Neck injuries

The approach to neck injuries is based on the zone affected. Carotid injures in zone III (above the angle of the mandible), unless close enough to be approached with jaw dislocation, may require a combination of neurosurgical, maxillofacial, and radiological interventions. Traumatic pseudoaneurysms and arteriovenous fistulas (including carotid-cavernous sinus fistula) can often be embolized if they are at the level of the siphon or higher, although retrograde bleeding may still occur. Rarely, ligation of the internal carotid is necessary, and if neurological sequelae develop, a bypass from the external carotid to the middle cerebral artery may be considered. If ligation is needed to control massive bleeding, anticoagulation, although not universally practiced, should be considered (unless contraindicated by other major injuries) because of the risk of propagation of thrombus into the cerebral circulation. More proximal injuries in zones I or II, affecting the common or internal carotid arteries, may be managed by primary repair, interposition graft, or carotid-subclavian bypass graft. The external carotid can be ligated or repaired, depending on the extent of injury. Specific concerns exist in the patient who presents with a neurological deficit. Most of these result from ischemia due to interruption of cerebral perfusion and therefore are not hemorrhagic. Thus, revascularization rarely worsens the defect, and may improve a deficit or prevent it from occurring.

The vertebral artery is difficult to approach surgically and the extensive cranial circulation provides a source of retrograde flow that often complicates management. Options include ligation at both ends in the cervical spine (where it is more accessible), radiographic embolization, or placement of a Fogarty balloon catheter to promote thrombosis.

Vascular injuries in the thoracic inlet are approached through a variety of operative procedures, and occasionally cardiopulmonary bypass is needed. As many as a third of patients will have associated venous injuries.

Tracheal injury may be seen acutely following penetrating injuries, burn inhalation, blast trauma, or foreign body ingestion, but more often may be a sequela of prolonged intubation. Initial management must always involve ensuring a patent airway and adequate ventilation, usually by intubation. Flexible or rigid bronchoscopy may be needed for intubation, ventilation, and/or to assess cord function. Complete tracheal transection may require the distal trachea to be grasped with clamps in the thoracic outlet and pulled into the field. The trachea usually can be primarily repaired unless the defect is greater than 5 cm. Surgical practices include the use of absorbable sutures, limiting dissection to within 1 cm of either side of the proposed site (to prevent laryngeal nerve injury and devascularization) and avoiding tension (neck flexion, laryngeal or hypoglossal release, mobilization of the anterior trachea, or carinal release). If tracheostomy is necessary, it should be 2 to 3 cm away from the resection line. Viable tissue should be interposed between the trachea, esophagus, and carotid sheath to avoid fistula formation. Vocal cord function always needs to be assessed. Primary repair of transected recurrent nerves can be attempted, but more commonly unilateral paralysis (with unilateral cord abduction) is managed by injection to allow effective cough.

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