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Assessment of penetrating neck trauma requires special attention to the airway, breathing, and neurological status. The patient is questioned about the mechanism of injury, pain, respiratory distress, dysphagia, and voice changes. He or she is assessed for active bleeding, hematoma formation, subcutaneous emphysema, bruits, cranial nerve function, and hemispheric or upper-extremity neurological deficits. Victims with gunshot wounds in proximity to the cervical spine require immobilization until the vertebrae are assessed with radiographs. Probing of the wound or coughing induced by placement of nasogastric tubes may dislodge thrombus and result in significant hemorrhage, and should be done only in the operating room. Diagnostic studies are contraindicated in patients with uncontrolled bleeding. Hemorrhage is controlled digitally until the patient is prepared and draped for operation. The patient with pulsatile hemorrhage or expanding hematoma must have the airway controlled by early intubation, as delay may lead to tracheal deviation or compression necessitating surgical airway placement. Awake intubation is preferred because the patient maintains spontaneous respiration. A fiber-optic endoscope can improve visualization in difficult cases. Upper airway or laryngeal injuries require a surgical airway; intubation is contraindicated. Radiographs of the neck are useful in identifying bullet fragments, vertebral injury, tracheal compression, and subcutaneous air, and in helping to reconstruct missile trajectories.

In the stable patient, assessment varies with the anatomical location of the injury. The neck is divided into three zones ( Fig 1). Violation of the platysma mandates a thorough evaluation for vascular, airway, and esophageal injury. Physical examination has a sensitivity of approximately 80 per cent and a specificity of only 61 per cent for predicting vascular injuries. Arteriography is recommended, with a four-vessel study having an accuracy of around 95 per cent. Duplex scanning and intravenous digital subtraction angiography have not been investigated extensively in trauma. Zone I and zone III patients require angiography for diagnosis, possible therapeutic intervention, and planning of operative approach. Operative exposure of zone I injuries may require thoracotomy, sternotomy, clavicular excision, and/or trap-door incisions. Zone III injuries are not easily accessible at exploration and require rotational osteotomy or subluxation of the temporomandibular joint to expose the injury. Angiography in zone III injuries allows for embolization of vertebral or external carotid injuries. Zone I and zone III injuries also require laryngoscopy and/or bronchoscopy to evaluate the airway; physical examination is not sufficient to evaluate esophageal injury. Rigid esophagoscopy and contrast esophagraphy have a sensitivity of 80 per cent individually, but when they are combined the sensitivity approaches 1O0 per cent. Flexible endoscopy may miss up to 50 per cent of esophageal injuries. Asymptomatic zone II injuries are effectively managed either by mandatory exploration protocols or selective plans which use double endoscopy, arteriography, and esophagraphy. Symptomatic patients are taken to the operating room. A subclass of zone II injuries are transcervical (injuries that cross the midline) and result in visceral injury in 83 per cent of cases; mandatory exploration is advocated. The need for mandatory arteriography in all selective protocols is being questioned at present. (CD Figure,, ,,6)

Fig. 1 Zone I extends from the sternal notch to the level of the cricoid cartilage and includes the thoracic outlet. Zone II extends from the cricoid to the angle of the mandible. Zone III lies above the angle of the mandible. The recommended diagnostic evaluation for each zone is shown.

CD Figure 6. The three images refer to a patient with a zone III injury to the left neck. On the anteroposterior radiograph (a) the bullet has come to rest in the midline at the level of the maxilla. After initial airway assessment, physical examination, and resuscitation, the diagnostic work-up includes endoscopy, arteriography, and radiographic clearance of the C-spine. Radiograph (b) demonstrates an external carotid-jugular vein fistula. This injury may be controlled via angiographic embolization. The CT scan (c) reveals a C1/C2 fracture and reinforces the point that all gunshot wounds in proximity to the C-spine demand formal evaluation.

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