Tips & Techniques in Operative Surgery II: Neck Exploration

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1 Tips & Techniques in Operative Surgery II: Neck Exploration ศ.ดร.นพ. พรช ย โอเจร ญร ตน สาขาว ชาศ ลยศาสตร ศ รษะ-คอ และเต านม ภาคว ชาศ ลยศาสตร คณะแพทยศาสตร ศ ร ราชพยาบาล

2 Indications to Explore a Neck Removing a suspicious growth or growths Getting tissue to make a diagnosis Draining an infection or abscess Removing a foreign body Looking for evidence of trauma

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4 The Surface Anatomy of the Neck

5 III Zone III Base of skull to angle of mandible: distal extracranial carotid & vertebral arteries, uppermost segments of jugular veins II Zone II Angle of mandible to cricoid process: internal and external carotid arteries, jugular veins, pharynx, larynx, esophagus, recurrent laryngeal nerve, spinal cord, trachea, thyroid, and parathyroids I Zone I Cricoid process to clavicle: proximal common carotid, vertebral, and subclavian arteries and trachea, esophagus, dome of pleura, recurrent nerve thoracic duct, and thymus,

6 Fascial Compartments of the Neck

7 Penetrating Neck Injury Complex anatomy, many organ systems, each requiring evaluation: 1) Vascular 2) Respiratory 3) Digestive 4) Neurologic 5) Endocrine 6) Skeletal

8 Signs: Vascular Injury Shock Hemorrhage Hematoma Evolving stroke Pulse differential in upper extremities Bruit or thrill

9 Signs: Laryngotracheal Injury Subcutaneous emphysema Sucking wound Hemoptysis Dyspnea Stridor Hoarseness or dysphonia

10 Signs: Esophageal Injury Often clinically silent Milder subcutaneous emphysema Bloody saliva Dysphagia or odynophagia Fever (late)

11 Signs: Spinal Injury Neurologic defect Spinal shock Hypotensive, often not tachycardic (But in a hypotensive trauma pt, always assume hemorrhagic shock first)

12 Mechanism Stab wound What you see is what you get GSW Unpredictable trajectory Thermal injury Maintain high level of suspicion

13 Evaluation Old standard: formal neck exploration for all penetrating trauma that violates platysma Was a/w 50% negative exploratory rate New focus on directed exams: angiography, esophagoscopy, esophagography, laryngoscopy

14 * SHOCK, ENLARGING HEMATOMA, ACTIVE BLEEDING, SUBCUTANEOUS EMPHYSEMA, DYSPHAGIA, HOARSENESS, STRIDOR, OBVIOUS TRACHEAL OR ESOPHAGEAL INJURIES

15 Zone I Signs of significant injury may be hidden from inspection in the mediastinum or chest Adequate exposure for exploration and repair may require sternotomy, clavicle resection, or thoracotomy High morbidity of exploration, thus suspicion must be great before taking the patient to OR Cardiothoracic surgery consultation a must

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17 Zone II Few injuries will escape clinical examination Most carotid injuries occur here Adjunctive studies, except barium swallow and esophagoscopy where indicated, are not necessary Asymptomatic zone II injuries can generally be safely managed by observation

18 Zone III High rate of vascular and cranial nerve injuries, often multiple Often difficult to obtain proximal and distal vessel control (foley cath in hole) Exploration has high rate of injury to cranial nerves Adequate exposure may require mandibular subluxation or mandibulotomy Angiography needed to delineate site of injury Embolization techniques of greatest value here

19 Observation Observation requires admission to an intensive care unit where serial examination can be performed by a surgeon Adjunctive studies must be available at all times and at a moments notice Absence of these dictates exploration of all patients - such as in a rural setting

20 Incisions for Neck Exploration

21 Incisions for Neck Exploration

22 Management: Vascular Injuries Zone II vascular injuries readily apparent Zone I and III injuries more difficult to detect due to anatomical constraints: 32% of pts w/ major Zone I vascular injury had no localizing PE findings

23 Management: Vascular Injuries Angiography: adjunctive diagnostic tool Arteriogram can also be therapeutic w/ embolization (works esp well in Zone III where vessels are smaller) Duplex exam: in qualified centers may be acceptable alternative

24 Management: Vascular Injuries Major arteries should be repaired where possible except the vertebral which can be ligated or embolized if the contralateral vertebral artery is intact Partial lacerations can be closed primarily -- vein patches will help prevent subsequent stenosis High velocity wounds produce a surrounding area of contusion which may be thrombogenic and must be resected; then primary re-anastamosis if possible Internal Jugular: Repair vs. ligation

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26 Carotid artery injuries Repair has lower morbidity & mortality rates than ligation Preop. neurologic deficits, coma, and shock are poor prognostic signs but are not absolute contraindications for repair Carotid ligation: - comatose patients with no antegrade flow in the internal carotid artery - uncontrollable hemorrhage and temporary shunt is difficult

27 Management: Esophageal Injury Early detection of injury is paramount If repaired < 24hrs, survival 90% If > 24 hours, survival 64% Best detected by combination of esophagoscopy and esophagography (sensitivity near 100%) in symptomatic patients Rigid / flexible endoscopy both acceptable Injection of air or methylene blue in the mouth may aid in localizing injuries

28 Management: Esophageal Injury Operative repair: Primary closure is ideal (esp < 24 hrs) Close over a T-tube Buttress w/ muscle flaps or pleura Divert with esophageal stoma Widely drain Fistula rate up to 57% Consider routine swallow studies All patients should be NPO for 5-7 days

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30 Management: Laryngo-tracheal Injury Any doubt about the extent of injury endoscopy should be performed Indications for surgical exploration include: Large mucosal lacerations Exposed cartilage Multiple or displaced cartilaginous fractures Vocal cord immobility Fractured cricoid Disruption of the cricoarytenoid joint Lacerations involving the free margin of the vocal cord or anterior commisure Explore within 24 hours of the injury Maximize airway and phonation results Verschueren et al. Management of Laryngo-Tracheal Injuries. J Oral Maxillofac Surg 2006.

31 Management: Laryngo-tracheal Injury DL where laryngeal injury is suspected Primary repair is the rule, tracheal mobility allows closure of defects up to 2-3cm Mucosal tears are closed with absorbable sutures Tracheotomy one ring below injury when laryngeal or high tracheal injury May need graft if more than two rings gone

32 Management: Laryngo-tracheal Injury Laryngeal skeleton is exposed from the hyoid to sternal notch Midline thyrotomy May use a vertical fracture (2 to 3mm of midline) Nondisplaced fractures Suture outer perichondrium Primary closure with nonabsorbable sutures Debridement should be minimized Mucosal lacerations Meticulously repaired using fine absorbable sutures Knots outside the laryngeal lumen (prevent granulation)

33 Management: Laryngo-tracheal Injury

34 Management: Spinal Injury Can only prevent further injury Steroids appear to have some benefit in blunt trauma, but no evidence for routine use in penetrating trauma

35 Complications of Neck Exploration Hemorrhage Pseudoaneurysms Arterial dissection Thrombosis of an internal jugular vein Massive air emboli Fistulas - esophagocutaneous, esophagotracheal, tracheocutaneous, venoarterial Anastomotic or repair disruption

36 Complications of Neck Exploration Infections - missed esophageal or laryngotracheal injuries Stenosis or obstruction of luminal structures: esophagus, larynx, trachea, or vessels Neurologic deficits - direct injury to a nerve or ischemic infarct caused by arterial injury leading to numbness, hoarseness, difficulty in swallowing, speaking, shoulder movement and diaphragm movement Chyle Leak

37 Conclusions Know your anatomy ABC s Neck exploration is no longer mandatory in asymptomatic pts Physical exam is probably the most useful diagnostic tool (esp Zone II) Intervention should be directed to sites of possible injury Non-invasive diagnostic/therapeutic modalities should be utilized

38 Thank you for your attention

39 Case Presentation 50 yo M, s/p single stab wound to R neck, at level of the larynx, overlying the SCM muscle. VS: HR 110, BP 130/80. No respiratory distress. What are the zones of the neck? What structures are at risk? Who needs a neck exploration? If no exploration, what dx studies should be done?