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To Look or Not to Look: Controversies in Surgical Exploration of Penetrating Neck Trauma

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To Look or Not to Look: Controversies in Surgical Exploration of Penetrating Neck Trauma Anne Conlin, BA&Sc, MD PGY-2, Otolaryngology Case 46 year old male working in ... – PowerPoint PPT presentation

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Title: To Look or Not to Look: Controversies in Surgical Exploration of Penetrating Neck Trauma


1
To Look or Not to LookControversies in
Surgical Exploration of Penetrating Neck Trauma
  • Anne Conlin, BASc, MD
  • PGY-2, Otolaryngology

2
Case
  • 46 year old male working in abattoir
  • Was butchering beef when a live steer broke
    through gate, knocking him over
  • Sustained penetrating trauma to the neck w/ a
    meat hook

3
Case
  • Treated at local ED w/ irrigation and
    antibiotics penrose drain placed
  • Transferred to TOH

4
Case
  • Hx
  • Pt. unsure of mechanism of injury
  • Complained of pain in the neck
  • Px
  • VSS, O2 sats gt92
  • General moderate discomfort
  • Neck 2 cm wound inferior to R body of mandible,
    penetrating platysma pain on palpation neck
    otherwise unremarkable

5
What should we do?
  • Day call ENT staff booked patient as P3
  • Night call ENT staff Why are we here?

6
Objectives
  • Case presentation
  • Approach to penetrating neck wounds
  • To look or not to look? The controversy.
  • Adult population
  • Pediatric population
  • Summary

7
An Approach to Penetrating Neck Trauma
8
Penetrating Neck Trauma
  • 5-10 of all trauma admissions
  • Low overall mortality 0-11
  • 30 of cases involve multi-system injury

9
Approach to Penetrating Neck Trauma
  • Zone I
  • Sternal notch to cricoid cartilage
  • Zone II
  • Cricoid cartilage to angle of mandible
  • Zone III
  • Angle of mandible to base of skull

10
Zone I
  • High risk of serious injury
  • Difficult region for exposure and control
  • Vital structures
  • Proximal carotid, vertebral subclavian a
  • Major BV of upper mediastinum
  • Lung apices
  • Esophagus
  • Trachea
  • Thoracic duct

11
Zone II
  • Easier access and control
  • Vital structures
  • Carotid sheath carotid a, jugular v, vagus n
  • Vertebral a
  • Esophagus
  • Trachea
  • Larynx
  • Recurrent laryngeal n
  • Spinal cord

12
Zone III
  • Difficult region for exposure control
  • Vital structures
  • Distal carotid a
  • Vertebral a
  • Parotid other salivary glands
  • Pharynx
  • CN IX, X, XI, XII
  • Spinal cord

13
Systems at Risk
  • Vascular
  • Including
  • Internal, external common carotid arteries
  • Vertebral subclavian arteries
  • Internal external jugular veins
  • Signs
  • ABCs
  • External hemorrhage
  • Hematoma
  • Shock
  • Present in 25
  • Mortality 50

14
Systems at Risk
  • Pharyngo-esophageal
  • Symptoms Signs
  • Dysphagia odynophagia
  • Hemoptysis hematemesis
  • Subcutaneous emphysema
  • Air bubbling at wound (w? cough)
  • Often difficult to detect
  • Potential consequences
  • Mediastinitis
  • Sepsis
  • Present in 5

15
Systems at Risk
  • Laryngotracheal
  • Signs
  • Dyspnea
  • Hoarseness
  • Stridor
  • Subcutaneous emphysema
  • Present in 10
  • Mortality 20

16
Systems at Risk
  • Nervous system
  • Cranial nerves
  • Facial
  • Glossopharyngeal
  • Recurrent laryngeal
  • Accessory
  • Hypoglossal
  • Spinal cord
  • Brachial plexus
  • Median n fist
  • Radial n wrist ext
  • Ulnar n finger abd
  • MCC n elbow flex
  • Axillary n arm abd
  • GCS
  • Uncommon injury
  • Common missed injury

17
Mechanism of Injury
  • Stab wounds
  • depth direction difficult to determine on exam
  • Bullets projectiles
  • entry exit sites provide little information on
    amount of tissue injured

18
Management of Penetrating Neck TraumaHistorical
Approach
19
Classic Approach to Penetrating Neck Wounds
  • Until 1950s
  • Seen almost exclusively by military surgeons
  • Recommended mandatory exploration for all wounds
    penetrating the platysma
  • Rationale high morbidity mortality from
    missed injuries

20
Controversy Arises
  • Mandatory surgical exploration was challenged in
    the 1970s 1980s
  • Arteriography available
  • Health economics
  • Risk vs. benefit

21
Annals of Surgery, 1985
  • Retrospective study
  • 257 patients w/ injury penetrating platysma
  • Group I (1975-1981) mandatory exploration
  • Group II (1981-1984) selective neck exploration
  • Indications hypotension, shock, profuse
    external bleed, expanding hematoma, dysphagia,
    neurological deficit, diminished carotid pulse,
    subQ emphysema, hemoptysis, hemetemesis, spitting
    blood, respiratory distress

22
Annals of Surgery, 1985
  • Group I 69 of pt w/ mandatory exploration had
    no injury
  • Group II 22 of pt w/ selective exploration had
    no injury none of the observed pt required
    subsequent exploration
  • Group II 2 mortalities in observed pt (MI
    spinal cord transection)
  • Remainder of mortalities in explored patients

23
The Importance of the Zones
  • Annals of Surgery study did not subgroup patients
    by zone of injury
  • Considerable variation in surgical access and
    structures at risk by zone of injury

24
Investigations
25
World Journal of Surgery, 1997
  • Demetriades et al, 1997
  • Prospective study, n223
  • Objective to asses role of clinical
    examination, angiography, colour flow Doppler

26
World Journal of Surgery, 1997
  • Clinical examination
  • Emergency surgery
  • Severe active bleeding
  • Refractory shock
  • Air bubbling at wound
  • Dyspnea
  • All other patients underwent investigations
    according to protocol

27
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28
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29
World Journal of Surgery
30
World Journal of Surgery
31
Emergency Operations
  • 38 patients (17) subjected to emergency
    operation
  • Only therapeutic in 30 (13.5 of all cases)
  • 6 had negative exploration
  • 2 had non-therapeutic surgery thrombosed
    vertebral artery
  • One missed esophageal perforation during
    exploration
  • Deaths 6 total 5 due to non-neck injuries
    unclear if deaths in surgery or non-surgery grp

32
Results Vascular Assessment
  • Angiography
  • 176 patients
  • 34 abnormalities (19.3)
  • 14 required surgery (8)
  • Most common
  • vertebral artery occlusion (5)
  • Others
  • VA tear, ICA occlusion, CCA aneurysm/tear
    unnamed vessel thrombosis

33
Results Vascular
  • Angiography Colour Flow Doppler
  • 99 patients
  • w/ angiography as gold standard, CFD had
  • Sensitivity 91.7
  • Specificity 100
  • PPV 100
  • NPV 99
  • 100 all-around if only injuries requiring
    surgery were considered

34
Results Vascular
  • Angiography complications
  • Femoral hematoma in 5 patients (2.2)
  • Clinical Exam for Vascular Injury
  • w/ angiography or surgical exploration as gold
    standard
  • NPV 91.7
  • 100 if only injuries requiring surgery were
    considered

35
Results Aerodigestive Assessment
  • 216 patients clinically evaluated
  • 64 had SSx
  • 10 required surgical repair
  • 0 asymptomatic patients required operation
  • Contrast swallow study
  • 98 patients w/ Sx or proximity injury
  • 2 esophageal injury (Sx)
  • Esophagoscopy
  • 22 patients, all normal
  • Laryngoscopy
  • 149 patients w/ Sx or proximity injury
  • 25 abnormal (VC dyskinesia, edema, blood)
  • 5 required surgery

36
Discussion
  • If policy of mandatory surgical exploration
  • Non-therapeutic in 86.5
  • Angiography has low yield and does not change
    management
  • 7.8 of asymptomatic patients had ve AG
  • 0 asymptomatic patients had ve AG finding
    requiring surgery

37
Discussion
  • Esophageal studies
  • Selective contrast swallow study yield 2
  • Esophagoscopy yield 0
  • Overall
  • Clinical exam has 100 NPV for vascular and
    aerodigestive injuries requiring surgery
  • Clinical exam 38.1 sensitivity for vascular
    and aerodigestive injuries requiring surgery
  • CFD is a reliable and inexpensive alternative to
    angiography

38
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39
Discussion
  • Developed algorithm
  • If this had been followed
  • Total cost would be 30,500 vs. actual cost
    444,500
  • If CFD done instead of AG 250,000 savings

40
The Canadian Experience
41
Canadian Journal of Surgery, 2001
  • Retrospective chart review
  • 130 consecutive pt. w/ neck wounds penetrating
    platysma
  • Surgical exploration vs. observation

42
CJS 2001
  • Location
  • Zone I 15
  • Zone II 81
  • Zone III 4
  • Mechanism
  • Knife/broken bottle 73
  • GSW 5

43
CJS, 2001
  • Management
  • Observation 50/130 (38)
  • Surgery 80/130 (62)

44
Important Findings
  • Zone II
  • All zone II major vascular injuries were
    symptomatic on presentation
  • Neck exploration was negative in all asymptomatic
    zone II injured patients

45
Asymptomatic Patients
  • 76 of all injuries were symptomatic on
    presentation
  • Mean hospital stay for asymptomatic patients
    treated w/ observation surgical exploration was
    similar (3.5 4.3 p0.575)

46
Missed Injuries
  • 1 pharyngeal injury missed in a pt who underwent
    surgical exploration
  • 1 pt developed pharyngocutaneous fistula after
    exploration repair of lacerated trachea
  • Follow-up visits
  • 1 brachial plexus injury
  • 1 accessory nerve injury

47
Long-term Disability
  • All neurologic
  • 3 pt managed by observation 6 pt managed by
    surgery
  • Phrenic (1)
  • Recurrent laryngeal (1)
  • Accessory (3)
  • Brachial plexus (4)

48
Canadian Study Overall
  • Majority of patients were asymptomatic
  • Optimal management of asymptomatic Zone II
    injured patient is not known
  • Neck exploration does not rule-out the
    possibility for missed injury
  • Bottom-line risk of death from missed
    esophageal injury, therefore, consider NPO x24
    hrs, close observation x48 hrs, low threshold
    for rigid esophagoscopy

49
The Pediatric Experience
50
Abujamra et al, 2003
  • Retrospective chart review
  • Age 16
  • N31
  • 84 in Zone II

51
Abujamra et al, 2003
  • Surgical exploration
  • 8 patients (25.8)
  • All penetrated platysma
  • None revealed injury
  • Barium swallow
  • 4 patients
  • 3 based on location mechanism (GSW)
  • 1 based on physical (hematoma)
  • All normal
  • 0 angiograms
  • Dependent on staff

52
Abujamra et al, 2003
  • Laryngoscopy
  • 3 patients
  • 2 had minor physical findings
  • (non-expanding neck hematoma SC air on neck XR)
  • 1 laceration ant. to larynx
  • All normal
  • 48 w/ other injuries
  • Most were facial lacerations
  • 3 patients died
  • All had major physical findings
  • 2 had GCS 3, pulseless
  • 1 had GCS 8, shock
  • No evidence of complications

53
Abujamra et al, 2003
  • Concluded
  • Penetrating neck injuries a rare in pediatric pt
  • Management varies
  • Observation in a stable patient is appropriate

54
Luqman et al, 2005
  • Case series (n3)
  • 1 patient w/ PNT secondary to attack by fighting
    rooster
  • Initially assessed puncture wounds to face
    neck D/Cd
  • RTER 24 hr later w/ fever, neck swelling,
    respiratory distress
  • Neck crepitus inflammation induration
  • CXR pneumomediastinum

55
Luqman et al, 2005
  • ICU w/ amp, gent clinda
  • Endoscopic EUA 0.5 cm perforation of lateral
    wall of pharynx
  • Neck explored through lateral incision ? pus
    drained
  • NG feeds ? N contrast study POD10
  • D/C HD14 on N diet

56
A Zone-Specific Approach to Management of
Penetrating Neck Trauma
57
Zones I III
  • Very difficult surgical access
  • Angiography indicated in all but the most
    unstable patients
  • Unstable ? O.R.
  • large expanding hematoma, severe active or
    pulsatile bleeding, shock unresponsive to fluids,
    signs of cerebral infarction, presence of a bruit
    or thrill, and diminished distal pulses
  • Otherwise angio observe

58
Zone II Management
  • Remains most controversial

59
Insull, 2007
  • Retrospective review of 63 pt. w/ only Zone II
    penetrating neck trauma in New Zealand
  • Hard signs
  • Active external bleeding, neck bruit, or thrill
  • Expansive, pulsatile hematoma
  • Dysphagia
  • Hoarseness
  • Subcutaneous emphysema
  • Sucking neck wound
  • Neurological deficit

60
Insull, 2007
61
Insull, 2007
  • Multivariable regression analysis
  • Hard signs were predictive of positive neck
    exploration
  • No other variables were significant predictors
  • Bayesian parameters re. hard signs
  • Sensitivity 93
  • Specificity 96
  • Positive predictive value 87
  • Negative predictive value 98

62
Insull, 2007
  • No complications of neck exploration
  • No missed injuries
  • If patients had been managed solely on basis Px
    without investigations, 1 injury would have been
    missed (foreign body)

63
Which C T ?
64
Contrast CT
  • 14 pt w/ Zone II injury, prospective
  • Surgical findings compared to high and low
    probability CT findings
  • 3 patients had 5 surgical findings
  • 4 of 5 were diagnosed by CT
  • Sens 100 Spec 91
  • PPV 75 NPV 100

Clinical Exam
Contrast CT
Surgeon reads CT
Surgery
65
Dynamic CT
  • Prospective blinded study, DCT vs. Px
  • 42 patients not requiring emergent surgery
  • 250 cc contrast, 0.5 cm cuts
  • Result minimal contribution to clinical exam
    esophagoscopy, no change in surgical intervention

Clinical Exam
Dynamic CT
Esophagoscopy
Surgery
66
CT Angiography
  • Retrospective review
  • N130, zone II
  • 34 patients had CTA, 96 did not
  • Significantly fewer neck explorations among pt w/
    CTA
  • (No comparison to clinical exam or conventional
    angiography no reports on sens, spec, PPV, NPV)

67
CT Angiography with 3-D Reconstruction
68
Case Revisited
  • Contrast CT penrose drain no vascular,
    aerodigestive, or nerve injury identified
  • Neck exploration negative
  • Course in Hospital observed x48 hours then
    D/Cd home on oral Abx

69
Take Home Messages
  • Management of penetrating neck trauma is
    controversial
  • Selective surgical management is common practice
  • Variety of investigations available
  • Physical exam alone is very useful and may be
    sufficient
  • Adoption of unified, evidence-based approach to
    management of PNT is elusive
  • Limited literature in pediatric population

70
Discussion
  • Thanks.
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