VIEWS: 0 PAGES: 70 POSTED ON: 12/3/2011
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.
Pages to are hidden for
"To Look or Not to Look: Controversies in Surgical Exploration "Please download to view full document