Penetrating injuries of the visceral compartment of the neck

A Throwing Knife Injury to the Neck: Management of a Unique Airway Situation

Penetrating neck injuries (PNIs) can present as a simple wound or can be complicated by a disruption of the airway or associated vasculature. As such, stabilization of the vasculature and the airway is paramount. Here we present a case in which a hemodynamically stable 28-year-old female presents with a PNI involving the oropharynx and laryngopharynx.

Predictors of dysphagia in critically injured patients with neck trauma

PURPOSE

Trauma patients admitted to the intensive care unit (ICU) are at heightened risk for oropharyngeal dysphagia and pulmonary aspiration. Timely and appropriate referrals for dysphagia may reduce mortality rates and hospital readmissions. This study sought to identify predictors of dysphagia in a large cohort of patients with multiple traumatic injuries.

METHODS

The Trauma Registry Database was queried for admissions at a level 1 trauma center from 2012 to 2016 who underwent instrumental swallowing evaluations. Relevant demographics, injuries, and interventions known to be associated with dysphagia were collected. The Dysphagia Outcome and Severity Scale (DOSS) was utilized to define severity of dysphagia. Regression analyses were performed to identify predictors of dysphagia.

RESULTS

Two hundred and sixty two patients met criteria. Multivariate analyses found injury severity (p<0.01), tracheostomy (p<0.05), TBI (p<0.05), and cervical spinal bracing (p<0.001) to be predictors of dysphagia development. Furthermore, length of ICU stay (p<0.01) and cervical spinal bracing (p<0.01) were associated with a greater severity of dysphagia.

CONCLUSIONS

Oropharyngeal dysphagia is a common complication in trauma patients. Our results propose a set of predictors that should be considered when identifying critically injured patients at risk for dysphagia.

Cut throat injuries at a university teaching hospital in northwestern Tanzania: a review of 98 cases

Background

Cut throat injuries though rarely reported in literature pose a great therapeutic challenge because multiple vital structures are vulnerable to injuries in the small, confined unprotected area. A sudden increase in the number of cut throat patients in our centre in recent years prompted the authors to analyze this problem. This study was conducted in our local setting to describe the etiology, patterns and treatment outcome of these injuries.

Methods

This was a combined retrospective and prospective study of cut throat injury patients who were managed at Bugando Medical Centre between February 2009 and January 2013. Statistical data analysis was done using SPSS software version 17.0.

Results

A total of 98 patients with cut throat injuries were studied. Males outnumbered females by a ratio of 2.4: 1. The median age of patients was 26 years (range 8 to 78 years). Majority of patients (79.6%) had no employment and most of them (65.3%) came from rural community. Homicide was the commonest (55.1%) cause, followed by suicidal attempts (34.7%) and accidental (10.2%) injuries. Interpersonal conflict (24.4%) was the most common motivating factor for homicidal injury whereas psychiatric illness (16.2%) and road traffic accidents (9.2%) were the most frequent motivating factors of suicidal attempt and accidental injuries respectively. The majority of injuries were in Zone II accounting for 65.3% of cases and most of them had laryngeal (57.1%) injury. Surgical debridement, laryngeal/hypopharynx repair and tracheostomy were the most common surgical procedures performed in 93.9%, 73.5% and 70.4% of patients respectively. Postoperative complication rate was 57.1%, the commonest being surgical site infections in 28.1% of patients and it was significantly associated with late presentation and anatomical zones (P < 0.001). The overall median duration of hospitalization was 12 days. Patients who had postoperative complications stayed longer in the hospital and this was statistically significant (p = 0.011). Mortality rate was 11.2% and was significantly associated with co-morbidities, delayed presentation and presence of complications (p < 0.001). The follow up of patients was poor.

Conclusions

Cut throat injuries are a major cause of morbidity and mortality among young adult males in our setting. Addressing the root causes of violence such as poverty, unemployment, and substance abuse will reduce the incidence of these injuries in our environment.

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.

Unstable cervical spine fracture after penetrating neck injury: a rare entity in an analysis of 1,069 patients

BACKGROUND

The value of cervical spine immobilization after penetrating trauma to the neck is the subject of lively debate. The purpose of this study was to review the epidemiology of unstable cervical spine injuries (CSI) after penetrating neck trauma in a large cohort of patients.

METHODS

This is a retrospective analysis of patients admitted with penetrating neck injuries to a Level I trauma center from January 1996 through December 2008. A penetrating neck injury was defined as a gunshot wound (GSW) or stab wound (SW) between the clavicles and the base of the skull. Univariate and multivariate analyses were performed to investigate associations between injury mechanisms, the presence of CSI instability, and mortality. Risk factors independently associated with the presence of a CSI were identified.

RESULTS

A total of 1,069 patients met inclusion criteria, of which 463 patients (43.3%) and 606 patients (56.7%) were sustaining GSW and SW, respectively. Overall, 65 patients (6.1%) were diagnosed with a CSI with a significantly higher incidence after GSWs compared with SWs (12.1% vs. 1.5%; p < 0.001). In four patients (0.4%), the CSI was considered unstable, all of them following GSW. All patients with unstable CSI had obvious neurologic deficits or altered mental status at the time of admission. Risk factors independently associated with the presence of a CSI were GSW to the neck and a Glasgow Coma Scale score ≤8 on admission (R = 0.16).

CONCLUSION

The overall incidence of unstable CSI after penetrating trauma to the neck is exceedingly low at 0.4%. Following GSW to the neck, an unstable CSI was noted in <1% of patients. After cervical SW, however, no spinal instability was noted precluding the need for spinal precautions in these instances.

Upper airway injury and its management

Injuries to the upper airways are rare, but carry a significant morbidity and mortality. The degree of injury and presentation varies; thus recognition often requires a high index of suspicion based on mechanism. Effective management of laryngotracheal injuries begins with immediate control of the airway whether by orotracheal and surgical route. Definitive management of upper airway injuries relies on an understanding of the anatomy of the larynx, trachea and surrounding structures. Associated injuries are common and must be addressed concomitantly. Postoperative complications are frequent, requiring perioperative vigilance and long-term follow-up to ensure best outcome.

Imaging of Traumatic Neurovascular Injury

Traumatic injury to the major vessels of the head and neck can result in potentially devastating neurologic sequelae. Until recently, conventional angiography was the primary imaging modality used to evaluate these often challenging patients. Advances in cross-sectional imaging have improved the ability to screen for these lesions, which have been found to be more common than previously thought; however, accepted protocols of imaging evaluation have not yet been fully established. This article presents a general approach to the patient with suspected neurovascular injury. This includes a discussion of the histopathologic spectrum, clinical presentation, mechanisms, radiologic work-up, pertinent issues of the most common lesions, and some of the endovascular techniques used in their management.

Redefining the role of arterial imaging in the management of penetrating zone 3 neck injuries

The purpose of this study was to assess the role of arteriography (AG) in the diagnosis and treatment of vascular trauma in patients with zone 3 penetrating neck injuries. The records of all cases of penetrating neck trauma for the past 14 years at a level 1 trauma center were reviewed retrospectively. Eight hundred forty-four penetrating neck injuries were documented, of which 72 (8.5%) traversed zone 3 of the neck (gunshot, 35; stab, 32; shotgun, 5). Twenty patients (27%) had hard signs of vascular injury (hemorrhage, expanding hematoma, bruit, thrill, neurologic deficit). Twelve of these (60%) underwent immediate exploration, 1 had no significant injury, and 11 had successful surgical repair or ligation of the vascular injury. AG in the other eight patients with hard signs revealed injuries requiring embolization (three patients), urokinase infusion (one patient), and observation (three patients) and one normal examination. Fifty-two patients had no hard signs of vascular injury. Twenty-four of these underwent AG, of which 18 were negative. Positive findings included internal carotid artery narrowings (two patients), external compression of the internal carotid artery (one patient), vertebral artery intimal flap (one patient), and nonbleeding injuries to small, noncritical arteries (two patients), none of which required treatment. Twenty-four of the remaining 28 patients were observed clinically, and 4 patients had negative explorations. Nine patients had ultrasonography performed, but these examinations did not yield any useful information. The absence of hard signs reliably excludes surgically significant vascular injuries in penetrating zone 3 neck trauma, suggesting that AG is not necessary. Hard signs in stable patients should mandate AG because these vascular injuries may be amenable to endovascular therapy.

Factors affecting outcome in penetrating oesophageal trauma

Background

Penetrating oesophageal trauma is rare and the risk factors affecting outcome have not been clearly identified. Delayed management has been cited as a factor contributing to the high rates of morbidity and mortality, but evidence for this is lacking.

Methods

A retrospective study was undertaken of patients with penetrating oesophageal trauma presenting to a level I trauma centre over 8 years. Outcome was assessed in terms of mortality, morbidity (oesophageal and non-oesophageal), and length of hospital and intensive care unit (ICU) stays.

Results

Fifty-two patients with oesophageal injury who reached the operating theatre were included. The overall mortality rate was 6 per cent. Fifteen patients (29 per cent) developed oesophageal injury-related complications. Time from injury to management was the only important risk factor for the development of oesophageal complications (P = 0·001), but did not affect the length of ICU (P = 0·560) or hospital (P = 0·329) stay, incidence of non-oesophageal injury-related complications (P = 0·963) or death (P = 0·937). Patients with gunshot injuries spent longer in the ICU (P = 0·007) and the duration of hospital stay was longer for those with higher-grade oesophageal injuries (P = 0·025).

Conclusion

The risk of oesophageal injury-related complications was directly related to the interval between the trauma and definitive management of the oesophageal injury.

Laryngotracheal Injuries: Does Injury Mechanism Matter?

Laryngotracheal injuries are potentially lethal injuries whose diagnosis can be difficult. The purpose of this study was to delineate the effect of injury mechanism on the types of injury sustained and patient outcome. Patient records during a 7-year period were reviewed for injury mechanism, patient demographics, clinical presentation, patient evaluation, injury location, associated injuries, operative interventions, and outcome. Fifteen patients with laryngotracheal injuries were studied. Blunt injuries were more common (60%). Patient demographics, mortality, average length of stay, and Injury Severity Score were similar for both groups. Prevalent physical findings on examination included subcutaneous air (53%), hoarseness (47%), stridor (20%), and neck tenderness (27%). Diagnosis was confirmed by CT scan of the neck (66% blunt, 33% penetrating) or bronchoscopy (44% blunt, 66% penetrating). Injury location, patient disposition, and associated injures were the same for both groups. The most frequent operative intervention performed for both groups consisted of a primary airway repair via a collar incision within 8 hours of injury. Only patients with a laryngeal injury required concomitant tracheostomy regardless of mechanism. Blunt and penetrating neck injuries resulted in similar types of tracheal and laryngeal injuries. Anatomic location of the injury determined the need for tracheostomy. Regardless of mechanism, the overall outcome for patients with laryngotracheal injuries is good when injuries are recognized and treated expeditiously. A high level of suspicion must be maintained when evaluating all potential laryngotracheal injury patients irrespective of the mechanism of injury.