Download RTC AERODIGESTIVE TRACT INJURIES

Principles of Neck
Exploration and
Aerodigestive Tract Injuries
Niqui Kiffin, MD
Operative Skills Conference
04 August 2009
Introduction

Only 5-10% of traumas actually involve the neck


Numerous vital structures are concentrated in a
very small anatomic area





Penetrating most common
Vascular
Aerodigestive
Vertebral
Nerve Injury
Generally, unprotected by bone or dense
muscular covering
Contents

Anatomy


“Zones”
Platysma

Initial Evaluation
 Injury Management
 Exposure Options
 Aero-Digestive Injury


Trachea
Esophagus
Anatomy

Borders




Lower margin of the
mandible
Superior nuchal line of
the occipital bone
Suprasternal notch
Upper border of the
clavicle
Anatomy

Triangles

Anterior
• Posterior belly of the
digastric muscle
• Anterior margin of the
SCM
• Sternohyoid muscle
• Divide these structures
with the inferior belly of
the omohyoid muscle


Carotid Triangle
Muscular Triangle
Anatomy

Posterior




Anterior border of the
trapezius muscle
Posterior border of the
SCM
Superior border of the
clavicle
Divide with the
posterior belly of the
omohyoid muscle
• Occipital Triangle
• Omoclavicular Triangle
Anatomy
 Posterior


Triangle Wounds
Rarely involve the esophagus, airway or
major vascular structure
However, be aware that any penetrating
wound that appears to enter in one triangle
may traverse into another compartment of the
neck and cause a lot of damage.
“Zones” of the Neck

Anterior Triangle
Wounds

Zone I
• “Base of the neck”
• Sternal notch
• Lower border of the
cricoid cartilage
• Highest mortality rate
due to risk of major
vascular and
intrathoracic injury
“Zones” of the Neck

Zone II
• Central/largest portion
• Extends from the
cricoid cartilage to the
angle of the mandible
• Most common
• Lower mortality rate
because injuries are
usually apparent and
exposure is easily
accomplished
“Zones” of the Neck

Zone III



Above the angle of the
mandible
High risk of injury to
the distal carotid
artery, pharynx, and
salivary glands
Exposure can be
exceedingly difficult
“Zones’ of the Neck

Zone I


Zone II


Thoracic outlet vasculature, vertebral and proximal
carotid arteries, lung, trachea, esophagus, spinal
cord, thoracic duct, and major cervical nerve trunks
Jugular veins, vertebral and common carotid arteries,
and external and internal carotid arteries
Zone III

Pharynx, jugular veins, vertebral arteries and the
distal internal carotid arteries
Platysma
 Platysma


Thin, broad muscle that lies just beneath the
skin and covers the entire anterior triangle
and the anteroinferior aspect of the posterior
triangle.
Wounds that do not penetrate the platysma
are considered superficial and do not require
additional work-up
Initial Evaluation

Secure an adequate airway

Preferably translaryngeal ETT
• May require fiberoptic bronchoscopy



Cricothyroidotomy
Emergent tracheostomy via neck wound
Chest tubes as necessary
• PTX, hemothorax

Circulatory Assessment/Stabilization

Significant hemorrhage
• Direct pressure
• Immediate transfer to the operating room
• No role for blind clamping or tourniquets in penetrating neck
trauma
Initial Evaluation
 History/Physical

If patient is hemodynamically stable and able
to participate
Injury Management
 Depends
on the status of the patient, the
“zone” of injury, and the presence/absence
of “hard” or “soft findings” of vascular or
aero-digestive injury.
 In the past, all Zone II injuries were
surgically explored, however now with
access to endoscopy, fluoroscopy, CT and
angiography; it is not always necessary.
“Soft Findings”
 Dysphagia
 Voice
Change
 Hemoptysis
 Hematemesis
 Widened Mediastinum
“Hard Findings”
 Airway
compromise
 Shock/active bleeding
 Pulsatile hematomas
 Extensive subcutaneous emphysema
Management
 If

 If




“hard findings” present:
Immediate operative exploration
“soft findings” present:
CT/CT Angio
Bronchoscopy
Esophageal Swallow +/- Endoscopy
If these studies positive for injury, pt deserves
an operative exploration
Exposure Options

Zone I

Supraclavicular incision
• Distal subclavian artery

Left Thoracotomy
• Proximal left subclavian artery
• Distal Esophagus

Right Thoracotomy
• Distal Trachea

Median Sternotomy
• Innominate artery/proximal right subclavian artery

Removal of the head of the clavicle
• Subclavian arteries
Exposure Options

Zone I (con’t)

“Trapdoor” incision
• Subclavian arteries

Collar incision
• Esophagus
• Proximal Trachea

Midline
• Trachea

Sternocleidomastoid
• Esophagus
• Carotid
• Jugular Veins
Exposure Options

Zone III



Sternocleidomastoid
Incision +/- extension
May require
disarticulation or
partial mandibular
resection
Limited craniotomy
Exposure Options
 Zone


II
Sternocleidomastoid Incision
Collar Incision
• Provides access to both sides of the neck
Aero-Digestive Injuries

10% of penetrating neck injuries

Esophagus
• < 1% of all traumatic injuries
• <0.1% are secondary to blunt trauma
• >80%



Secondary to penetrating neck trauma
However, 0.5-7% of penetrating neck injuries are associated
with esophageal involvement
Trachea
• 3-8% - injure cervical trachea
• Only 4% of all injuries related to the cervical trachea are from
blunt trauma

Both
• May be as much as 28%
Pathophysiology

Penetrating


Knife – cervical
trachea
GSW – cervical or
intrathoracic
• Intrathoracic – higher
incidence when
projectile crosses the
mediastinum.
Associated with injuries
to great vessels, heart,
and esophagus
Pathophysiology
 Penetrating


Stab Wounds
Gunshot Wounds
• Shotgun Wounds
Pathophysiology

Blunt

Direct Blows
•
•
•
•

“clothesline”-type injury
Crushes the cervical trachea against the vertebrae
May be called a “dashboard” injury
May also occur secondary to a high-riding shoulder harness
Rapid Hyperextension
• Produces a traction and distraction injury
• Most commonly results in laryngotracheal separation

Shear Stress
• Creates damage at fixed points (cricoid and carina)

Burst Injury
•
•
•
•
Rapid AP compression of the thorax
Simultaneous expansion in the lateral thoracic diameter
Closure of the glottis (increased intratracheal pressure)
Results in linear tears within the membranous portion
Pathophysiology
 Iatrogenic

Tracheostomy/Intubation
•
•
•
•
Improper stilette use
Erroneous choice of tube size
Over-inflation of balloon
Ill-positioned tracheostomy tube
Presentation

SQ emphysema
 PTX

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
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Persistent
Continuous air leak
Pneumomediastinum
Hemoptysis
Dyspnea
Dysphonia
Difficulty with
mechanical ventilation
Presentation

Fallen Lung of Kumpe



Lung falling away from the
hilum (laterally and
posteriorly), in contrast to
simple PTX which
collapses towards the
hilum
Abnormal migration of
ETT
Overdistention of the ETT
outside the confines of
the normal tracheal
diameter
Management
Nonoperative Management
 When?



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
Small TBI
< 1/3 circumference
Well-opposed edges
No tissue loss
No associated injuries
No need for PPV
 Controversial……
Nonoperative Management
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Retrospective Study
33 TBI
60% conservative/40% operative
5 deaths (none attributed to treatment choice)
Selection Criteria


Absence of major symptoms, no progressive SQ or
mediastinal emphysema, no severe dyspnea
requiring intubation, no difficulty with mechanical
ventilation, no PTX with persistent air leak, no open
tracheal injuries or mediastinitis
Independent of injury length, location, diagnostic
delay or pathogenesis
J of Trauma, Vol 61 (6), 2006
Nonoperative Management

What?

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Humidified air
Voice rest
Frequent suctioning
Prophylactic abx
PPI
Close observation
Bronchoscopy follow-up
Intubation distal to lesion
• If already intubated…
Operative Management

Airway Management

Single lumen ETT (long)
• May be passed distal to
injury

Proximal Injuries
• May be passed into
contralateral bronchus


Distal Injuries
Double lumen ETT
• Allow for one lung
ventilation
• Larger size


Cardiopulmonary Bypass
High Frequency Jet
Ventilation
• Low airway pressures

ECMO
Operative Management

Exposure

Cervical Injuries
• Transverse Collar Incision

May be extended up or down into median sternotomy if
necessary
• SCM Incision

Intrathoracic Injuries
• Right posterolateral thoracotomy (avoids heart and aorta)



Intrathoracic trachea
Right mainstem bronchus
Proximal left mainstem bronchus
• Left posterolateral thoracotomy

Distal left mainstem bronchus (>3cm from carina)
Operative Management
 Prophylactic Abx
 Debridement
 Repair

Primary
• Interrupted
• Absorbable Sutures

Some studies have shown effective repair with nonabsorbable sutures as well
• Knots external to trachea
Operative Management

Resection
• 4-5 cm of trachea can be mobilized to obtain
length after resection

Additional length can be obtained by cervical flexion
• Dissection should be carried out anteriorly and
posteriorly to avoid lateral pedicles (devascularize
the trachea)
• End to end anastomosis



Interrupted sutures
Assure mucosa to mucosa approximation
Suture line should be buttressed with pleural flap,
intercostal muscle flap, or pericardial flap
Operative Management

Intercostal Muscle Flap




If considered, should be preserved on entrance into
the thoracic cavity
An incision is made directly over the rib and the
periosteum stripped off
Incision is carried on through the posterior layer of the
periosteum to enter the pleural space
The muscle is then divided from the ribs above and
below while sparing the blood supply and used as a
flap to buttress your repair
Operative Management
 Cervical

Injuries
Tracheostomy +/• Avoid placing your tracheostomy through the injury
• End tracheostomy is performed only for extensive
devitalization and contamination

Repair +/• Simple anterior injuries may require repair only
Outcomes

Suture Granulomas


Can usually be alleviated with laser or bronchoscopic
intervention
Stenosis



May present later with “asthma”
Can be improved with serial dilatation and stents (rubber and
metal)
May require additional resection
• 3-6 months after initial repair

Occlusion


May require additional resection, possible pulmonary resection
Fistulas


Tracheal/Innominate artery
Tracheoesophageal
Post-Operative Management
 Extubate


immediately if possible
If pt remains intubated, keep endotracheal
balloon distal to suture line or proximal if
injury is near the carina.
Keep airway pressures low.
 Aggressive
pulmonary toilet
 Repeated bronchoscopy as needed to
evaluate repair
Highlights

Initial priority is airway stabilization


May require fiberoptic bronchoscopy
Penetrating injury predominantly affects the cervical
trachea
 Blunt injury affects the distal trachea and carina
 Suspect the diagnosis in any patient with a significant air
leak, SQ emphysema, and/or PTX despite chest tube
placement
 Collar incision – upper half of the trachea
 Right 4th ICS posterolateral thoracotomy – distal trachea
 Operative repair involves debridement of devitalized
tissue, but in most cases simple reconstruction with
absorbable interrupted sutures will suffice.
Pharynx and Esophagus

Esophageal injuries



5% of patients with penetrating neck wounds
Blunt - < 10% of all esophageal perforations
If suspected, it must be ruled out…
•
•
•
•


Direct visualization (OR)
Esophagraphy – sensitivity 50-90%
Endoscopy – sensitivity 29-100%
Combined – accuracy of almost 100%
It must be suspected in any patient with a penetrating
neck wound, a hyperextended neck or a blast injury
If diagnosis delayed, mortality increases
exponentially….based on length of time from
diagnosis to treatment.
Clinical Presentation








May be suggested by mechanism of injury
Dx can be suggested or obscured by the presence of associated
injuries
Hoarseness
Hemoptysis
Subcutaneous air
Anterior tracheal deviation
Extra-esophageal NGT
Late Presentation





Fever
Erythema
Abscess
Mediastinitis
Sepsis
Diagnosis

Gastrograffin Swallow

If negative, should be followed by barium
• Confirms leak
• Gives location (right or left)
• False negative 10%

Esophagoscopy


CT Scan


Can miss 15-40% of injuries
May show track of penetrating trauma, contrast/air around the
mediastinum, pleural effusions, or as a follow-up
Esophagram + Esophagoscopy

Sensitivity - Nearly 100%
Operative Repair
 Collar

Incision
Particularly useful if bilateral injuries present
 Sternocleidomastoid

“Carotid” incision
 Right

posterolateral thoracotomy
Upper 2/3 of the thoracic esophagus
 Left

Incision
posterolateral thoracotomy
Distal thoracic esophagus
Management




Control leak
Adequate drainage
Esophageal debridement
Primary repair




Buttress repair






Single vs. double layer closure
Absorbable suture internally, may use nonabsorbable for external layer
Interrupted vs. running repair
SCM
Intercostal muscle
Pleural flap
Pericardial flap
Nutritional Support
Early use of Abx
Operative Management
 If
in doubt…..operate on the side of the
wound or the leak.
 Most injuries can be repaired primarily,

If not possible, (large defects, extensive tissue
damage, or delayed diagnosis) may consider:
•
•
•
•
•
Tissue flaps,
T-tube drainage,
End-to-end anastomosis, or
Diversion with cervical esophagostomy
Esophagectomy
Complications

Leaks after repair may heal spontaneously if drained
adequately and antibiotic support provided.





Thoracic leaks may require radiographically placed drains
Consider stents for mid-esophageal leaks
Unstable or septic patients require re-operation
Post-operative stenosis can usually be managed with
repeated endoscopic dilatation
Fistula

Tracheoesophageal
•
•
•
•
New onset cough or pneumonia
Repeated aspiration
Usually avoided if repair is buttressed adequately
Requires operative repair
Highlights
 Signs

and symptoms are nonspecific
Must have a high degree of suspicion
 Most
injuries require a simple repair
 All repairs should be buttressed by local
tissue
 Outcome is critically affected by delay in
diagnosis
References…
 Trauma
David V. Feliciano, Kenneth L. Mattox, Ernest E.
Moore
CH 23 Management of Acute Neck Injuries
CH 27 Esophagus, Trachea and Bronchus
 ACS
Surgery: Principles and Practice
CH 7 Trauma and Thermal Injury
Sect 4 Injuries to the Neck