Neck Injuries

Abstract

Pediatric traumatic neck injuries are uncommon, occurring in less than 5% of trauma cases involving children. Despite their low frequency, they are associated with mortality rates approaching 10%. The management of such injuries can be challenging and continues to be debated. Injuries to the neck can be blunt or penetrating. Despite improvements in imaging technology and surgical care, neck injuries of either type continue to pose diagnostic and therapeutic challenges because a missed injury can result in significant morbidity and mortality. Unless the patient is hemodynamically unstable or an emergent surgical airway is required, blunt injuries to the neck are traditionally investigated using a variety of imaging modalities. Furthermore, the traditional and somewhat dogmatic a priori surgical exploration of penetrating neck injuries that violate the platysma has been challenged by many who advocate clinical paradigms that support a selective but methodical non-operative approach. No matter the paradigm, management of these injuries requires a systematic approach to assess for potential injury to the aerodigestive, nervous and vascular systems.

Appendices

Summary Points

Pediatric traumatic neck injuries are uncommon but are associated with mortality rates approaching 10%.

Unstable patients with hard signs of vascular or aerodigestive injury should be managed operatively.

Stable patients with possible injuries should be further evaluated (Fig. 16.2).

Fig. 16.2

Management flow diagram

Esophageal injuries are rare and often present in a completely asymptomatic patient, going unnoticed for days.

Esophageal injuries should be excluded by standard imaging practices in the context of a penetrating injury to the neck.

The blind approach of treating the patient simply according to which zone is involved has for the most part been abandoned.

A systematic diagnostic approach that considers the possibility of injury to major blood vessels, the esophagus, and the airway is the preferred approach

Editor’s Comment

Neck injuries have been traditionally associated with a significant concern over missed injuries and aggressive attempts to exclude injuries with invasive diagnostic procedures and the frequent use of surgical exploration. Recent advances in medical imaging have helped to minimize both missed injuries as well as iatrogenic trauma. Based on the mechanism and a thorough physical assessment for soft signs of injury to the vascular and aerodigestive structures of the neck, one can now use Doppler US, CT, CT angiography, or MRI to produce accurate and detailed images of the complex anatomy of the neck.

It is becoming increasingly common to detect intimal injuries of the carotid artery after blunt trauma or deceleration injuries of the neck. Most are minor (slight irregularity, small thrombus) and can be managed safely with anticoagulation and follow-up angiography. More serious injuries (transections, pseudo-aneurysms, significant occlusive thrombus) should be treated surgically. If the vessel is inaccessible or completely occluded by thrombus, the patient is probably best treated with anticoagulation. Consultation with an experienced interventional radiologist is critical as endovascular techniques such as stenting or embolization of smaller vessels might be available options.

The surgical approach in children is usually best done through a transverse incision in one of the skin creases, though occasionally a traditional oblique carotid incision is necessary. The exposure should be generous and all structures should be dissected carefully to avoid iatrogenic nerve injury. The thigh should be sterilely prepared in case saphenous vein graft is needed. If the patient is stable, a brief rigid bronchoscopy and esophagoscopy before intubation can be very useful and should be part of the standard surgical approach in most cases. Vocal cord position and movement should be documented before exploration is undertaken. Vascular injuries are treated using standard principles such as proximal and distal control and direct suture repair. Patch repairs should be done with autologous vein. The external jugular vein can be used but needs to be doubled (by eversion) to prevent aneurysm in the long term. Postoperative anticoagulation or aspirin therapy should be considered for complex repairs.

Most pharyngeal or cervical esophageal injuries can be treated nonoperatively or with simple drainage, though associated airway injury needs to be excluded. Airway injuries can usually be treated with simple direct repair, but intra-operative control of the airway can be treacherous and requires coordination with the anesthesiologist and a carefully planned approach, including consideration of fall-back positions in the event of an airway catastrophe. A multi-disciplinary approach that includes a vascular surgeon who specializes in adults, otolaryngologist, neurosurgeon or oral surgeon should also be considered.

Diagnostic Studies

Vascular injuries

CT arteriogram

Arteriography

Pharyngeoesophageal injuries

CT esophagogram

Contrast esophagogram

Laryngotracheal injuries

Plain radiographs of the neck and chest

CT scan of the neck and chest

Bronchoscopy