Penetrating neck trauma: a 5-year review of the literature, 1983 to 1988

Laryngotracheal and pharyngoesophageal traumatic injuries from US military operations in Iraq and Afghanistan, 2003-2017

INTRODUCTION

Laryngotracheal and pharyngo-oesophageal trauma present military providers with especially difficult, life-threatening challenges. Although effective treatment strategies are crucial, there is no clear consensus. This study of combat injuries from Iraq and Afghanistan describes initial treatment outcomes.

METHODS

US service members who sustained 'laryngotracheal' and 'pharyngoesophageal' injuries while deployed in military operations from 2003 to 2017 were identified from the Expeditionary Medical Encounter Database. Those with inhalation or ingestion injuries and an Injury Severity Score (ISS) <16 were excluded. Data on demographics, survival, mechanism and type of injury and diagnostic and therapeutic intervention were recorded.

RESULTS

A total of 111 service members met inclusion criteria. Nearly one-third (32.4%) were killed in action (KIA) or died of wounds (DoW). Fatality was not significantly associated with age, theatre of operation, type of injury or mechanism of injury, but was associated with a higher ISS and those in the Marines. Although survival rates were not significantly different, the frequency of these injuries decreased after the introduction of cervical collar protection in 2007. Of those who DoW or survived, 41.1% required a surgical airway. Tracheobronchoscopy was performed in 25.6%, oesophagoscopy in 20.0% and oesophagram in 6.7%. Of the 85 with penetrating neck injuries, 43 (50.6%) underwent neck exploration, in which 31 (72.1%) required intervention.

CONCLUSIONS

Severe laryngotracheal and pharyngo-oesophageal injuries have a high fatality rate and demand prompt treatment from skilled providers. Further work will elucidate preventive measures and clear management algorithms to optimise outcomes.

Do palliative embolization in unresectable, unsalvageable recurrent and metastatic head and neck cancer patients help?

BACKGROUND

Bleeding from the unsalvageable recurrent and metastatic head and neck cancer is not an uncommon occurrence. It is extremely distressing for the patients and their family members and also to the treating doctors. One of the ways to manage this crisis is by selective embolization of the bleeding vessel.

METHODOLOGY

In this retrospective study, we audited the patients with unresectable, unsalvageable recurrent and/or metastatic head and neck cancer who underwent selective (palliative) embolization for bleeding at our institute between Jan 2015 and Nov 2019, and assessed its possible benefit in terms of bleeding free interval achieved.

RESULTS

Twenty-six palliative embolization was done during the above mentioned period. The majority were male patients (n = 23, 88.4%) with a median age of 54.5 years. The performance status (PS) of most patients was 2 (n = 15, 57.6%). The most common bleeding vessel was the external carotid artery or one of its branches, most commonly lingual artery (n = 5). The bleeding vessel was identified and embolized with PVA/gel foam/coil/glue. All the procedures were uneventful. Out of 26 patients, 3 patients had another bleeding episode subsequently. Most patients had 20 days to 21 months of bleeding free interval. The cost involved in the procedure was between 400 and 2100 US dollars.

CONCLUSIONS

Selective embolization is an option to be considered in certain patients with unresectable, unsalvageable recurrent and/or metastatic head and neck cancer, when they present with sudden and massive bleeding to the emergency department, at centres where the facility and expertise for this procedure might be available.

Penetrating Neck Injuries Treated at a U.S. Role 3 Medical Treatment Facility in Afghanistan During Operation Resolute Support

Introduction

Military trauma registries can identify broad epidemiological trends from neck wounds but cannot reliably demonstrate temporal casualty from clinical interventions or differentiate penetrating neck injuries (PNI) from those that do not breach platysma.

Materials and Methods

All casualties presenting with a neck wound to a Role 3 Medical Treatment Facility in Afghanistan between January 1, 2016 and September 15, 2019 were retrospectively identified using the Emergency Room database. These were matched to records from the Operating Room database, and computed tomography (CT) scans reviewed to determine damage to the neck region.

Results

During this period, 78 casualties presented to the Emergency Room with a neck wound. Forty-one casualties underwent surgery for a neck wound, all of whom had a CT scan. Of these, 35/41 (85%) were deep to platysma (PNI). Casualties with PNI underwent neck exploration in 71% of casualties (25/35), with 8/25 (32%) having surgical exploration at Role 2 where CT is not present. Exploration was more likely in Zones 1 and 2 (8/10, 80% and 18/22, 82%, respectively) compared to Zone 3 (2/8, 25%).

Conclusion

Hemodynamically unstable patients in Zones 1 and 2 generally underwent surgery before CT, confirming that the low threshold for exploration in such patients remains. Only 25% (2/8) of Zone 3 PNI were explored, with the high negative predictive value of CT angiography providing confidence that it was capable of excluding major injury in the majority of cases. No deaths from PNI that survived to treatment at Role 3 were identified, lending evidence to the current management protocols being utilized in Afghanistan.

Development of Novel Photosensitizer Using the Buddleja officinalis Extract for Head and Neck Cancer

Photodynamic therapy (PDT) is generally safer and less invasive than conventional strategies for head and neck cancer treatment. However, currently available photosensitizers have low selectivity for tumor cells, and the burden and side effects are so great that research is needed to develop safe photosensitizers. In this study, it was confirmed that the Buddleja officinalis (BO) extract, used in the treatment of inflammation and vascular diseases, shows fluorescence when activated by LED light, and, based on this, we aimed to develop a new photosensitive agent suitable for PDT. MTT, Diff-Quick® staining, and DCF-DA were performed to measure the effects of treating head and neck cancer cells with BO extract and 625 nm LED light (BO-PDT). Cell cycle, TUNEL, and western blot assays, as well as acridine orange staining, were performed to explore the mechanism of BO-PDT-induced cell death. We found that when the BO extract was irradiated with 625 nm LED light, it showed sufficient fluorescence and stronger intracellular toxicity and ROS effect than the currently commercially available hematoporphyrin. BO-PDT resulted in a decrease of mTOR activity that was correlated with an increase in the levels of ATG5, beclin-1, and LC3-II, which interfere with the formation of autophagosomes. In addition, BO-PDT induced the activation of PARP and led to an increase in the expression of proapoptotic protein Bax and a decrease in the expression of the antiapoptotic protein Bcl-2. Moreover, BO-PDT has been shown to induce the autophagy pathway 4 h after treatment, while apoptosis was induced 16 h after treatment. Finally, we confirmed that BO-PDT caused cell death of head and neck cancer cells via the intrinsic pathway. Therefore, we suggest that BO extract can be used as a new photosensitizer in PDT of head and neck cancer.

Management of High-Velocity Injuries of the Head and Neck

Trauma centers must prepare to manage high-velocity injuries resulting from a mass casualty incidents as global terrorism becomes a greater concern and an increasing risk. The most recent conflicts in Iraq and Afghanistan have significantly improved understanding of battlefield trauma and how to appropriately address these injures. This article applies combat surgery experience to civilian situations, outlines the physiology and kinetics of high-velocity injuries, and reviews applicable triage and management strategies.

Stab injury to the preauricular region with laceration of the external carotid artery without involvement of the facial nerve: a case report

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.

Experience of First Deployed Otolaryngology Team in Operation Iraqi Freedom: The Changing Face of Combat Injuries

OBJECTIVES: In September, 2004, an Air Force otolaryngology team was deployed to Iraq as a member of the multispecialty head and neck team, which had historically consisted of neurosurgery, ophthalmology, and oral surgery. We examined our operative and outpatient experience to determine if otolaryngology would be a critical component of this new head and neck team.

STUDY DESIGN AND SETTING: Between September 7, 2004, and January 22, 2005, we collected data on all otolaryngology operative procedures and outpatient visits at the Air Force Theater Hospital at Balad Air Base, Iraq.

RESULTS: One hundred fifty-nine patients underwent 257 operative procedures with the 3 most common procedures being complex facial laceration repair, tracheostomy, and neck exploration for penetrating neck trauma. In the otolaryngology clinic, we examined and treated 529 patients from throughout the Middle East.

CONCLUSIONS: The otolaryngology team proved to be a critical component of the Air Force multispecialty head and neck team.

EBM rating: C-4

Airway Management in Severe Combat Maxillofacial Trauma

OBJECTIVES

Airway stabilization is critical in combat maxillofacial injury as normal anatomical landmarks can be obscured. The study objective was to characterize the epidemiology of airway management in maxillofacial trauma.

STUDY DESIGN

Retrospective database analysis.

SETTING

Military treatment facilities in Iraq and Afghanistan and stateside tertiary care centers.

SUBJECTS

In total, 1345 military personnel with combat-related maxillofacial injuries sustained March 2004 to August 2010 were identified from the Expeditionary Medical Encounter Database using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes.

METHODS

Descriptive statistics, including basic demographics, injury severity, associated injuries, and airway interventions, were collected. A logistic regression was performed to determine factors associated with the need for tracheostomy.

RESULTS

A total of 239 severe maxillofacial injuries were identified. The most common mechanism of injury was improvised explosive devices (66%), followed by gunshot wounds (8%), mortars (5%), and landmines (4%). Of the subjects, 51.4% required intubation on their initial presentation. Of tracheostomies, 30.4% were performed on initial presentation. Of those who underwent bronchoscopy, 65.2% had airway inhalation injury. There was a significant relationship between the presence of head and neck burn and association with airway inhalation injury (P < .0001). There was also a significant relationship between the severity of facial injury and the need for intubation (P = .002), as well as the presence of maxillofacial fracture and the need for tracheostomy (P = .0001).

CONCLUSIONS

There is a high incidence of airway injury in combat maxillofacial trauma, which may be underestimated. Airway management in this population requires a high degree of suspicion and low threshold for airway stabilization.

[Embolization of carotid arteria branch in stanching of nasal bleeding]

BACKGROUND

Epistaxis is a common clinical problem, especially in otolaryngology. This disorder affects equally both genders. Most cases manifest as spontaneous nasal bleeding. It can also appear as a result of trauma, high blood pressure, Osler-Rendu-Weber disease. When the bleeding is massive it can be potentially life-threatening. A great majority of epistaxis can be treated conservatively, if not it sometimes requires endovascular treatment. It is specially reserved for extensive, dangerous epistaxis. Angiography with selective embolization has become an accepted method of treating epistaxis that is not controlled with conservative methods.

MATERIAL AND METHODS

Authors analyzed the efficacy of selective embolization treatment of epistaxis. 61 patients treated in the Department of Otolaryngology in Bialystok in years 1999-2011 were examined. There were 39 men and 22 women aged 24-48 years. Patients were referred for endovascular treatment when primary management was ineffective. Arteries suspected of bleeding were embolized superselectively.

RESULTS

Immediate, complete control of bleeding was achieved in 100% patients. After few hours recurrent nasal bleeding occurred in 4 (7%) patients who underwent successful reembolization. There were no severe complications after procedure. Nine patients experienced few days lasting mild headache which disappeared after medicament treatment. Five patients suffered from unaided removing facial oedema. Out of 61 patients, 56 were available for 12-month follow-up evaluation. No neurological or otolaryngological complications were certified. There was also no relapse of epistaxis.

CONCLUSIONS

Selective angiographic embolization is an effective method that should be considered in the treatment of refractory epistaxis. It is safe and not traumatic for patients.

Palliative embolization of hemorrhages in extensive head and neck tumors

Background:

A lot has changed in terms of intervention technique, indications and embolic agents since Duggan introduced embolization to management of postraumatic epistaxis in 1970.

Embolization is used in treatment of spontaneous and traumatic epistaxis, palliative tumors and vascular defects, as well as vascularized tumors and juvenile nasopharyngeal angiofibromas. The possibility of simultaneous visualization of pathology and implementation of therapy is one of its greatest advantages.

Material/Methods:

Authors analyzed the efficacy of selective embolization treatment of haemorrhage in advanced head and neck tumors. Seventy-six patients with such tumors treated at the Department of Otolaryngology in Bialystok between1999 and 2011 were examined.

Results:

Embolization of bleeding vessel within the tumor was effective (hemorrhage was stopped) in 65 patients (86%). Although the method is highly efficient, it is still associated with complications. Fourteen patients suffered from headaches that lasted for several days and six from face edema. Rebleeding was rare. Unfortunately, there was one case of hemiparesis.

Conclusions:

We conclude that superselective endovascular treatment deserves to be considered alongside standard options for the palliative or preoperative management of acute hemorrhage from advanced head and neck cancers.

Penetrating injury neck - An unusual presentation

In a patient presenting with a penetrating injury of the neck, the problems contemplated can be very many and life threatening as well. This case demonstrates an unusual presentation of only a simple rupture of the Sternocleidomastoid muscle sparing all the vital structures beneath it following the penetration of a metallic rod of approx. 1.5 cm diameter in the neck.

Penetrating Neck Trauma in Operation Iraqi Freedom

Objectives. To examine the surgical outcomes of penetrating neck trauma patients in Operation Iraqi Freedom (OIF) and compare treatment and perioperative survival to historical data with low-velocity penetrating neck trauma seen in a noncombat clinical setting.

Study Design. Case series with chart review.

Setting. Air Force Theater Hospital at Balad Air Base, Iraq.

Subjects and Methods. The surgical management of penetrating neck trauma by 6 otolaryngologists deployed over a 30-month period at the United States Air Force Theater Hospital in Balad, Iraq, was retrospectively reviewed. The presenting signs and symptoms, operative findings, and outcomes of patients who underwent neck exploration for high-velocity penetrating neck trauma were determined. A treatment algorithm defining the management of both high-velocity and low-velocity penetrating neck trauma is recommended.

Results. One hundred and twelve neck explorations for penetrating neck trauma were performed in OIF over 30 months. Ninety-eight percent of these neck injuries were due to high-velocity projectiles. In patients, zone 1 injuries occurred in 10%, zone 2 injuries in 77%, zone 3 injuries in 5%, combined zone 1/2 injuries in 5%, and combined zone 2/3 injuries in 3%. The positive exploration rate (patients with intraoperative findings necessitating surgical repair) was 69% (77/112). The mortality of patients undergoing neck exploration for high-velocity penetrating neck trauma was 3.7%.

Conclusions. The perioperative mortality and the positive exploration rate for high-velocity penetrating neck trauma by deployed surgeons in OIF are very comparable to those rates seen in civilian centers managing low-velocity penetrating neck trauma.

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

OBJECTIVE

The purpose of this study was to prospectively evaluate the utility of dynamic computed tomographic (CT) scanning as a diagnostic tool and adjunct to physical examination in the identification of surgically significant penetrating zone II neck injuries.

METHODS

All patients older than 14 years of age who suffered penetrating zone II neck injuries were eligible for entry into the study protocol at an urban Level I trauma center. All patients that presented with signs of surgically significant injury on physical examination underwent immediate neck exploration. Patients that did not show signs of surgically significant injury were entered into the study protocol and underwent soft tissue dynamic CT scan (1/2-cm cuts, 250-mL oral contrast) of the neck after initial resuscitation. After CT scan, all patients entered into the study protocol underwent esophagography. After completion of radiologic assessment, all study protocol patients underwent surgical exploration of the neck. The patient's surgical team was blinded to results of the CT scan and esophagography before and during surgical exploration of the neck.

RESULTS

During a 42-month period from May 1997 to March 2001, 42 patients were entered into the study protocol. Thirty-six (86%) of the injuries were secondary to stab wounds and the rest were caused by gunshot wounds. Surgical exploration revealed four esophageal injuries, of which two (50%) were missed by CT scan. Esophagography missed the identical esophageal injuries, as did CT scan. Both of the missed esophageal injuries were secondary to stab wounds. Seven internal jugular vein injuries were diagnosed intraoperatively, of which four (57%) were diagnosed by CT scan. During the study period, all patients with carotid artery and tracheal injuries were diagnosed by physical examination and thus underwent immediate surgical exploration without study entry.

CONCLUSION

Dynamic CT scan contributes minimally to the sensitivity of physical examination in the diagnosis of surgically significant penetrating zone II neck injury. Diagnosis of esophageal injuries with dynamic CT scan appears no better than esophagography. CT scan has greater sensitivity than physical examination for the diagnosis of jugular venous injuries; however, the majority of these injuries do not require identification or surgical intervention.

Continued experience with physical examination alone for evaluation and management of penetrating zone 2 neck injuries: results of 145 cases

PURPOSE

Our preliminary experience with physical examination alone in the evaluation of penetrating zone 2 neck injuries for vascular trauma was previously reported in 28 patients over a 2-year period (1991-1993). The purpose of the current study was to examine the results of this approach in a much larger group of patients over an 8-year period.

METHODS

The medical records for all patients admitted to our level I trauma center (all of them entered into our prospective protocol) between December 1991 and April 1999 with penetrating zone 2 neck trauma were reviewed for their initial presentation and any documented vascular injury.

RESULTS

A total of 145 patients made up the study group; in 30 of these patients, the penetrating trajectory also traversed zone 1 or 3. Thirty-one patients (21%) had hard signs of vascular injury (active bleeding, expanding hematoma, bruit/thrill, pulse deficit, central neurologic deficit) and were taken immediately to the operating room; 28 (90%) of these 30 patients had either major arterial or venous injuries requiring operative repair (the false-positive rate for physical examination thus being 10%). Of the 114 patients with no hard signs, 23 underwent arteriography because of proximity of the injury to the vertebral arteries or because the trajectory included another zone. Of these 23 arteriograms, three showed abnormalities, but only one required operative repair. This case had no complications relating to the initial delay. The remaining 91 patients with no hard signs were observed without imaging or surgery for a minimum of 23 hours, and none had any evidence of vascular injury during hospitalization or during the initial 2-week follow-up period (1/114; false-negative rate for physical examination, 0.9%).

CONCLUSIONS

This series confirms the earlier report indicating that patients with zone 2 penetrating neck wounds can be safely and accurately evaluated by physical examination alone to confirm or exclude vascular injury. The missed-injury rate is 0.7% (1/145) with this approach, which is comparable to arteriography in accuracy but less costly and noninvasive. Long-term follow-up is needed to confirm this management option.

Penetrating neck trauma

Penetrating neck trauma can pose significant diagnostic and therapeutic challenges for emergency physicians. Factors contributing to these problems are complex anatomy, proximity of vital structures, and potential for rapid deterioration of airway, vascular, or neurologic injuries. Other contributing factors are the lack of consensus in the literature regarding appropriate evaluation and management of penetrating neck injuries, and insufficient resources or experienced personnel at some institutions. This review focuses on the key components of the history and physical examinations that allow for an assessment of the severity and type of structures involved. In addition, current methods of airway management, as well as ways to manage penetrating neck trauma efficiently and cost effectively, are discussed.

Selective management of penetrating neck trauma based on cervical level of injury

BACKGROUND

Selective surgical exploration of penetrating neck wounds is now the standard of care, but the safety and cost effectiveness of selective diagnostic testing remains controversial. We herein review our 18-year prospective evaluation of a progressively selective approach.

PATIENTS AND METHODS

Since 1979, 312 patients sustained penetrating trauma to the anterior neck; 75% were stabbed and 24% were shot. Zone I was penetrated in 13%, zone II in 67%, and zone III in 20%.

RESULTS

In all, 105 (34%) of the patients had early exploration (16% were nontherapeutic). Of the 207 (66%) observed, 1 (0.5%) required delayed exploration. Length of stay was 8.0 days following exploration, 5.1 days following negative exploration, and 1.5 days following observation. In the last 6 years, 40% have had adjunctive testing: 69% of zone I, 15% of zone II, and 50% of zone III injuries.

CONCLUSION

Selective management of penetrating neck injuries is safe and does not mandate routine diagnostic testing for asymptomatic patients with injuries in zones II and III.

Complex problems in penetrating neck trauma

This article discusses the problems and controversies in the assessment of penetrating injuries of the neck. The role of physical examination and color-flow Doppler imaging in the initial assessment is highlighted. Complex injuries of major vessels, the aerodigestive tract, and the parotid are discussed and therapeutic options are presented.

Angiography and transcatheter arterial embolization of vascular injuries of the face and neck

The condition of patients sustaining penetrating neck trauma often appears deceptively stable, even when major structures have been injured. The clinician must identify patients who require treatment and limit invasive procedures in those without significant injuries. Angiography is often used to search for vascular damage following penetration of the neck and face. The charts of 401 hemodynamically stable patients with penetrating cervicofacial wounds who were evaluated by angiography followed, when necessary by either transcatheter arterial embolization and observation or surgery were reviewed. One hundred twelve patients (27.9%) had 131 vascular injuries identified by angiography; 77 (68.8%) of these patients sustained injuries to zone III of the neck or the face. The most commonly injured vessels were the internal carotid artery (ICA), the vertebral artery, and the external carotid artery (ECA) system. Multiple vessel injuries were seen in 17 (15.2%) of 112 patients and were more likely in patients with wounds in zone III or above than in those wounded in zone II or below (20.8% vs. 2.9%, respectively; P < .025). Injuries to the internal maxillary artery (IMA) (60%), ECA (53.3%), and the ICA (30.8%) were also significantly more likely to be accompanied by additional vascular injuries (P < .005). No clinically significant venous injuries were missed. Complications were noted in only 4 patients, and no deaths occurred as a result of angiography. Angiography is a safe, effective modality in the head and neck trauma setting. Particular scrutiny should be given to patients with zone III or facial wounds, particularly those with documented ICA, IMA, and ECA injuries, since these patients have a higher incidence of multiple vascular injuries.

Penetrating neck trauma in children: a reappraisal

The management of penetrating neck injuries in adults is controversial, with a trend toward selective neck exploration. These injuries are uncommon in children, and only limited information exists regarding their management. To assess the management of these injuries in the authors' geographic region, they reviewed the records of children with injuries penetrating the platysma muscle who were treated between 1980 and 1994. Forty-six children (aged 2 to 16 years) suffered a total of 55 penetrating neck injuries. The injuries were classified according to type and location. Fifty-two percent were caused by missiles, 30% by stab wounds, and 18% by dog bites. Fifty-eight percent of injuries were in zone II, 31% in zone I, and only 11% in zone III. The diagnostic workup, including arteriography, esophagography, or endoscopy, was performed preoperatively in 10 patients. Overall, 21 patients had exploration, and the rate of negative explorations was 48%. All cases explored for bleeding or a positive diagnostic workup result were found to have significant injury. On the other hand, all neck explorations performed solely because of injury to zone II were negative. The overall morbidity and mortality rates were 31% and 7%, respectively. A more selective approach, similar to that used for adult patients, emphasizing preoperative diagnostic evaluation, is recommended to decrease the rate of negative neck explorations among children.

The management of penetrating injuries of the anterior triangle of the neck

The management of penetrating injuries of the anterior triangle of the neck is controversial and poses several problems. A policy of mandatory neck exploration of these injuries is followed in the Department of General Surgery at the State Hospital, Windhoek. A retrospective study of patients presenting to one of the four surgical firms at The State Hospital was performed to see if this policy was justified. Twenty-seven patients were reviewed of which 25 presented acutely and two presented late with severe complications. The clinical and operative findings and the mortality rate of 7 per cent were similar to previous reports. The negative exploration of 30 per cent was less than previous reports of mandatory neck exploration for penetrating trauma. This may have been because exploration was limited to injuries involving the anterior triangle of the neck in this series. All 14 patients with positive clinical findings were found to have injuries at exploration and five of 13 patients (38 per cent) with no clinical signs were found to have injuries. Given these results and in the setting of The State Hospital it was felt that the policy of mandatory exploration was justified.

Clinical analysis of external laryngeal trauma

Thirty patients with external laryngeal trauma were analysed retrospectively. Injuries were mostly caused by motor vehicle accidents (car = 36.7 per cent; motorcycle = 23.3 per cent). The main presenting symptoms and signs were hoarseness, neck tenderness, dysphagia, and neck emphysema. Sites of laryngeal injury included arytenoid swelling, vocal fold injury, soft tissue contusion or superficial mucosal laceration, cricoarytenoid dislocation, thyroid fracture, epiglottic fracture and mixed injuries. Treatment was varied depending on the severity of the injuries. Sixteen cases were managed conservatively by medical treatment; two cases received intubation; four cases were treated initially by tracheostomy; eight cases received surgical repair and/or reconstruction; cases made a full recovery of the voice and 18 cases fair voice recovery due to either sustained vocal fold swelling or limitation of vocal fold movement. One case was graded as poor. Twenty-eight cases had good airway patency and two cases fair airway patency. A delay in the early detection of laryngeal trauma may precipitate into life-threatening airway problems, therefore prompt and accurate diagnosis should be followed immediately by skillful airway management.