Thyroid & Adrenal
You evaluate an 18-yrs-old male who sustained a right-sided cervical laceration during a gang fight. Which of the following is a relative rather than an absolute indication for neck exploration?
a. Penetrating injuries of the anterior neck that violate the platysma are considered significant because of the density of critical structures in this region.
b. While mandatory exploration may be appropriate in some circumstances, patients are now managed selectively in most centers .
c. Selective management is based on the neck and is divided into three zones.
i. Zone I is between the clavicles and cricoid cartilage and is also referred to as the thoracic outlet.
ii. Zone II is between the cricoid cartilage and the angle of the mandible.
iii. Zone III is above the angle of the mandible.
d. The evaluation and management of visceral and vascular injuries in the thoracic outlet (zone I) are complicated by the overlying ribs, sternum, and clavicles.
e. Since the incision may be different depending on the injured structures, a precise preoperative diagnosis is desirable.
f. Patients with zone I injuries should undergo angiography of the great vessels, soluble contrast esophagram followed by barium esophagram, esophagoscopy, and bronchoscopy. However, as outlined above, Hemodynamically unstable patients should not undergo this extensive evaluation, but rather should be taken directly to the OT.
g. Patients with zone II injuries are the easiest to evaluate. Unstable patients or those with evidence of airway compromise, an expanding hematoma, or significant external hemorrhage (including hemorrhage into the mouth) should be explored promptly.
h. Penetrating neck wounds in stable patients should be locally explored to determine the depth of penetration. Those that do not penetrate the platysma are insignificant and should be closed; these patients can be sent home.
i. The vast majority of the remaining zone II penetrating wounds are observed for 12 hours. However, patients with right to left transcervical GSWs may warrant diagnostic evaluation. Carotid and vertebral angiography, direct laryngoscopy, tracheoscopy, esophagoscopy, and esophagram may be necessary, depending on the trajectory.
j. Patients with zone III penetrating injuries require carotid and vertebral angiography if there is evidence of arterial bleeding. This is important for three reasons:
i. Exposure of the distal internal carotid and vertebral arteries is difficult,
ii. The internal carotid artery may have to be ligated, a maneuver associated with a high risk of stroke, and
iii. Active hemorrhage from the external carotid and vertebral arteries can be controlled by selective embolization.
Associated injuries of the pharynx are of little consequence and require no special evaluation.