58
Injury. 7. 58-60
Penetrating
injuries of the neck
A. Thavendran, N. Y. Wijemanne, and Rudra Rasaretnam
Ananda
Soysa
Colombo General Hospital, Sri 1 anka Summary
Vascular
In view of the close arrangement of a large number of vital structures in the neck, penetrating wounds in
Haemorrhage is inevitable after injury to any of the major blood vessels in the neck and 5 patients were admitted with profuse bleeding through the cervical wound, which was initially controlled by pressure on the wound with the ungloved thumb or fingers. As all these patients showed various degrees of shock and hypotension, immediate resuscitation with blood through a cannula inserted in one of the veins of the lower limbs was necessary, while the bleeding was controlled with a gauze dressing in the wound and suture of the
this region should be considered as potentially lethal. Nineteen cases of injury to great vessels and food and air passages which required repair are analysed. There were 4 deaths, giving an overall mortality of 21 per cent. Two of these were injuries of the subclavian and innominate veins when prolonged delay for resuscitation was probably the main reason for the deaths. The third was in a patient with tracheal injury in whom a coexistent oesophageal lesion was missed and the fourth a case of spinal cord injury. When adequate exposure cannot be obtained by exploration of the neck, median sternotomy or anterior thoracotomy is advisable. PENETRATING injuries of the neck are encountered only rarely, but the close relationship of vessels and trachea makes possible the serious injury to one or more vital structures which require immediate repair. Delay in effecting definitive treatment is associated with a considerable morbidity and mortality. The serious threat to life that may be posed by these injuries makes it necessary that any surgeon should be able to proceed with exploration and repair.
CLINICAL
MATERIAL
This paper is based on the management of 19 patients with serious structural injury requiring repair. Seventeen were due to knife wounds, the majority of which were inflicted in brawls, and 2 werecases of penetration by wooden spikes, including one unusual case of peroral penetration of the lateral wall of the pharynx and neck. Fifteen of the knife wounds were anteriorly placed with consequent damage to a variety of structures, and only the posterior wounds caused spinal cord and vertebral artery damage. There were 17 males and 2 females. Two patients had received primary treatment at other hospitals and were transferred to us because of complications. The major structures injured are shown in Table Z.
injury
Tab/e 1. Penetrating
injuries
Visceral
of the neck
lesions
in 19 patients
Vascular
internal carotid artery Vertebral artery Internal jugular vein External jugular vein Anterior jugular veins Innominate veins Subclavian vein Intercostal artery
3 1 1 1 2 3 1 1
Other structures
Larynx Trachea Pharynx Pyriform fossa Oesophagus Parotid gland Thyroid gland Spinal cord Facial nerve Cervical nerves
6 1 2 1 2 2 2 1 1 1
skin over it. Resuscitation was carried out in the operating theatre and, as soon as a normal blood pressure was obtained and fluid replacement judged to be adequate, exploration of the wound was undertaken. This brief interval for resuscitation was considered to be essential, but it should
Thavendran
et al.
: Penetrating
Injuries
of Neck
not exceed 30-45 minutes (Beahrs and Devine, 1963; Shirkey et al., 1963). These patients have usually lost a considerable proportion of their blood volume, the systemic pressure being maintained by peripheral vasoconstriction, the beneficial effects of which may be eradicated by the induction of anaesthesia resulting in circulatory collapse. Access is limited in the neck and profuse haemorrhage may occur on exploration; leading to exsanguination unless adequate fluid replacement has been carried out. The brief period for resuscitation also allows time for examination of other injuries. It is not always possible to make a correct preoperative assessment of the structural lesions, and, particularly with the lower cervical wounds, damage to the vessels either behind the clavicle or at the root of the neck must be anticipated. In both these sites it is difficult to obtain control of bleeding with just a cervical incision. The clavicle was divided for a subclavian vein injury, and for bleeding from the innominate vein we prefer a median sternotomy with division of the strap muscles on the affected side-an approach that gives excellent exposure and adequate proximal and distal control. At operation, the patient lies supine with the neck slightly extended, and skin preparation should include the whole of the anterior chest with drapes applied appropriately. If exploration of the neck shows theneed for sternotomy, the additional access may then be easily obtained by splitting the sternum with a Gigli saw. Three young adults sustained injury to the internal carotid artery, one as a result of penetration through the pharyngeal wall. In the other 2 cases the external wound was above the level of the angle of the jaw. Access in all 3 patients was poor, necessitating ligature of the affected internal carotid artery in order to achieve haemostasis. All 3 patients developed neurological signs, including contralateral hemiparesis, which were fortunately temporary, except for one case of nominal aphasia, which persisted for longer. Lesions of the vertebral arteries are uncommon becauseoftheirprotectedcoursethrough the vertebral canals. One such injury was seen in a patient who had a posterolateral cervical stab wound, and presenting with profuse haemorrhage and circulatory collapse. At operation, as the vessel was inaccessible, the bleeding was staunched with the index finger until adequate exposure was obtained by using bone nibblers on the transverse process of the cervical vertebra, the vertebral artery being secured with artery forceps and then ligated. Recovery was uneventful.
59
Venous injury usually had the same dramatic urgency. Only one of the 6 cases had no external haemorrhage, but this patient had suffered penetration of the apical pleura and the lung as well and consequently as the subclavian vein, developed a haemopneumothorax. An unnecessary delay of 4 hours which elapsed before the patient was taken for operation probably contributed to the fatal outcome 3 days later from the effects of hypovolaemia. All the venous injuries were repaired, except the cases involving the anterior and external jugular veins, which were ligated. Injury to the air and food passages Seven cases of injury to the upper air passages, all of which were caused by the knife, were admitted. Six had injury to the larynx and one to the upper trachea. In addition 2 patients had oesophageal penetration, one had bilateral pyriform fossa injury, and 2 had associated severe bleeding from cut anterior jugular veins. Varying degrees of dyspnoea, stridor and cough occurred. All 7 cases were repaired under general anaesthesia shortly after admission; in 5 cases the endotracheal tube was passed through the wound and subsequently changed to an orotracheal tube. Two patients had preliminary tracheostomy with local anaesthesia, followed by repair under general anaesthesia. With knife injuries the edges of the wounds were clean cut, and repair was effected with interrupted chromic catgut sutures. Coincident injury to the pharynx and oesophagus was repaired in 2 cases. In a third patient the oesophageal injury was unrecognized and resulted in an oesophagocutaneous fistula which required a hospital stay of 94 days, during which time feeding was carried out through a nasogastric tube. Six patients had a temporary usually performed through a tracheostomy, separate incision below the level of the injury. Drainage of the neck wound was carried out in every case. Gland injury There were 2 cases each of thyroid and parotid gland injury which were treated by suture without complication. Spinal cord injury Only one patient had a posterior stab wound at the level of the spine of the third cervical vertebra. The knife had cut through the spinous process and the vertebral lamina, damaging the spinal cord and resulting in quadriplegia. The patient succumbed 2 days after injury.
60
Injury: the British Journal of Accident Surgery Vol. ~/NO. 1
DISCUSSION The possibility of injury to the larynx and trachea should be considered in all wounds of the neck, particularly anterior ones when dyspnoea, stridor, cough or a fine bloody froth is present. Airway injury has been found in only 8.4 per cent and 13 per cent of cases in 2 large series of penetrating wounds (Fogelman and Stewart, 1956; Shirkey et al., 1963). The diagnosis can be confidently made in penetrating injuries when a hissing sound occurs with respiration and when subcutaneous emphysema is present. Varying degrees of respiratory distress occur, depending on the size of the wound, the extent of airway obstruction and the aspiration of blood. Any concomitant vascular injuries dominate the clinical picture, and the need for surgical exploration is then obvious. Simultaneous injury to the pharynx and oesophagus occurs not infrequently, and should be suspected if the patient complains of difficulty in swallowing or if blood is aspirated from a gastric tube. The management of the individual case depends on the clinical presentation. The provision of an adequate airway is the prime requirement, and when severe respiratory distress exists, tracheal intubation may be carried out through the rent. Bronchoscopy can also be life saving, both by providing a clear airway, and for tracheobronchial toilet. Minor tracheal injuries are frequently undiagnosed, but require no treatment. However, 2 fatal cases in infants after accidental needle perforation of the trachea with the development of mediastinal emphysema were reported by Goldstein (1949). Failure to diagnose the laryngeal or tracheal injury has been the main cause of death in various series (Fogelman and Stewart, 1956; Gray et al., 1958; Harrington et al., 1962). Vascular wounds may present with external bleeding, hypotension, haematoma, haemothorax or with a thrill or bruit over the vessel, and the presence of any of these signs is an indication for early exploration. However, such an injury may exist without any of these signs, becoming manifest only some hours later because of sudden severe haemorrhage; herein Iies the danger in the expectant management of stab wounds of the neck. Haemorrhage may also occur into the chest and may not be obvious. Primary control Requests for rrprbzfs should be addressed to: Rudra
Rasaretnam,
of haemorrhage by pressure, and adequate replacement of lost blood before exploration, are essential, but operation should not be delayed for more than 40 minutes.’ Two of the 4 deaths in this series occurred in patients with venous injury in whom the delay was 24 and 4 hours respectively, and in one of them continued haemorrhage into the chest made futile the repeated efforts at resuscitation. A.rteries should preferably be repaired, but if there is evidence before operation of cerebral ischaemiawith neurological deficit, ligature of the vessel is probably advisable to prevent the conversion of an ischaemic into a haemorrhagic infarct (Cohen et al., 1970; Penn, 1973). Although haemothorax from a penetrating thoracic wound may be treated by simple drainage, if it results from extension of a penetrating cervical injury, it is an indication for immediate exploration, mainly to exclude bleeding from one of the great vessels in the root of the neck (Shirkey et al., 1963). A supraclavicular incision may provide sufficient access, but if it fails to do so anterior thoracotomy will allow adequate exposure. Acknowledgement We have pleasure in thanking Mrs Mohini Crossette Thambyah for typing the manuscript.
REFERENCES
BEAHRS0. H. and DEVN K. D. (1963) Treatment of traumatic lesions of the head and neck. Surg. C/in. N. Am. 43, 917. COHEN A., BRIEF D. and MATHEWSON C. (1970) Carotid artery injuries. Am. J. Surg. 120, 210. FOGELMANM. J. and STEWARTR. D. (1956) Penetrating wounds of the neck. Am. J. Surg. 91, 581. GOLDSTEINP. (1949) Fatal interstitial and mediastinal emphysema. Am. J. Dis. Child. 78, 373. GRAY A. R., HOWARD J. M., HARRISONW. H. and COUVESC. M. (1958) lnjuries of the trachea. Arch. Surg. 76, 138. HARRINGTON0. B., BEALLA. C. and DEBAKEY M. E. (1962) Traumatic injuries of the cervical trachea. Am. J. Surg. 103, 541. PENN I. (1973) Penetrating injuries of the neck. Surg. Clin. N. Am. 53, 1469. SHIRKEY A. L., BEALL A. C. and DEBAKEY M. E. (1963) Surgical management of penetrating wounds of the neck. Arch. Surg. 86, 955.
58 Kynsey Road, Colombo
8, Sri Lanka.
Injury. 7. 58-60
Penetrating
injuries of the neck
A. Thavendran, N. Y. Wijemanne, and Rudra Rasaretnam
Ananda
Soysa
Colombo General Hospital, Sri 1 anka Summary
Vascular
In view of the close arrangement of a large number of vital structures in the neck, penetrating wounds in
Haemorrhage is inevitable after injury to any of the major blood vessels in the neck and 5 patients were admitted with profuse bleeding through the cervical wound, which was initially controlled by pressure on the wound with the ungloved thumb or fingers. As all these patients showed various degrees of shock and hypotension, immediate resuscitation with blood through a cannula inserted in one of the veins of the lower limbs was necessary, while the bleeding was controlled with a gauze dressing in the wound and suture of the
this region should be considered as potentially lethal. Nineteen cases of injury to great vessels and food and air passages which required repair are analysed. There were 4 deaths, giving an overall mortality of 21 per cent. Two of these were injuries of the subclavian and innominate veins when prolonged delay for resuscitation was probably the main reason for the deaths. The third was in a patient with tracheal injury in whom a coexistent oesophageal lesion was missed and the fourth a case of spinal cord injury. When adequate exposure cannot be obtained by exploration of the neck, median sternotomy or anterior thoracotomy is advisable. PENETRATING injuries of the neck are encountered only rarely, but the close relationship of vessels and trachea makes possible the serious injury to one or more vital structures which require immediate repair. Delay in effecting definitive treatment is associated with a considerable morbidity and mortality. The serious threat to life that may be posed by these injuries makes it necessary that any surgeon should be able to proceed with exploration and repair.
CLINICAL
MATERIAL
This paper is based on the management of 19 patients with serious structural injury requiring repair. Seventeen were due to knife wounds, the majority of which were inflicted in brawls, and 2 werecases of penetration by wooden spikes, including one unusual case of peroral penetration of the lateral wall of the pharynx and neck. Fifteen of the knife wounds were anteriorly placed with consequent damage to a variety of structures, and only the posterior wounds caused spinal cord and vertebral artery damage. There were 17 males and 2 females. Two patients had received primary treatment at other hospitals and were transferred to us because of complications. The major structures injured are shown in Table Z.
injury
Tab/e 1. Penetrating
injuries
Visceral
of the neck
lesions
in 19 patients
Vascular
internal carotid artery Vertebral artery Internal jugular vein External jugular vein Anterior jugular veins Innominate veins Subclavian vein Intercostal artery
3 1 1 1 2 3 1 1
Other structures
Larynx Trachea Pharynx Pyriform fossa Oesophagus Parotid gland Thyroid gland Spinal cord Facial nerve Cervical nerves
6 1 2 1 2 2 2 1 1 1
skin over it. Resuscitation was carried out in the operating theatre and, as soon as a normal blood pressure was obtained and fluid replacement judged to be adequate, exploration of the wound was undertaken. This brief interval for resuscitation was considered to be essential, but it should
Thavendran
et al.
: Penetrating
Injuries
of Neck
not exceed 30-45 minutes (Beahrs and Devine, 1963; Shirkey et al., 1963). These patients have usually lost a considerable proportion of their blood volume, the systemic pressure being maintained by peripheral vasoconstriction, the beneficial effects of which may be eradicated by the induction of anaesthesia resulting in circulatory collapse. Access is limited in the neck and profuse haemorrhage may occur on exploration; leading to exsanguination unless adequate fluid replacement has been carried out. The brief period for resuscitation also allows time for examination of other injuries. It is not always possible to make a correct preoperative assessment of the structural lesions, and, particularly with the lower cervical wounds, damage to the vessels either behind the clavicle or at the root of the neck must be anticipated. In both these sites it is difficult to obtain control of bleeding with just a cervical incision. The clavicle was divided for a subclavian vein injury, and for bleeding from the innominate vein we prefer a median sternotomy with division of the strap muscles on the affected side-an approach that gives excellent exposure and adequate proximal and distal control. At operation, the patient lies supine with the neck slightly extended, and skin preparation should include the whole of the anterior chest with drapes applied appropriately. If exploration of the neck shows theneed for sternotomy, the additional access may then be easily obtained by splitting the sternum with a Gigli saw. Three young adults sustained injury to the internal carotid artery, one as a result of penetration through the pharyngeal wall. In the other 2 cases the external wound was above the level of the angle of the jaw. Access in all 3 patients was poor, necessitating ligature of the affected internal carotid artery in order to achieve haemostasis. All 3 patients developed neurological signs, including contralateral hemiparesis, which were fortunately temporary, except for one case of nominal aphasia, which persisted for longer. Lesions of the vertebral arteries are uncommon becauseoftheirprotectedcoursethrough the vertebral canals. One such injury was seen in a patient who had a posterolateral cervical stab wound, and presenting with profuse haemorrhage and circulatory collapse. At operation, as the vessel was inaccessible, the bleeding was staunched with the index finger until adequate exposure was obtained by using bone nibblers on the transverse process of the cervical vertebra, the vertebral artery being secured with artery forceps and then ligated. Recovery was uneventful.
59
Venous injury usually had the same dramatic urgency. Only one of the 6 cases had no external haemorrhage, but this patient had suffered penetration of the apical pleura and the lung as well and consequently as the subclavian vein, developed a haemopneumothorax. An unnecessary delay of 4 hours which elapsed before the patient was taken for operation probably contributed to the fatal outcome 3 days later from the effects of hypovolaemia. All the venous injuries were repaired, except the cases involving the anterior and external jugular veins, which were ligated. Injury to the air and food passages Seven cases of injury to the upper air passages, all of which were caused by the knife, were admitted. Six had injury to the larynx and one to the upper trachea. In addition 2 patients had oesophageal penetration, one had bilateral pyriform fossa injury, and 2 had associated severe bleeding from cut anterior jugular veins. Varying degrees of dyspnoea, stridor and cough occurred. All 7 cases were repaired under general anaesthesia shortly after admission; in 5 cases the endotracheal tube was passed through the wound and subsequently changed to an orotracheal tube. Two patients had preliminary tracheostomy with local anaesthesia, followed by repair under general anaesthesia. With knife injuries the edges of the wounds were clean cut, and repair was effected with interrupted chromic catgut sutures. Coincident injury to the pharynx and oesophagus was repaired in 2 cases. In a third patient the oesophageal injury was unrecognized and resulted in an oesophagocutaneous fistula which required a hospital stay of 94 days, during which time feeding was carried out through a nasogastric tube. Six patients had a temporary usually performed through a tracheostomy, separate incision below the level of the injury. Drainage of the neck wound was carried out in every case. Gland injury There were 2 cases each of thyroid and parotid gland injury which were treated by suture without complication. Spinal cord injury Only one patient had a posterior stab wound at the level of the spine of the third cervical vertebra. The knife had cut through the spinous process and the vertebral lamina, damaging the spinal cord and resulting in quadriplegia. The patient succumbed 2 days after injury.
60
Injury: the British Journal of Accident Surgery Vol. ~/NO. 1
DISCUSSION The possibility of injury to the larynx and trachea should be considered in all wounds of the neck, particularly anterior ones when dyspnoea, stridor, cough or a fine bloody froth is present. Airway injury has been found in only 8.4 per cent and 13 per cent of cases in 2 large series of penetrating wounds (Fogelman and Stewart, 1956; Shirkey et al., 1963). The diagnosis can be confidently made in penetrating injuries when a hissing sound occurs with respiration and when subcutaneous emphysema is present. Varying degrees of respiratory distress occur, depending on the size of the wound, the extent of airway obstruction and the aspiration of blood. Any concomitant vascular injuries dominate the clinical picture, and the need for surgical exploration is then obvious. Simultaneous injury to the pharynx and oesophagus occurs not infrequently, and should be suspected if the patient complains of difficulty in swallowing or if blood is aspirated from a gastric tube. The management of the individual case depends on the clinical presentation. The provision of an adequate airway is the prime requirement, and when severe respiratory distress exists, tracheal intubation may be carried out through the rent. Bronchoscopy can also be life saving, both by providing a clear airway, and for tracheobronchial toilet. Minor tracheal injuries are frequently undiagnosed, but require no treatment. However, 2 fatal cases in infants after accidental needle perforation of the trachea with the development of mediastinal emphysema were reported by Goldstein (1949). Failure to diagnose the laryngeal or tracheal injury has been the main cause of death in various series (Fogelman and Stewart, 1956; Gray et al., 1958; Harrington et al., 1962). Vascular wounds may present with external bleeding, hypotension, haematoma, haemothorax or with a thrill or bruit over the vessel, and the presence of any of these signs is an indication for early exploration. However, such an injury may exist without any of these signs, becoming manifest only some hours later because of sudden severe haemorrhage; herein Iies the danger in the expectant management of stab wounds of the neck. Haemorrhage may also occur into the chest and may not be obvious. Primary control Requests for rrprbzfs should be addressed to: Rudra
Rasaretnam,
of haemorrhage by pressure, and adequate replacement of lost blood before exploration, are essential, but operation should not be delayed for more than 40 minutes.’ Two of the 4 deaths in this series occurred in patients with venous injury in whom the delay was 24 and 4 hours respectively, and in one of them continued haemorrhage into the chest made futile the repeated efforts at resuscitation. A.rteries should preferably be repaired, but if there is evidence before operation of cerebral ischaemiawith neurological deficit, ligature of the vessel is probably advisable to prevent the conversion of an ischaemic into a haemorrhagic infarct (Cohen et al., 1970; Penn, 1973). Although haemothorax from a penetrating thoracic wound may be treated by simple drainage, if it results from extension of a penetrating cervical injury, it is an indication for immediate exploration, mainly to exclude bleeding from one of the great vessels in the root of the neck (Shirkey et al., 1963). A supraclavicular incision may provide sufficient access, but if it fails to do so anterior thoracotomy will allow adequate exposure. Acknowledgement We have pleasure in thanking Mrs Mohini Crossette Thambyah for typing the manuscript.
REFERENCES
BEAHRS0. H. and DEVN K. D. (1963) Treatment of traumatic lesions of the head and neck. Surg. C/in. N. Am. 43, 917. COHEN A., BRIEF D. and MATHEWSON C. (1970) Carotid artery injuries. Am. J. Surg. 120, 210. FOGELMANM. J. and STEWARTR. D. (1956) Penetrating wounds of the neck. Am. J. Surg. 91, 581. GOLDSTEINP. (1949) Fatal interstitial and mediastinal emphysema. Am. J. Dis. Child. 78, 373. GRAY A. R., HOWARD J. M., HARRISONW. H. and COUVESC. M. (1958) lnjuries of the trachea. Arch. Surg. 76, 138. HARRINGTON0. B., BEALLA. C. and DEBAKEY M. E. (1962) Traumatic injuries of the cervical trachea. Am. J. Surg. 103, 541. PENN I. (1973) Penetrating injuries of the neck. Surg. Clin. N. Am. 53, 1469. SHIRKEY A. L., BEALL A. C. and DEBAKEY M. E. (1963) Surgical management of penetrating wounds of the neck. Arch. Surg. 86, 955.
58 Kynsey Road, Colombo
8, Sri Lanka.
