Outline:
A. Penetration and Blunt Trauma to the Neck
B. Differential Diagnosis of Neck Masses
a. Inflammatory Neck Masses
b. Congenital Neck Masses
c. Primary Neoplasms of the Neck
d. Thyroid Neck Masses
i. Papillary
ii. Follicular
iii. Medullary
iv. Anaplastic
STAB INJURIES
VITAL STRUCTURES Single-entry vs multiple stab wounds
Air passages – trachea, larynx, pharynx, lungs Higher incidence of subclavian vessel laceration due to
Vascular – carotid, jugular, subclavian, innominate, aortic downward direction
arch Lower incidence of spinal injuries
Gastrointestinal - pharynx, esophagus
Neurologic – spinal cord, brachial plexus, peripheral nerves, IMMEDIATE SURGICAL EXPLORATION
cranial nerves Massive bleeding
Expanding hematoma
KINETIC ENERGY
Nonexpanding hematoma with hemodynamic instability
Kinetic energy affects magnitude of injury: Hemomediastinum
o KE = ½ M (V1 – V2)
Hemothorax
Hypovolemic shock
HANDGUNS
Projectile type
MANAGEMENT
Speed
“For the stable patient, the choice of management remains
o Handguns/pistols are low velocity (90-600 m/s)
controversial: either mandatory exploration for all penetrating
Caliber neck wounds or selective exploration with observation [and
o .44-caliber magnum is comparable to a rifle
monitoring]”
Yaw
o Tumbling bullet causes injury in a wider path NECK ZONES
RIFLE
Military bullets
o Jacket creates smoother flight, clean hole, through-
and-through wound
o High velocity (760 m/s) transmits energy waves
surrounding tissue
Hunting rifles with expanding bullets
o Soft-tips expand, create large wound cavity, may
not exit, may fragment
High mortality
SHOTGUNS ZONE I
Velocity ~ 300 m/s o Vascular structures are in close proximity to thorax
Distance o Protection by bony thorax and clavicle
o Pellets scatter at longer distances o Difficult to explore
Type of weapon o Median sternotomy for R injuries
o Sawed-off shotgun sprays the shot earlier o Left anterior thoracotomy for L injuries
Size of projectile (shot) o High mortality rate: 12%
o Birdshots (< 3.5 mm, 12m range) o Management:
o Buckshots (> 3.5 mm, 150m range). Comparable to Angiography if stable
handgun bullet wounds Mandatory exploration usually not
Wadding recommended
May consider barium swallow
ZONE III
o Protected by skeletal structures
o Difficult to explore; may need craniotomy for high
carotid injury
Lagmay, Nalupta, Quigao Schwartz, Cummings, Doc, 1 of 2
SURG 32: THYROID 3.6
o CN injuries may indicate great vessel injury preoperative arteriography on stable patients because their
o Management surgical approach is more difficult than zone II injuries.
Angiography if abnormal neurologic In addition, when wounds involve both sides of the neck with zone
exam in stable patient I and zone III injuries, four-vessel angiography (bilateral carotid
Frequent intraoral examination for and vertebral arteries) should be considered in stable but
edema/hematoma symptomatic patients.
ZONE II Approximately 30% of patients with carotid artery injury present
o Most common region injured (60-75%) with a neurologic deficit. Arterial injury or propagation of a
o Isolated venous and pharyngoesophageal injuries thrombus into the skull can lead to cerebral ischemia. One third of
are most commonly missed the population cannot tolerate complete unilateral carotid
o Management occlusion.
Admit for observation
Radiology and endoscopy if stable and MANAGEMENT OF PENETRATING ZONE II INJURY
no signs of major injury
INITIAL MANAGEMENT
Airway establishment
o Intubation
o Cricothyroidotomy
o Tracheostomy
Blood perfusion maintenance
o Large-bore IV
Clarification and classification of wound severity
Do not probe wound
Routine AP/lat neck and chest films
In the emergency department, satisfactory control of the
airway is established by intubation, cricothyroidotomy, or
tracheostomy. Direct transcervical tracheal intubation is safer Certain indications for an angiogram in zone II injuries
than oral or nasal intubation when the oral cavity, pharynx, or include a stable patient who has persistent hemorrhage or
larynx are traumatized and filled with blood. neurologic deficits compatible with adjacent vascular
In the setting of a gunshot wound, it may be difficult to fully structure damage. An example of this is a Horner’s syndrome
evaluate the cervical spine until the airway is controlled. indicative of sympathetic nerve plexus injury or hoarseness
Similarly, a tracheal tear may be exacerbated by extending indicating a recurrent laryngeal nerve injury. This neurologic
the neck, which distracts the proximal and distal segments. picture suggests that the carotid sheath has been violated,
and vascular integrity needs confirmation by angiography, as
MANAGEMENT OF PENETRATING INJURY well as frequent close observation to detect for a lacerated
*this part is lifted from Cumming’s Otolaryngology Head and Neck carotid artery, intimal tear, or pseudoaneurysm.
surgery which was Doc’s source for this part, I think, or so I believe
hehe.