the lateral soft tissue of the neck. MATERIALS AND METHODS Case report and review of the literature. RESULTS A 54-year-old patient was brought to our clinic with destructive spondylodiscitis C3/4 with paravertebral and epidural abscesses. He had been involved in a fight and had suffered multiple stab wounds to his neck with a knife 1 month prior. The initial CT scan had revealed one deeper wound canal behind the sternocleidomastoid muscle on the left side without any injury to the vessels. The wound was cleaned and an antibiotic therapy with cefuroxime was given for 1 week. After an uneventful and complete healing of the wound the patient developed severe neck pain. Inflammatory laboratory parameters were elevated, and a MRI of the neck revealed a distinct spondylodiscitis C3/4 with paravertebral and epidural abscess formations. Surgery was performed and included debridement, abscess drainage, decompression of the spinal canal, fusion of the C3/4 segment using an autologous iliac crest bone graft and a plate osteosynthesis. A course of calculated antibiotic therapy was administered for 8 weeks. Normal laboratory parameters and no radiological signs of an ongoing inflammatory process were observed during follow-up examinations. The C3/4 segment was consolidated. CONCLUSION Stab wound injuries to the neck not only bear the risk of injuries to the nerves, vessels and organs of the neck but also increase the risk of developing secondary spondylodiscitis. Specifically, cervical spondylodiscitis can result in distinct neurological symptoms, and surgical intervention should be performed in a timely manner.
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Affiliation(s)
- Anna Voelker
- Department of Orthopedic, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany.
| | - Nicolas H von der Hoeh
- Department of Orthopedic, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany.
| | - Jens Gulow
- Department of Orthopedic, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany.
| | - Christoph-Eckhard Heyde
- Department of Orthopedic, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany.
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