Timely management of penetrating neck trauma: Report of three cases.

In head and neck surgery, penetrating neck injuries are uncommon. The neck contains many important structures, so such trauma can cause significant morbidity and mortality. A patient with penetrating neck trauma should be examined promptly in the emergency room. If possible, damaged tissue and organ fragments should be preserved carefully.

INTRODUCTION

The neck contains many important structures belonging to the vascular, respiratory, digestive, and neural systems, so penetrating neck trauma can cause significant morbidity and mortality.[12] The skeletal system does not protect the neck like it does other areas of the body.[3] The mortality rate was 11% in World War I, 7% in World War II, and 3-6% in civilians today.[45] The mechanism of penetration is important for understanding the extent of damage.[6] Gun or knife wounds are the most common causes of penetrating neck injuries: Stab wounds cause 1-2%, gunshot wounds 5-10% and rifles cause 50% of the deaths.[7] Prompt diagnosis and treatment are key to saving life. Major arterial and venous injuries are the most common causes of death.[8] Initially, these patients should be examined according to general trauma principles. A primary survey should be performed consisting of checking and treating the airway, breathing, and circulation. It is not easy to make a decision regarding neck exploration. With the current advances in diagnostic capabilities, contemporary management has changed with regard to penetrating neck injuries.[9] Selective management, i.e., observation and checking for major arterial and venous injury, is the most popular practice now for stable patients with penetrating neck trauma.[10] Saving patients’ lives is important, but saving the function of the larynx is also important, because people must eat, talk, and breathe. Therefore, to save the function of the larynx, it is important, if at all possible, to preserve damaged tissue and organ fragments.

CASE REPORTS

Case 1

A 20-year-old male was admitted to our emergency room in respiratory distress. He had been stabbed in the neck in a fight. A laceration in the submental area had been sutured at another hospital. After being followed for 1 hour in the first hospital, he was discharged. Subsequently, he developed swelling in the submental region and then progressively worsening respiratory distress. Indirect laryngoscopy showed a mass in the vallecula, and his vocal cords could not be seen clearly. There was an approximately 7-cm-long horizontal skin incision in the submental area. Neck ultrasonography showed a hematoma in the submental region. Under orotracheal general anesthesia, we opened the sutures and extended the incision by 1 cm at both ends. We drained the hematoma and saw that a branch of the lingual artery had been cut. We ligated the bleeding vessel and followed the incision to the right vallecula. On direct laryngoscopy, we saw a small laceration on the right anterior vallecula surface and no other pathology. We used a Hemovac tube for drainage. Then, we sutured the cut muscles, platysma, and cutaneous tissue on both sides. He was extubated without any problem and did not need a tracheotomy.

Case 2

A 53-year-old male was admitted to our emergency room with a laceration in the left neck. The laceration started in the sternocleidomastoid muscle, a third of the way anterior to the midpoint and continued to the anterior neck midline horizontally [Figure 1]. The injury occurred when he was being shaved by barber who had epilepsy and had a seizure while he was shaving him. When we examined the patient initially in the emergency room, he was not in respiratory distress. The flexible laryngoscopy examination was normal. His hemodynamic condition was stable. Doppler ultrasonography did not show any pathology of the vascular system. Under orotracheal intubation, we extended the wound at both ends by 1 cm. We saw that the lower third of the sternocleidomastoid muscle, thyrohyoid muscle, and omohyoid muscle had been cut horizontally. The anterior jugular vein was also cut. We stopped the bleeding with ligation and sutured the ends of the sternocleidomastoid, thyrohyoid, and omohyoid muscles together. We used a Hemovac tube for drainage. He was extubated without any problem and did not need a tracheotomy.

Figure 1

Case 2-Lateral view of neck laceration

Case 3

A 53-year-old male was admitted to our emergency room with a deep stab wound in his neck after attempting suicide. The wound started to the left of the medial head of the sternocleidomastoid muscle and continued horizontally to the right of the medial head of the right sternocleidomastoid [Figure 2]. The laceration was at the level of the lower third of the thyroid cartilage. The wound continued deep into the larynx. The thyroid cartilage was cut horizontally and away from the supraglottic region, and the damage continued to the hypopharynx and ended anterior to the prevertebral mucosa [Figure 3]. When initially examined in the emergency room, he was in moderate respiratory distress. There was no massive bleeding. His larynx was obviously badly damaged. Shortly after admission, he developed respiratory distress and started bleeding, preventing a radiological examination. We did not attempt orotracheal or nasotracheal intubation because of the badly damaged larynx. Under local anesthesia, we made a tracheotomy and then induced general anesthesia. Using his self-inflicted wound, when we dissected the neck, we saw that the thyroid ala, both laryngeal ventricles, and the lower third of the epiglottis were cut horizontally. The supraglottic and infraglottic regions were separated horizontally. We consulted a vascular surgeon in the operating room. The patient has no significant carotid or venous injuries, although there were some minor venous injuries. We reconstructed all of the damaged structures and sutured the sinus piriformis mucosa, epiglottis petiole, and thyroid cartilage alae. We used Prolene sutures to reconstruct the epiglottic and thyroid cartilages. After 5 days’ follow-up, he was transferred to the psychiatric ward. We closed his tracheotomy after 3 months. He has not had any voice, swallowing, or breathing problems since his tracheotomy was closed. There is some residual damage to the epiglottis on the right side [Figure 4].

Figure 2

Case 3-Anterior view of neck laceration

Figure 3

Case 3-After laceration it was seen that thyroid cartilage was cut horizontally and epiglottis and vocal cords were exposed

Figure 4

Case 3-Endoscopic view of larynx 3 months after surgery

We gave all patients second-generation antibiotics for surgical prophylaxis. After 5 days’ follow-up, the first and second patients were discharged without any complications.

DISCUSSION

Anatomically, the neck can be divided into three major zones for surgery: Zone 1, below the cricoids to the thoracic inlet; zone 2, from the cricoids to the angle of the mandible; and zone 3, above the angle of the mandible. Zone 2 injuries are the most common injuries.[11] If a neck laceration is limited to within the platysma muscle, serious morbidity is unlikely. All of our patients had lacerations in zone 2.

Although the skin laceration might be small, the damage can be extensive. Waseem and Gernsheimer reported a 16-year-old boy with a minimal laceration on the neck, but serious injuries to the larynx and esophagus.[12] In our study, all three patients’ neck lacerations reached the subplatysmal region.

In the initial assessment and management of any critically ill patient, maintaining the airway, breathing, and circulation (ABC) are the first steps.[13] All patients with neck lacerations should be examined for respiratory difficulty. A portable flexible laryngoscope might be helpful for examining a patient with a cut throat in the emergency room. We used a portable cold light machine with a flexible laryngoscope. If the patient has difficulty with respiration, orotracheal, or nasotracheal intubation should be tried first. The probability of success in airway management is further increased by the provision of equipment and skills for advanced airway management, including endotracheal intubation and cricothyroidotomy.[13] These are deemed essential at secondary- and tertiary-care hospitals. However, do not forget that an emergency tracheotomy could be needed. If there is a large laceration in the neck, the laryngeal structures appear to be badly damaged, and the patient is in worsening respiratory distress, do not attempt oral or nasal intubation, but perform an emergency tracheotomy. Our third patient required an emergency tracheotomy. The ATLS protocol must be followed in all cases.

The patient's hemodynamic system should be examined, and hemogram and coagulation parameters should be measured. The surgeon should be ready for a transfusion if necessary.

If a patient's vital signs are stable and the patient is not in hypovolemic shock or serious respiratory distress, the physical examination can be performed in the emergency room. However, any surgical treatment should be done in an appropriate operating room. Additionally, Doppler ultrasonography and computed tomography (CT) angiography are useful for detecting carotid and venous system injuries. In two patients, we used Doppler ultrasonography. As one patient needed an emergency tracheotomy, we did not have time for a radiological examination, but called a cardiovascular surgeon for a consultation in the operating room.

The indications for neck exploration with a neck laceration are continuing hemorrhage, serious respiratory distress, subcutaneous emphysema, a hematoma of the neck, hematemesis, hemoptysis, hoarseness, and stridor.[14] All three of our patients had hemorrhage, two had respiratory distress, and one had hemoptysis [Table 1].

Table 1

Clinical characteristics of the reported subjects

Our first patient was not followed sufficiently after treatment at the first hospital. Six hours later, he came to our emergency department in respiratory distress. Anyone with a neck laceration who needs surgical treatment should be followed for at least 24 hours after the operation before he or she is discharged. This could prevent morbidity caused by hemorrhage.

In our second case, we opted for orotracheal intubation because the patient was not in respiratory distress, his vital signs were normal, and we did not detect any damage to the larynx. His flexible indirect laryngoscopy examination was normal.

Our third case presented to our emergency department after attempting suicide. Attempted suicide by cutting the throat is rare.[1516] In a right-handed patient, the incision starts on the left side of the neck and continues to the right side.[151718] Usually, the wound is deeper on the left. Major depression is the most important cause of attempted suicide.[19]

Stone and Callahan reported that with vascular injury, the mortality rate of neck lacerations was 50%.[20] In our series, there were no deaths. With vascular injury, it is helpful to consult a vascular surgeon in the operating room.

With extensive laryngeal injury, it might be impossible to reconstruct the laryngeal structures. A total or partial laryngectomy or tracheal pull-up and re-anastomosis might be needed in some cases.[13] In our case, the patient's larynx was cut through in a horizontal line. We reconstructed all of the damaged structures, suturing the sinus piriformis mucosa, epiglottis petiole, and two thyroid cartilage alae. We closed the tracheotomy in 3 months. At the 6-month follow-up, there was no pathology on indirect laryngoscope other than a small defect in the right epiglottis surface. The patient's swallowing was normal, and he had no voice problem. Therefore, it is beneficial to reconstruct all of the laryngeal structures whenever possible, even when the laryngeal skeleton has been damaged seriously.

Lacerations in the pharyngo-esophageal region can be missed when the patient is first examined. A rigid or flexible laryngo-esophagoscope can be useful for evaluating these lacerations.[21] None of our patients had esophageal injuries. The esophagus is sheltered by the larynx cartilages and is not easily injured.

In one series of penetrating neck lacerations, 15% had vascular injuries, 10% had laryngotracheal injuries, and 7% had esophageal injuries.[22] In our small series, 66% had laryngeal injuries, 33% had minor vascular injuries, and 0% had esophageal injuries.

CONCLUSIONS

Penetrating neck injuries are life-threatening emergencies. The ATLS guidelines outline the initial management of neck trauma patients. Airway management is the first action, if the patient has no significant vascular injury. All patients who have penetrating neck trauma should be examined periodically for hematoma or edema of the neck. Voice quality and airway patency might be improved if laryngeal repair is performed within 24 hours of trauma. CT angiography should be performed for all neck penetration patients whose injuries penetrate the platysma. CT might be helpful for diagnosing laryngeal fractures in intubated patients. A patient who has a neck injury should be admitted and monitored for 24 hours after surgical treatment. This could prevent morbidity or mortality from hemorrhage or respiratory distress. If possible, the injured laryngeal tissues should be preserved and not sacrificed.