To Look or Not to Look: Controversies in Surgical Exploration by ekx2ojOV

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									      To Look or Not to Look:

     Controversies in Surgical
    Exploration of Penetrating
          Neck Trauma

Anne Conlin, BA&Sc, MD
PGY-2, Otolaryngology
                    Case

   46 year old male working in abattoir
   Was butchering beef when a live steer
    broke through gate, knocking him over
   Sustained penetrating trauma to the neck
    w/ a meat hook
                     Case

   Treated at local ED w/ irrigation and
    antibiotics; penrose drain placed
   Transferred to TOH
                            Case
   Hx
        Pt. unsure of mechanism of injury
        Complained of pain in the neck
   Px
        VSS, O2 sats >92%
        General: moderate discomfort
        Neck: 2 cm wound inferior to R body of mandible,
         penetrating platysma; pain on palpation; neck
         otherwise unremarkable
          What should we do?

   Day call ENT staff: booked patient as P3
   Night call ENT staff: “Why are we here?”
                    Objectives

   Case presentation
   Approach to penetrating neck wounds
   To look or not to look? The controversy.
       Adult population
       Pediatric population
   Summary
An Approach to Penetrating
      Neck Trauma
       Penetrating Neck Trauma
   5-10% of all trauma
    admissions
   Low overall mortality
    0-11%
   30% of cases involve
    multi-system injury
        Approach to Penetrating Neck
                  Trauma
   Zone I
       Sternal notch to cricoid
        cartilage
   Zone II
       Cricoid cartilage to
        angle of mandible
   Zone III
       Angle of mandible to
        base of skull
                              Zone I
   High risk of serious injury
   Difficult region for
    exposure and control
   Vital structures
       Proximal carotid, vertebral
        & subclavian a
       Major BV of upper
        mediastinum
       Lung apices
       Esophagus
       Trachea
       Thoracic duct
                             Zone II
   Easier access and control
   Vital structures:
       Carotid sheath: carotid a,
        jugular v, vagus n
       Vertebral a
       Esophagus
       Trachea
       Larynx
       Recurrent laryngeal n
       Spinal cord
                            Zone III
   Difficult region for
    exposure & control
   Vital structures:
       Distal carotid a
       Vertebral a
       Parotid & other
        salivary glands
       Pharynx
       CN IX, X, XI, XII
       Spinal cord
                  Systems at Risk

   Vascular                         Signs:
       Including:                      ABCs
                                        External
          Internal, external &
           common carotid                hemorrhage
           arteries                     Hematoma

          Vertebral &                  Shock

           subclavian arteries       Present in: 25%
          Internal & external
                                     Mortality: 50%
           jugular veins
                Systems at Risk
   Pharyngo-                   Often difficult to
    esophageal                   detect
       Symptoms & Signs:       Potential
         Dysphagia &            consequences:
          odynophagia              Mediastinitis
         Hemoptysis &             Sepsis
          hematemesis           Present in: 5%
         Subcutaneous
          emphysema
         Air bubbling at
          wound (w̸ cough)
                 Systems at Risk

   Laryngotracheal          Present in: 10%
       Signs:               Mortality: 20%
          Dyspnea
          Hoarseness

          Stridor

          Subcutaneous
           emphysema
                     Systems at Risk
   Nervous system                    Brachial plexus:
       Cranial nerves:                    Median n – fist
                                           Radial n – wrist ext
            Facial
                                           Ulnar n – finger abd
            Glossopharyngeal
                                           MCC n – elbow flex
            Recurrent laryngeal
                                           Axillary n – arm abd
            Accessory
            Hypoglossal              GCS
       Spinal cord
                                      Uncommon injury
                                      Common missed injury
             Mechanism of Injury
   Stab wounds
       depth & direction
        difficult to determine
        on exam
   Bullets & projectiles
       entry ± exit sites
        provide little
        information on amount
        of tissue injured
Management of Penetrating Neck
          Trauma:
     Historical Approach
    Classic Approach to Penetrating
             Neck Wounds
   Until 1950s:
       Seen almost exclusively by military surgeons
       Recommended mandatory exploration for all
        wounds penetrating the platysma
       Rationale: high morbidity & mortality from
        missed injuries
              Controversy Arises

   Mandatory surgical exploration was
    challenged in the 1970s & 1980s
       Arteriography available
       Health economics
       Risk vs. benefit
          Annals of Surgery, 1985
   Retrospective study
   257 patients w/ injury penetrating platysma
   Group I (1975-1981): mandatory exploration
   Group II (1981-1984): selective neck exploration
       Indications: hypotension, shock, profuse external
        bleed, expanding hematoma, dysphagia, neurological
        deficit, diminished carotid pulse, subQ emphysema,
        hemoptysis, hemetemesis, spitting blood, respiratory
        distress
            Annals of Surgery, 1985
   Group I: 69% of pt w/
    mandatory exploration
    had no injury
   Group II: 22% of pt w/
    selective exploration had
    no injury; none of the
    observed pt required
    subsequent exploration
   Group II: 2 mortalities in
    observed pt (MI; spinal
    cord transection)
   Remainder of mortalities
    in explored patients
    The Importance of the Zones

   Annals of Surgery study did not subgroup
    patients by zone of injury
   Considerable variation in surgical access
    and structures at risk by zone of injury
Investigations
World Journal of Surgery, 1997

   Demetriades et al, 1997
   Prospective study, n=223
   Objective: to asses role of clinical
    examination, angiography, colour flow
    Doppler
    World Journal of Surgery, 1997
   Clinical examination
   Emergency surgery:
                                               PNT
        Severe active bleeding
        Refractory shock
                                  Hard Signs         No Hard Signs
        Air bubbling at wound
        Dyspnea                                     Investigations
   All other patients              To OR             According to
                                                        Protocol
    underwent investigations
    according to protocol
World Journal of Surgery
World Journal of Surgery
           Emergency Operations
   38 patients (17%) subjected to emergency
    operation
   Only therapeutic in 30 (13.5% of all cases)
       6 had negative exploration
       2 had non-therapeutic surgery: thrombosed vertebral
        artery
   One missed esophageal perforation during
    exploration
   Deaths: 6 total; 5 due to non-neck injuries;
    unclear if deaths in surgery or non-surgery grp
    Results: Vascular Assessment
   Angiography
       176 patients
       34 abnormalities (19.3%)
       14 required surgery (8%)
       Most common:
            vertebral artery occlusion (5%)
       Others:
            VA tear, ICA occlusion, CCA aneurysm/tear;
             unnamed vessel thrombosis
               Results: Vascular
   Angiography + Colour Flow Doppler
       99 patients
       w/ angiography as gold standard, CFD had:
          Sensitivity = 91.7%
          Specificity = 100%

          PPV = 100%

          NPV = 99%

          100% all-around if only injuries requiring surgery
           were considered
               Results: Vascular
   Angiography                  Clinical Exam for
    complications                 Vascular Injury
       Femoral hematoma in          w/ angiography or
        5 patients (2.2%)             surgical exploration as
                                      gold standard:
                                          NPV = 91.7%
                                          100% if only injuries
                                           requiring surgery were
                                           considered
Results: Aerodigestive Assessment
   216 patients clinically      Contrast swallow study
    evaluated                        98 patients w/ Sx or
   64 had +SSx                       proximity injury
                                     2% esophageal injury
   10 required surgical              (+Sx)
    repair                       Esophagoscopy
   0 asymptomatic patients          22 patients, all normal
    required operation
                                 Laryngoscopy
                                     149 patients w/ Sx or
                                      proximity injury
                                     25 abnormal (VC
                                      dyskinesia, edema, blood)
                                     5 required surgery
                   Discussion

   If policy of mandatory surgical
    exploration:
       Non-therapeutic in 86.5%
   Angiography has low yield and does not
    change management
       7.8% of asymptomatic patients had +ve AG
       0% asymptomatic patients had +ve AG
        finding requiring surgery
                      Discussion
   Esophageal studies
       Selective contrast swallow study yield: 2%
       Esophagoscopy yield: 0%
   Overall
       Clinical exam has 100% NPV for vascular and
        aerodigestive injuries requiring surgery
       Clinical exam: 38.1% sensitivity for vascular and
        aerodigestive injuries requiring surgery
   CFD is a reliable and inexpensive alternative to
    angiography
                   Discussion

   Developed algorithm
   If this had been followed:
       Total cost would be $30,500 vs. actual cost
        $444,500
       If CFD done instead of AG: $250,000 savings
The Canadian Experience
    Canadian Journal of Surgery,
               2001
   Retrospective chart review
   130 consecutive pt. w/ neck wounds
    penetrating platysma
   Surgical exploration vs. observation
                       CJS 2001
   Location:
       Zone I: 15%
       Zone II: 81%
       Zone III: 4%
   Mechanism:
       Knife/broken bottle:
        73%
       GSW: 5%
                      CJS, 2001
   Management
       Observation: 50/130
        (38%)
       Surgery: 80/130
        (62%)
           Important Findings

   Zone II:
   All zone II major vascular injuries were
    symptomatic on presentation
   Neck exploration was negative in all
    asymptomatic zone II injured patients
        Asymptomatic Patients

   76% of all injuries were symptomatic on
    presentation
   Mean hospital stay for asymptomatic
    patients treated w/ observation & surgical
    exploration was similar (3.5; 4.3;
    p=0.575)
                 Missed Injuries
   1 pharyngeal injury missed in a pt who
    underwent surgical exploration
   1 pt developed pharyngocutaneous fistula
    after exploration & repair of lacerated
    trachea
   Follow-up visits
       1 brachial plexus injury
       1 accessory nerve injury
             Long-term Disability

   All neurologic
   3 pt managed by observation + 6 pt
    managed by surgery:
       Phrenic (1)
       Recurrent laryngeal (1)
       Accessory (3)
       Brachial plexus (4)
         Canadian Study Overall
   Majority of patients were asymptomatic
   Optimal management of asymptomatic Zone II
    injured patient is not known
   Neck exploration does not rule-out the possibility
    for missed injury
   Bottom-line: risk of death from missed
    esophageal injury, therefore, consider NPO x24
    hrs, close observation x48 hrs, & low threshold
    for rigid esophagoscopy
The Pediatric Experience
          Abujamra et al, 2003
   Retrospective chart
    review
   Age ≤16
   N=31

   84% in Zone II
            Abujamra et al, 2003
   Surgical exploration          Barium swallow
       8 patients (25.8%)            4 patients
       All penetrated                3 based on location &
        platysma                       mechanism (GSW)
       None revealed injury          1 based on physical
                                       (hematoma)
                                      All normal
                                  0 angiograms
                                  Dependent on staff
               Abujamra et al, 2003
   Laryngoscopy                      48% w/ other injuries
       3 patients                        Most were facial
       2 had minor physical               lacerations
        findings                      3 patients died
            (non-expanding neck          All had major physical
             hematoma; SC air on
             neck XR)                      findings
                                                2 had GCS 3, pulseless
       1 laceration ant. to                

                                                1 had GCS 8, shock
        larynx                              


       All normal                    No evidence of
                                       complications
            Abujamra et al, 2003

   Concluded
       Penetrating neck injuries a rare in pediatric pt
       Management varies
       Observation in a stable patient is appropriate
              Luqman et al, 2005
   Case series (n=3)
   1 patient w/ PNT secondary to attack by fighting
    rooster
       Initially assessed; puncture wounds to face & neck;
        D/C’d
       RTER 24 hr later w/ fever, neck swelling, &
        respiratory distress
       Neck: crepitus; inflammation; induration
       CXR: pneumomediastinum
            Luqman et al, 2005
   ICU w/ amp, gent &
    clinda
   Endoscopic EUA: 0.5 cm
    perforation of lateral wall
    of pharynx
   Neck explored through
    lateral incision  pus
    drained
   NG feeds  N contrast
    study POD#10
   D/C HD#14 on N diet
A Zone-Specific Approach to
     Management of
 Penetrating Neck Trauma
                              Zones I & III
   Very difficult surgical access
   Angiography indicated in all
    but the most unstable patients
   Unstable  O.R.
       large expanding hematoma,
        severe active or pulsatile
        bleeding, shock unresponsive
        to fluids, signs of cerebral
        infarction, presence of a bruit
        or thrill, and diminished distal
        pulses
   Otherwise: angio & observe
         Zone II Management

   Remains most controversial
                      Insull, 2007
   Retrospective review of 63 pt. w/ only Zone II
    penetrating neck trauma in New Zealand
   Hard signs:
       Active external bleeding, neck bruit, or thrill
       Expansive, pulsatile hematoma
       Dysphagia
       Hoarseness
       Subcutaneous emphysema
       Sucking neck wound
       Neurological deficit
Insull, 2007
                     Insull, 2007
   Multivariable regression analysis
       Hard signs were predictive of positive neck
        exploration
       No other variables were significant predictors
   Bayesian parameters re. hard signs
       Sensitivity 93%
       Specificity 96%
       Positive predictive value 87%
       Negative predictive value 98%
                Insull, 2007

   No complications of neck exploration
   No missed injuries
   If patients had been managed solely on
    basis Px without investigations, 1 injury
    would have been missed (foreign body)
Which C T ?
                    Contrast CT
   14 pt w/ Zone II injury,
    prospective                 Clinical Exam
   Surgical findings
    compared to high and
    low probability CT          Contrast CT
    findings
   3 patients had 5 surgical                   Surgeon reads CT
    findings
   4 of 5 were diagnosed by      Surgery
    CT
       Sens: 100% Spec: 91%
       PPV: 75%   NPV: 100%
                    Dynamic CT
   Prospective blinded
    study, DCT vs. Px            Clinical Exam

   42 patients not requiring
    emergent surgery              Dynamic CT
   250 cc contrast, 0.5 cm
    cuts
                                Esophagoscopy
   Result: minimal
    contribution to clinical
    exam & esophagoscopy,           Surgery
    no change in surgical
    intervention
             CT Angiography
   Retrospective review
   N=130, zone II
   34 patients had CTA, 96 did not
   Significantly fewer neck explorations
    among pt w/ CTA
   (No comparison to clinical exam or
    conventional angiography; no reports on
    sens, spec, PPV, NPV)
CT Angiography with 3-D
    Reconstruction
              Case Revisited

   Contrast CT: penrose drain; no vascular,
    aerodigestive, or nerve injury identified
   Neck exploration: negative
   Course in Hospital: observed x48 hours
    then D/C’d home on oral Abx
          Take Home Messages
   Management of penetrating neck trauma is
    controversial
   Selective surgical management is common
    practice
   Variety of investigations available
   Physical exam alone is very useful and may be
    sufficient
   Adoption of unified, evidence-based approach to
    management of PNT is elusive
   Limited literature in pediatric population
              Discussion

   Thanks.

								
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