2. Background
Few emergencies pose as great a challenge
as neck trauma. Because a multitude of organ
systems (eg, airway, vascular, neurological,
gastrointestinal) are compressed into a
compact conduit, a single penetrating wound
is capable of considerable harm.
Airway occlusion and exsanguinating
hemorrhage pose the most immediate risks to
life. From the time when Ambroise Pare
successfully treated a neck injury in 1552,
debate has continued about the best
approach for particular neck wounds
3. Neck trauma accounts for 5-10% of all serious
traumatic injuries. Approximately 3500 people die
every year from neck trauma secondary to hanging,
suicide, and accidents.
Initially missed cervical injuries secondary to neck
trauma result in a mortality rate of greater than 15%.
10% of neck wounds lead to respiratory compromise.
Loss of the airway patency may occur precipitously,
resulting in mortality rates as high as 33%.
Zone I injuries are associated with the highest
morbidity and mortality rates.
Sex-Trauma is more common among males than
among females.
Age-Most people who experience neck trauma are
adolescents and young adults.
4. PATHOPHYSIOLOGY
A clear understanding of the
anatomic relationships within
the neck and the mechanisms
of injury is critical to devising a
rational diagnostic and
therapeutic strategy.
5. ANATOMY
Think: vessels, airway, esophagus, spine, spinal cord, nerves,
ducts
Superficial fascia: covers the platysma just below the skin
Platysma: b/w the superficial and the deep fascia; violation
increases risk of damage
Deep Fascia
Investing layer: surrounds neck and splits to encase the SCM
and trapeziuz
Pretracheal layer: adheres to cricoid and thyroid cartilage and
travels behind the sternum to attach to the pericardium:
PRETRACHEAL LAYER IS THE REASON THE NECK
CONNECTS TO THE MEDIASTINUM
Prevertebral: envelops the cervical and prevertebral muscles
and extends to form the axillary sheath Carotid sheath
Formed by components of all three layers
6. STRUCTURES AT RISK
With the neck protected by the spine
posteriorly, the head superiorly, and the
chest inferiorly, the anterior and lateral
regions are most exposed to injury.
The larynx and trachea are situated
anteriorly and are therefore readily exposed
to harm.
The spinal cord lies posteriorly, cushioned
by the vertebral bodies, muscles, and
ligaments.
The esophagus and the major blood
7.
8. •Musculoskeletal structures at risk include
the vertebral bodies; cervical muscles,
tendons, and ligaments; clavicles; first and
second ribs; and hyoid bone.
•Neural structures at risk include the spinal
cord, phrenic nerve, brachial plexus,
recurrent laryngeal nerve, cranial nerves
(specifically IX-XII), and stellate ganglion.
•Vascular structures at risk include the
carotid (common, internal, external) and
vertebral arteries and the vertebral,
brachiocephalic, and jugular (internal and
9. •Visceral structures at risk include the
thoracic duct, esophagus and pharynx,
and larynx and trachea.
•Glandular structures at risk include
the thyroid, parathyroid, submandibular,
and parotid glands.
•Associated structures at risk of
intrathoracic injuries include the
esophagus, tracheobronchial tree, lung,
heart, and great vessels.
10. Zone Classification
Anatomy classification is excellent for
describing the static location of
structures
Injury is not static, and an injury to the
neck may enter the anterior triangle
and then pass through the posterior
triangle.
A more useful classification of neck
anatomy for trauma is the Zone
classification developed by Roon and
11. This classification system can guide
the clinician in the diagnostic and
therapeutic management
Based on level of injury to the neck in
a caudal to cranial orientation
Zone 1:
Lower Border = Clavicles
Upper Border = Cricoid Cartilage
13. Zones of the Neck
.
Zone I: Thoracic inlet to
Cricoid cartilage
Zone II: Cricoid
cartilage to the Angle
of mandible
Zone III: Angle of the
mandible to skull base
16. Zone I the base of the neck, is
demarcated by the thoracic inlet
inferiorly and the cricoid cartilage
superiorly.
Zone II encompasses the midportion
of the neck and the region from the
cricoid cartilage to the angle of the
mandible.
Zone III characterizes the superior
aspect of the neck and is bounded by
the angle of the mandible and the
17. Zone I
Zone I Structures
◦ Vertebral arteries
◦ Proximal carotid arteries
◦ Major thoracic vessels
◦ Superior Mediastinum
◦ Lungs, trachea
◦ Esophagus
◦ Spinal cord
◦ Cervical nerve roots
◦ Signs of a significant injury in the zone I
region may be hidden from inspection of the
chest or the mediastinum
18. Zone I
From the clavicles to
the cricoid
Trachea
Lungs
Proximal carotid and
vertebral arteries
Jugular veins
Thoracic Vessels
Esophagus
Superior
Mediastinum
Thoracic Duct
Spinal Cord
Brachial Plexus
19. Zone I
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Mysteriouskyn (Wikipedia)
Zone 1
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Advanced Emergency Trauma Course
21. Zone II
From cricoid to angle of mandible
Trachea
Larynx
Carotid and vertebral aa.
Jugular Vein
Esophagus
Spinal Cord
22. Important structures in this region
include the carotid and vertebral
arteries,
jugular veins, pharynx, larynx, trachea,
esophagus, and cervical spine and
spinal cord.
Zone II injuries are likely to be the
most apparent on inspection and tend
not to be occult.
Additionally, most carotid artery injuries
are associated with zone II injuries
24. Zone III
Angle of mandible to base of skull
Distal carotid and vertebral arteries
Pharynx
Spinal cord
25. Diverse structures, such as the
salivary and parotid glands,
esophagus,
trachea, vertebral bodies, carotid
arteries,
jugular veins, and major nerves
(including cranial nerves IX-XII),
traverse this zone.
Injuries in zone III can prove difficult
to access surgically.
26. Zone III
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Zone 3
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27. ZONE CONTENTS COMMENTS
ZONE I Common carotid
Vertebral artery
Subclavian artery
Mediastinal major vessels
Apices of lungs
Esophagus
Tracheal
Thyroid
Thoracic duct
Spinal cord
Thoracic outlet thus neck AND
mediastinal structures
Difficult to apply pressure to
vascular
injuries thus more difficult to
examine
Difficult to examine for subtle
injuries
Difficult access to explore in OR
thus more likely to image before
OR
ZONE II Carotid and vertebral arteries
Larynx and tracheal
Esophagus and pharynx ,Jugular
vein
Vagus and recurrent
laryngeal n. ,spinal cord
Easier to apply pressure to
bleeders
Easier to locally explore in ED
Easier to examine in ED
Easier to explore in OR
MORE likely to investigate/operate
only if signs of significant injury
ZONE II Carotid and vertebrals
Distal jugular vein
Salivary and parotid glands
CN 9,10,11,12 Spinal cord
More difficult to examine
More likely to explore in OR
28. Signs of laryngeal or tracheal
injury
Voice alteration
Hemoptysis
Stridor
Drooling
Sucking, hissing, or air frothing or bubbling through the
neck wound
Subcutaneous emphysema and/or crepitus
Hoarseness
Dyspnea
Distortion of the normal anatomic appearance
Pain on palpation or with coughing or swallowing
Pain with tongue movement
Crepitus: Noteworthy in only one third of cases
29. Signs of esophageal and
pharyngeal injury
Dysphagia
Bloody saliva
Sucking neck wound
Bloody nasogastric aspirate
Pain and tenderness in the neck
Resistance of neck with passive motion
testing
Crepitus
Bleeding from the mouth or nasogastric
tube
30. Signs of carotid artery injury
Decreased level of consciousness
Contralateral hemiparesis
Hemorrhage
Hematoma
Dyspnea secondary to compression of the
trachea
Thrill
Bruit
Pulse deficit
31. Signs of jugular vein injury
These include hematoma,
external hemorrhage,
hypotension
32. Signs of spinal cord or brachial
plexus injury
Diminished upper arm capacity
Quadriplegia
Pathologic reflexes
Brown-Séquard syndrome
Priapism and loss of the bulbocavernous reflex
Poor rectal tone
Urinary retention, fecal incontinence, and
paralytic ileus
Horner syndrome
Neurogenic shock
Hypoxia and hypoventilation
33. Signs of cranial nerve injury
Facial nerve (cranial nerve VII): Drooping of the
corner of the mouth
Glossopharyngeal nerve (cranial nerve IX):
Dysphagia (altered gag reflex)
Vagus nerve (cranial nerve X, recurrent
laryngeal): Hoarseness (weak voice)
Spinal accessory nerve (cranial nerve XI):
Inability to shrug a shoulder and to laterally
rotate the chin to the opposite shoulder
Hypoglossal nerve (cranial nerve XII): Deviation
of the tongue with protrusion
35. Diagnosis
Imaging studies
In addition to cervical and chest radiography, the
following supplementary tests may be useful:
Computed tomography (CT) scanning
Magnetic resonance imaging (MRI)
Color flow Doppler ultrasonography
Contrast studies of the esophagus
Interventional angiography
Endoscopy--Laryngoscopy, bronchoscopy,
pharyngoscopy, and esophagoscopy may be useful in
the assessment of the aerodigestive tract. Rigid
endoscopes are superior to flexible scopes.
36. General Indications for Angiography
(assuming patient not unstable)
•Hematoma
• Vascular bruit/thrill
• Decreased pulse in upper extremity
• Signs of CVA
General Indications for TRIPLE SCOPE
• Hematemesis
• Hemoptysis
• Chest tube air leak
• Subcutanoues or mediastinal air
• Oropharyngeal blood
37. Rosen’s signs of injury
SOFT signs HARD signs
Hemoptysis/hematemesi
s
Oropharyngeal bleeding
Dyspnea
Dyphonia/dysphagia
SubQ or mediastinal air
Chest tube air leak
Nonexpanding
hematoma
Expanding hematoma
Severe active bleeding
Shock unresponsive to
fluids
Decreased/absent radial
pulses
Vascular bruits/thrills
Cerebral ischemia
Airway obstruction
38. Goals of the Guideline
Management of penetrating injuries to zone II of the
neck that penetrate the platysma.
1. Is mandatory operative management or selective
operative
management appropriate?
2. Can duplex ultrasonography (US) or CT angiography
rule
out an arterial injury in patients with no hard signs of
vascular injury on physical examination, thereby making
arteriography unnecessary?
3. Are both contrast studies (barium or gastrograffin
swallow)
and esophagoscopy needed to safely rule out esophageal
39. Mandatory versus Elective
Exploration
Immediately life threatening: massive
bleeding, expanding hematoma,
hemodynamic instability,
hemomediastinum, hemothorax, and
hypovolemic shock.Immediate surgical
exploration
Hemodynamically stable ,non–life-
threatening features can undergo thorough
imaging investigations to determine the
extent of injury.
40. Initial Management
Initial Management is the same as all trauma
cases
A : airway with C-spine control
B : breathing and ventilation
C : circulation
D : disability and neurologic status
E : exposure and evaluation other injury
41. Airway
◦ Securing the airway should be
considered if the patient is going to be
leaving your supervised area
◦ Endotracheal intubation using rapid
sequence technique is the first choice
◦ Cricothyrodotomy is second line
treatment when intubation is not
successful
◦ Care should be taken to when intubating
to avoid an injured trachea
42. • Patients with acute respiratory distress need a
definitive and secure airway
• In neck trauma there is sometimes a debate as to
when to intervene
Multiple blind intubation attempts will
risk enlarging a lacerated piriform sinus
wound and extending it iatrogenically
into the mediastinum.
• Blood and air from facial and neck injuries can
distort the normal anatomic appearance and
increase the difficulty of intubation
• Tracheal tear may be exacerbated by extending the
neck.
43. Breathing
◦ All patients should receive high-flow oxygen
◦ Based on the zone and the proximity to the
thoracic inlet, there could be simultaneous
injury to the thorax
◦ If you notice any difficulty ventilating then
suspect either upper airway injury or thorax
◦ Evaluate for asymmetric breath sounds
◦ Consider tension pneumothorax if there is
evidence of tracheal deviation
44. Circulation
◦ Active bleeding should be addressed
immediately by direct point pressure
◦ Do not clamp bleeding vessels
because you could cause further
ischemia
◦ Avoid placing IV access where the
flow would head towards the injured
area.
Extravasation could create more
distortion and compression
45. Disability
◦ Examine and inspect for evidence of
focal neurological deficit
◦ This could suggest direct nerve
injury, or spinal cord injury or
vascular injury leading to ischemia
46. Zone 1 injury
Below cricoid, dangerous
area
Protect zone bony thorax
and clavicle
Motality rate 12 %
◦ Potential for injury to great
vessel and mediastinum
Mandatory exploration : not
recommend
Angiography and esophageal
evaluation: usually suggest
◦ > 1/3 no symptom at
presentation
47. Zone 1 injury
Esophageal evaluation
endoscopy , contrast
esophagogram
◦ Contrast medium
Barium- based
Gastrografin ( meglumine diatrizoate)
◦ Combination tests should not miss an
njury
CT scan
◦ Determine the path of projectile
48. Zone 2 injury
Largest zone,most common site of
trauma 60-75%
Between angle of mandible & inf
border of cricoid cartilage
Isolate venous injury &
pharyngoesophageal injury most
common structure missed clinically
All pt. are admitted for observation
and 24 hr re-evaluation
50% of death hemorrhage from
vascular structure
49. Indications for Immediate
Surgery after Penetrating Neck
Trauma Shock
Pulsatile bleeding
Expanding hematoma
Unilateral extremity pulse deficit
Audible bruit or palpable thrill
Airway compromise
Wound bubbling
Extensive subcutaneous emphysema
Stridor
Hoarseness
Signs of stroke/cerebral ischemia
51. Zone II Injury
Operative management of GSW to carotid artery
Trauma.org
52. Zone 2 injury
Symptomatic neck exploration
Asymptomatic
◦ Directed evaluation and serial exam
Arteriography,
Laryngotraheoscopy
flexible esophagoscopy
barium swallow
Requires adequate physician ,24 hr facility
prepared for emergency testing and Surgery
53.
54.
55. Angiography
: Zone1 & 3
Routine preoperative arteriography in
stable case
Surgical approach is more difficult than
zone 2
If wound involve both side of neck (
stable but symptomatic) four vessel
angiography
57. Angiography
: Zone2
Easy accessible,low risk for exploration
Certain indication for an angiogram in zone 2
◦ Stable pt. who has persistent hemorrhage
◦ Neurodeficit compatible with adjacent vascular structure
damage eg. Horner’s syndrome , hoarseness
Need exploration
◦ Positive arteriography
◦ Negative arteriography but positive clinical sign
Asymptomatic in zone 2
◦ Controversy,
No sig difference btw. Clinical exam & angiography
◦ CTA fast ,minimal invasive in hemostatic stable
58. CT ANGIOGRAPHY
Advantages
•Superior image
quality
•Readily available,
quick
•Limited
interuservariability
•Safe
•Shows surrounding
structures
laryngeal injuries and
a stable patent airway
Limitations
Poor timing of contrast
load
Patient movement
Metallic artifact
Body habitus
Not therapeutic
59. Technique of vascular repair
End to end or autogenous graft
reccomended when stenosis is
evident by arteriography
Ligation of common or internal
carotid a.reserved for
irreparable injury and in pt, who
are in a profound coma state
Delayed complication from
unrepaired vascular injury
◦ Aneurysm formation
◦ Dissecting aneurysm
◦ AV fistulas
60. Pharynx and esophageal
injury
Clinical sign and symptom neck exploration
◦ subcutaneous emphysema
◦ Hematemesis
◦ Hypopharyngeal blood
>50%of Pt. asymptomatic at presentation
Combination of esophagoscopy and contrast
esophagography
◦ Most sensitive for detected injury
Delayed explore & repair beyond 24 hrs after
injury poorer outcome
62. Digestive tract evaluation
Flexible esophagoscopy
◦ Missed perforation :
cricopharyngeus, hypopharynx
◦ Negative endoscopy but air
leak in soft tissue
mandatory neck explore
Infiltrate methylene blue : localize
injury size
Combination of flexible and
rigid endoscopy
◦ Exam entire cervial and upper
esophagus
◦ No perforation missed
63. Digestive tract evaluation
Suspicious pharyngeal perforation
◦ NPO for several days
◦ S&S : fever , tachycardia,widening of
mediastinum
Repeat endoscopy or neck exploration
◦ Esophageal injury in the early phase
Two layer closure with wound irrigation
Debridement
Adequate drainage
◦ Extensive esophageal injury lateral
cervical esophagostomy
64. Penetrating of hypopharynx
Superior to the level of arytenoid
cartilage
◦ IV ABO
◦ NPO ทางปาก 5-7 days
◦ Primary closure not always necessary
Inferior to the level of arytenoid
cartilage
◦ Dependent portion
◦ Exploration with primary watertight
closure
◦ Use absorbable suture with drainage of
adjacent neck space
◦ NPO 5-7 days
◦ Treat liked esophageal injury
65. Treatment
Conservative
◦ Medical therapy
Adequate ventilation & oxygenation
Fluid resuscitation
Monitor neurolodic status
Pain control
ABO
Tetanus prophylaxis
66. Treatment
Surgical approach
◦ Zone 1
Median sternotomy
Thoracotomy
◦ Zone 2
Collar incision
Apron incision
◦ Zone 3
Consult neuroSx
67. Blunt neck trauma
motor vehicle accidents and sports
result in laryngeal, vascular, and
digestive injury
easily underdiagnosed because their
onset can be delayed
occult cervical spine injury
Strangulation
Blows from fists or feet
Excessive manipulation
68. Blunt Neck Trauma
Blunt trauma to the neck is less
frequent in occurrence
Mechanism is often related to motor
vehicle collisions
◦ Hyperextension
◦ Rotation
◦ Hyper flexion
◦ Direct blows against a non mobile object
(most commonly seatbelts)
69. Laryngotracheal Injury
Signs and symptoms:
◦ Difficulty swallowing
◦ Pain with swallowing
◦ Difficulty breathing (feeling breathless)
◦ Hoarseness of voice (or change in voice)
◦ Subcutaneous emphysema
◦ Tracheal deviation
However signs and symptoms may be
absent even with a major injury
70. Common to all traumatic mechanisms is the
direct transfer of severe forces to the larynx.
These forces have the potential to produce
many devastating injuries, including mucosal
tears, dislocations, and fractures.
Edema, hematoma, cartilage necrosis, voice
alteration, cord paralysis, aspiration, and airway
loss may accompany these injuries.
Common signs of laryngeal injury include
stridor, subcutaneous emphysema, hemoptysis,
hematoma, ecchymosis, laryngeal tenderness,
vocal cord immobility, loss of anatomical
landmarks, and bony crepitus.
72. Anterior neck bruise (see arrow)
in a middle-aged woman
involved in a motor vehicle
73. CT scan (A) revealing a paramedian fracture (see arrow) from an acute blunt laryngeal
trauma . This young man presented 1 week after being struck on the left side of the neck
with a hockey stick. Note that the 3D reconstruction (B) provides valuable information as
to the shape of the fracture and demonstrates that the anterior commissure has been
displaced
74. Laryngeal injuries vary by
anatomical location
Supraglottis: Traumatic forces commonly
produce horizontal fractures of the
thyroid alae and disruption of the
hyoepiglottic ligament with subsequent
superior and posterior displacement of
the epiglottis.
Repositioning of the epiglottis may result
in the creation of a false lumen anterior
to the epiglottis. This lumen may tunnel
into the larynx or pass anterior to the
thyroid cartilage and cause cervical
75. Glottis: Traumatic force results in cruciate
fractures of the thyroid cartilage near the
attachment of the true vocal cords.
Subglottis: Crushing forces to the cricoid
cartilage cause injury to the cricothyroid joint
and may result in bilateral vocal cord paralysis
from recurrent laryngeal nerve damage.
Hyoid bone: Found more commonly in women,
hyoid fractures tend to occur in the central part
of the hyoid bone because of the inherent
strength of the cornua.
76. Cricoarytenoid joint: Traumatic forces that
displace the thyroid alae medially or cause
compression of the larynx against the cervical
vertebrae often result in cricoarytenoid
dislocation. This injury generally occurs
unilaterally.
Cricothyroid joint: Injury occurs when traumatic
forces to the anterior portion of the neck cause
the inferior cornu of the thyroid cartilage to be
displaced posterior to the cricoid cartilage. This
dislocation limits cricothyroid muscle function and
therefore pitch control. Injury to the recurrent
laryngeal nerve may also contribute to vocal cord
paralysis
77. Group Symptoms Sign Management
Group 1 Minor airway
symptoms
Minor hematomas
Small Lacerations
No detectable
fractures
Observation
Humidified air
Head of bed
elevation
Group 2 Airway compromise Edema/hematoma
Minor mucosal
disruption
No cartilage exposur
Tracheostomy
Direct laryngoscopy
Esophagoscopy
Group 3 Airway compromise Massive edema
Mucosal tears
Exposed cartilage
Vocal cord
immobility
Tracheostomy
Direct laryngoscopy
Esophagoscopy
Exploration/repair
No stent necessary
Group 4 Airway compromise Massive edema
Mucosal tears
Exposed cartilage
Vocal cord
immobility
Tracheostomy
Direct laryngoscopy
Esophagoscopy
Exploration/repair
Stent required
78. Laryngotracheal Injury
Management:
◦ High index of suspicion is required to
diagnose these types of injuries especially in
the absence of classic symptoms
◦ Securing an airway is the initial focus.
Endotracheal intubation should be attempted by the
most experienced person
Other authors suggest immediate tracheostomy to
avoid creating a false path or further injury to the
unstable airway
Cricothyrodotomy should be avoided as this may
worsen the injury
83. Intraoperative photo graphs of the patient from Figure 34–2 . The first photograph (A)
was taken
before rigid fixation using a plating system; the second photograph (B) was taken after
the plate was inserted. Note that the plate is carefully bent to restore the proper anterior
84. (A) Vocal granulation tissue funned as a result of endotracheal
Intubation coalescing. If undivided this will become a mature scar
tissue (B) and lead to ankylosis of cricoarytenoid joints.
86. The anterior cartilaginous
sutures are placed and then tied
once all have been placed.
Vicryl and Prolene sutures are
alternated for this portion of the
closure.
87. Sutures are placed submucosally
around tracheal rings with the knot tied
externally.
89. Subglottic stenosis is a difficult
complication to treat effectively.
Incomplete ring and weblike subglottic
stenosis can be treated with laser
excision or incision and dilation.
More significant stenosis may require
anterior or posterior cricoid splits with
cartilage grafting.
91. The most common problem in the immediate
postoperative period is the development of
granulation tissue and ulceration from exposed
cartilage.
The main concern with granulation tissue
formation is the potential for the development of
fibrosis and eventually stenosis.
Many techniques have been used to slow the
formation of granulation tissue, including
systemic and intralesional administration of
corticosteroids, long-term splinting, and low-
dose radiation.
Debulking granulation tissue through
endoscopy is probably the most effective
alternative treatment currently available.
92. Laryngeal trauma complications can manifest as
inadequate voice and failure to decannulate. These can
be prevented or treated in the following ways
Granulation tissue
Covering all exposed
cartilage to prevent
Avoiding stents when
possible
Careful excision
Laryngeal stenosis
Excision with mucosal
coverage
Stenting selected
cases
Laryngotracheoplasty
Tracheal resection
with reanastomosis
Vocal fold immobility
Observation
Vocal fold injection
Thyroplasty-type vocal
fold medialization
Arytenoidectomy and
vocal fold lateralization
for bilateral paralysis
Editor's Notes
1Arteriogram demonstrating common carotid artery injury with small hematoma
2extravasation of the internal carotid artery near the base of the skull (arrow).
3. A follow-up arteriogram of the internal carotid artery 1 week later shows enlargement of the pseudoaneurysm.