Surgical exploration for severe neck trauma

INTRODUCTION — The complex anatomy of the neck makes any severe injury to the neck potentially lethal. An organized approach to the identification and treatment of any injuries facilitates care and reduces missed injuries. Surgical exploration for severe neck trauma is more likely to be required for penetrating neck injury compared with blunt mechanisms. Penetrating neck injuries can present in a subtle or dramatic fashion (picture 1). The most common etiologies are gunshot wounds (GSWs) and stab wounds (SWs). In general, stab wounds to the neck occur at a much higher rate compared with GSWs (61 percent versus 38 percent, in one review [1]). Overall, about 35 percent of all GSWs and 20 percent of SWs to the neck result in major injuries, though in both cases about one quarter require operative intervention [2].

The initial evaluation, indications, and technique for neck exploration for neck trauma are reviewed. General considerations for the evaluation and management of penetrating and blunt injury to specific structures of the neck are discussed separately.

●(See "Penetrating neck injuries: Initial evaluation and management" and "Overview of esophageal injury due to blunt or penetrating trauma in adults".)

●(See "Identification and management of tracheobronchial injuries due to blunt or penetrating trauma".)

●(See "Penetrating neck injuries: Initial evaluation and management" and "Overview of esophageal injury due to blunt or penetrating trauma in adults".)

●(See "Blunt cerebrovascular injury: Mechanisms, screening, and diagnostic evaluation" and "Blunt cerebrovascular injury: Treatment and outcomes" and "Vertebral artery revascularization".)

INITIAL EVALUATION — The initial physical examination of the patient with neck injury may demonstrate signs of vascular or aerodigestive tract injuries. These signs can be regarded as either "soft signs," which tend to be nonspecific, or "hard signs," which are indicative of severe injury necessitating immediate attention.

●Soft signs – Soft signs of neck injury may include neck pain, swelling, dysphagia, shortness of breath, among others. In a series of 207 patients evaluated in the emergency department with a penetrating neck injury, the sensitivity and negative predictive value of any soft sign to determine injuries that required surgical repair was 97.4 percent (95% CI 86.5-99.5%) and 98.7 percent (95% CI 92.8-99.8%), respectively. "Soft signs" in this study included minimal bleeding, mild-to-moderate bruising, hypotension responding to resuscitation, and minimal levels of any of the following: hoarseness, stridor, hemoptysis, subcutaneous emphysema, odynophagia, dysphagia, or hematemesis. Vascular soft signs were present in 57 percent of the patients, and soft signs of the airway and the upper gastrointestinal tract were present in 15.9 and 21.3 percent of the patients, respectively. Interestingly, 36.2 percent of patients did not exhibit any soft signs of injury and were considered "asymptomatic" [3].

●Hard signs

•Vascular injury – Hard signs of vascular injury include active severe external bleeding, expanding hematoma; bruit or thrill over a wound or injury site in the setting of hemorrhagic shock; absence of pulses distal to the injury (eg, carotid, axillary); evidence of peripheral ischemia (eg, upper extremity pallor, stroke); or unexplained hypotension. (See "Overview of blunt and penetrating thoracic vascular injury in adults" and "Blunt cerebrovascular injury: Mechanisms, screening, and diagnostic evaluation".)

•Aerodigestive injury – Hard signs of aerodigestive injury (eg, stridor, respiratory distress) include massive subcutaneous emphysema, mediastinal emphysema, air bubbling through the neck wound, and massive hemoptysis. (See "Identification and management of tracheobronchial injuries due to blunt or penetrating trauma" and "Overview of blunt and penetrating thoracic vascular injury in adults".)

Hemodynamically stable patients without hard signs of vascular or aerodigestive tract injuries should undergo computed tomography (CT) scanning to screen for potential injuries. CT is a minimally invasive, cost-effective diagnostic tool that provides information to direct treatment and improves outcomes. In one study of 405 patients, with the implementation of CT scan on arrival, mortality decreased from 6.9 to 3.7 percent and intensive care unit admissions decreased from 30.9 to 24.5 percent [4].

INJURY GRADING — The American Association for the Surgery of Trauma has provided injury grading that reflects the increasing severity of injury. These include:

●Esophagus injury scale (table 1)

●Cervical vascular injury scale (table 2)

The Schaefer classification is commonly used to grade the severity of laryngeal injury [5]. (See "Identification and management of tracheobronchial injuries due to blunt or penetrating trauma".)

INDICATIONS FOR NECK EXPLORATION — The patient presenting with a penetrating neck injury may be "unstable" with an airway emergency and/or active hemorrhage from the injury. The patient should be considered to have a tenuous airway, and immediate steps should be taken to secure the airway and control hemorrhage [6].

Airway emergency — The most immediate concern in the patient with severe neck injury is whether the airway is intact. Approximately 8 to 11 percent of patients with penetrating neck injury will present with airway compromise [2,7-10]. In a review of penetrating neck injuries, orotracheal intubation failed in 12 percent, requiring emergency cricothyroidotomy.

If the patient has significant subcutaneous air in the neck, a "blowing neck wound," is coughing up blood, or has stridor, these all are hard signs that should raise concern (table 3) for a significant airway injury (table 4). From the experience in Operation Iraqi Freedom, penetrating face (46 percent) and neck trauma (31 percent) was the most common mechanism of injury requiring airway control [11]. (See "Identification and management of tracheobronchial injuries due to blunt or penetrating trauma".)

The clinician should consider awake intubation, possibly a fiberoptic intubation, but the view may be distorted by a cervical hematoma, blood, or a foreign body (picture 2) in the airway. These factors may compromise the view of the airway. Several video laryngoscopes are available that can make intubating a difficult airway easier. For airway management in the emergency department, the GlideScope appears to have the best results with a 78 percent first-attempt success rate compared with 68 percent for direct laryngoscopy in difficult airways (eg, large tongue, obesity, small mandible, or presence of blood) [12]. (See "Airway management in the adult with direct airway trauma for emergency medicine and critical care" and "Devices for difficult airway management in adults for emergency medicine and critical care".)

A surgical airway may need to be performed in the trauma bay to stabilize the patient. Cricothyroidotomy is the safest procedure if the airway cannot be seen clearly to intubate using a laryngoscope. One must also be aware that the endotracheal tube may be lodged above the injury. Generally, an open surgical approach is preferred due to expediency, especially if the patient is hypoxic. Some surgeons may be comfortable performing an emergency percutaneous tracheostomy (eg, Medical Blue Rhino technique) [13,14]. However, securing the airway should not be delayed if this equipment is not immediately available. Ultrasound guidance can be used to increase the safety of the procedure. The trachea and surrounding structures can usually be identified with ultrasound, provided a significant amount of subcutaneous air is not present in the neck.

If the trachea appears to be transected, the neck wound should be extended to identify the level of the injury, and, if necessary, the patient can be intubated via the tracheal injury site. Bronchoscopy can confirm placement of the tube by visualizing the carina. If necessary, the airway can be revised once the patient is in the operating room (OR).

Active neck hemorrhage — For the patient presenting with active bleeding, direct pressure should be maintained on the wound with packing as needed for larger wounds. Hemostatic gauze (eg, kaolin-impregnated sponge) (table 5) is preferred for packing, if available. In some cases when bleeding cannot be controlled with direct pressure on the wound, pressure on the carotid artery may be required at the point proximal to the neck injury along the sternocleidomastoid muscle (SCM) pressing against the vertebral column.

There are reports of placing a Foley catheter into the wound and inflating it to control hemorrhage, though direct pressure using hemostatic gauze may be preferred [15-17]. If the bleeding is controlled, a bedside chest radiograph and possibly a neck radiograph should be quickly obtained to identify the potential for other missiles, foreign bodies, or injuries (eg, spine).

Specific organ injury — A hemodynamically stable patient with a penetrating neck injury who does not have an airway emergency or active hemorrhage may have other clinical signs of airway injury, vascular injury, esophageal injury, or other injury (eg, thyroid) that mandates surgical exploration and repair. The physical exam remains the primary screening method for determining the need for further evaluation, which may include surgical exploration. If a cervical collar was applied in the field, it should be carefully removed to inspect all aspects of the neck, provided there is no indication for ongoing spinal immobilization (generally not needed for penetrating neck injury due to low incidence of unstable cervical boney injuries). (See "Penetrating neck injuries: Initial evaluation and management", section on 'Clinical features of injury'.)

Whether the injury is anterior or in the posterior neck region determines the structures at risk (figure 1). Under most circumstances, the evaluation of the stable patient with severe injuries includes neck imaging with CT angiography. CT angiography of the neck includes imaging from the base of the skull to the aortic arch including both arterial and venous phases. Oral contrast is typically not given. In prospective studies, CT angiography has been shown to have 100 percent sensitivity and 97.5 percent specificity in detecting all clinically significant injuries [18,19]. The course of the injury can usually be mapped out (image 1 and image 2 and image 3).

The identification of specific injuries on imaging is briefly reviewed below. General management, including conservative care and indications for surgical exploration, is reviewed in the linked topic reviews.

●Tracheobronchial injury – If there is significant subcutaneous emphysema or other clinical concern that the airway may have been injured, the airway should be further evaluated using a fiberoptic bronchoscope, which is performed in the operating room. (See "Penetrating neck injuries: Initial evaluation and management", section on 'Laryngotracheal injury' and "Identification and management of tracheobronchial injuries due to blunt or penetrating trauma".)

●Vascular injury – Multidetector CT angiography identifies significant arterial or venous injuries with a sensitivity and specificity of 94.4 and 96.7 percent, respectively [20]. Findings concerning for a vascular injury are extravasation of contrast, luminal irregularities, pseudoaneurysm, or thrombosis of a vessel. (See "Blunt cerebrovascular injury: Mechanisms, screening, and diagnostic evaluation" and "Blunt cerebrovascular injury: Treatment and outcomes" and "Overview of blunt and penetrating thoracic vascular injury in adults".)

Venous injuries can also be easily identified on CT imaging (venous phase). Most minor venous injuries can be managed nonoperatively due to the low-pressure venous system. More severe injuries will require exploration. In a series of 817 patients with penetrating neck injury, 9.3 percent had venous injury [21]. Among these, 26.3 percent required immediate surgical exploration, and 7/20 had an associated arterial injury.

●Digestive tract injury – In hemodynamically stable patients, CT or fluoroscopic esophagography is reliable for evaluating the esophagus. In a study in which 92.2 percent of patients had combined angiography/esophagography, all but one upper digestive tract injury were diagnosed using only CT esophagography [22]. For patients who are taken to the operating room for another indication, the esophagus should be evaluated simultaneously using fiberoptic endoscopy. If necessary, the hypopharynx can be inspected using a direct laryngoscopy. (See "Penetrating neck injuries: Initial evaluation and management", section on 'Pharyngoesophageal injuries' and "Overview of esophageal injury due to blunt or penetrating trauma in adults".)

●Other injuries – Other injuries can include thyroid injury, neurologic injury (cervical spine, brachial plexus), and injury to the thoracic duct. These are generally identified upon surgical exploration. (See "Acute traumatic spinal cord injury" and "Traumatic peripheral neuropathies" and "Surgical treatment of brachial plexus injuries".)

SURGICAL APPROACH

Approach by zone of injury — Classically, the anatomic zones of the neck have dictated the surgical approach to penetrating neck injury in patients who do not have an airway emergency or active hemorrhage (figure 1) for evaluation and therapeutic management (table 6).

●Zone I extends from the sternal notch to the cricoid cartilage. The vessels of the neck, trachea, and esophagus are at risk of injury. In an emergency situation, one must be prepared to perform a median sternotomy to gain proximal control of major vascular structures. (See 'Median sternotomy' below.)

●Zone II extends from the cricoid cartilage to the angle of the mandible. The major neck vessels and the bifurcation of the carotid are in this region, and the trachea and larynx are in this region. The hypopharynx also extends to the cricoid region. This area has been traditionally managed with conservative evaluation or surgical exploration using an oblique (unilateral) or a collar incision (bilateral). (See 'Oblique incision' below and 'Collar incision' below.)

●Zone III extends from the angle of the mandible to the base of the skull. Penetrating neck injuries in zone III are very difficult to access surgically. Typically, only bleeding injuries are likely to require emergent/urgent management. Such vascular injuries are best managed via an endovascular approach. (See 'Endovascular options' below.)

Overall, following penetrating neck injury, zone II is the most commonly injured area (36 percent), followed by zone III (18 percent) and I (14 percent) [17]. The remaining 32 percent of penetrating neck injuries involve multiple zones, or the zone is difficult to characterize. While the zones of the neck can provide clues to potential injuries and course of the clinical workup and surgical management, with the advances in CT imaging, many argue that the zone of injury is less important. A good physical exam regardless of zone combined with CT angiography (CTA) identifies important injuries and helps avoid negative exploration for zone II injuries [6].

Neck exposure — Surgical neck exposure can be unilateral (ie, oblique incision) or bilateral (ie, collar incision) depending on the location(s) of vascular or aerodigestive tract injuries (figure 2), which dictates the initial approach.

Positioning — The patient should be positioned supine with the head turned laterally for a unilateral approach. The bed should be slightly in Trendelenburg position to decrease the risk of an air embolism in the event of a major venous injury. The patient should be prepared from the chin to the xiphoid process exposing the entire chest in case additional exposure is needed. Ideally, the arms should be tucked in, but in a trauma scenario the arms may need to be accessed for additional intravenous access or arterial lines.

Oblique incision — The standard unilateral approach is an oblique incision anterior to the sternocleidomastoid muscle. The incision can be extended to the sternal notch or to the mastoid process if more extensive exposure is required. The sternocleidomastoid muscle and the internal jugular vein are retracted laterally. The carotid sheath with the vagus nerve lies just inferior and medial. The omohyoid muscle crosses the carotid sheath inferiorly and will need to be divided. The facial vein crosses superiorly and may also need to be divided if additional exposure is required. The carotid bifurcation is at this level; the internal carotid is crossed by the hypoglossal nerve.

Collar incision — A transcervical penetrating neck injury requires both sides of the neck to be explored. A collar incision should be made two fingerbreadths above the sternal notch. This allows sufficient space for placement of a tracheostomy tube (picture 3).

The collar incision can be extended obliquely up on either side of the neck along the sternocleidomastoid muscle, which will allow for maximum exposure. The strap muscles (sternothyroid and sternohyoid muscles) can be divided for full exposure of the anterior neck structures. The carotid sheath can be mobilized together laterally to explore the trachea or esophagus in the lower aspect in the neck. Both the internal jugular and the carotid artery can be encircled with vessel loops for vascular control to either side of any injury. Care must be taken in the region of the thyroid to not injure the recurrent laryngeal nerve.

The esophagus is located posteriorly and can be easily identified once a nasogastric tube has been placed. The esophagus can be exposed from either side of the neck.

Indications for additional exposure

Median sternotomy — Injuries to zone I are concerning for proximal vascular injury at the thoracic inlet. Proximal control of such injuries will require vascular exposure in the chest since the origins of these vessels are from the thoracic aorta or innominate veins. This may require a median sternotomy. The proximal common carotid artery and the innominate, left and right subclavian, and vertebral arteries are best accessed via a median sternotomy. The subclavian arteries can be controlled via a thoracotomy (right or left) but are very difficult to repair using this approach. In addition, injury to major venous structures (internal jugular and innominate veins) may also require a median sternotomy. Evaluation and repair of trachea or thoracic esophagus may also require a sternotomy; the proximal esophagus and trachea are typically accessed via a right thoracotomy.

Clavicle resection — The majority of the major vascular structures can be accessed with a median sternotomy. The exception is the left subclavian artery near the thoracic inlet. The left subclavian is the last of the great vessels to take off the aortic arch. As such, the subclavian artery is positioned posteriorly in the upper mediastinum (figure 3). The classical surgical approach would be to create a "trap door" left-sided extension to a median sternotomy at the manubrial sternal junction between the T2 and T3 intercostal space (figure 4). However, this is a very morbid chest exposure (figure 5). The alternative is to perform a partial clavicle resection to expose the subclavian artery. To accomplish this, the incision is extended over the superior aspect of the clavicle. The dissection can be taken down to the clavicle proximally. The clavicular head can be disarticulated off the sternum (figure 6), but it is quicker to divide the clavicle using a Gigli saw at the sternum, skeletonize the clavicle to its midsection, and then transect with the clavicle laterally. The entire length of the subclavian artery and vein is now exposed.

REPAIR OF PENETRATING INJURIES — The general approach to injuries of the various neck structures is reviewed below. Complications associated with these repairs can be anticipated based on the initial operative management, the surgical setting, the amount of energy inflicted to the tissues due to trauma, and the instability of the patient.

Vascular injuries — In general, most penetrating vascular injuries in the cervicothoracic region can be repaired primarily.

Arterial repair or ligation — For hemodynamically unstable patients, the common carotid artery can be ligated [23]. Prior to ligation, the distal common carotid artery should be assessed for back bleeding. In general, collateral arterial flow from the face should be ample enough to supply blood flow into the internal carotid. However, if there is no or minimal back bleeding, the carotid artery must be repaired (picture 4). Temporary arterial shunting can be used in the setting of "damage control" with subsequent timely reconstruction. In one institutional experience comparing later injuries (2000 to 2013; including use of a shunt or endovascular stent placement) with those in the past (1974 to 1988; not shunt or endovascular), the rate of post-treatment stroke following carotid injury was similar for both time periods (2 versus 6 percent) [24].

A partial carotid artery injury <25 percent the diameter of the vessel can be debrided and repaired using fine Prolene suture. Arterial injuries due to gunshot wound are managed with debridement and repair, which may require resection of the injured segment of the artery. If more than 1 centimeter is resected, the repair will need an interposition graft. The internal carotid can be mobilized and a primary anastomosis performed. The common carotid is typically repaired with a 6 to 8 mm expanded polytetrafluoroethylene (ePTFE) graft. Occasionally, the common carotid artery is large enough for a 10 mm graft. If necessary, such as in the setting of contamination, a reversed saphenous vein graft can be used.

Internal carotid artery injuries should be repaired, if possible, with either a reverse saphenous vein graft or patch graft. For high internal carotid injury that approaches the base of the skull, ligation or endovascular embolization may be more prudent, but these injuries have a high rate of stroke.

Injuries to the external carotid artery can be repaired if a simple repair can be accomplished. The external carotid artery can also be ligated without significant concerns due to the extensive collateral flow through the face.

In the rare event that the vertebral artery requires surgical control, the following approaches are used for the V1 and V2 segment (figure 7). For injury in the V3 or V4, an endovascular approach is the only option. (See 'Endovascular options' below.)

●For injury in the V1 segment, a median sternotomy will be required with ligation of the vertebral artery at its origin, which is located in the subclavian artery.

●For injury in the V2 segment, endovascular management is preferred due to the challenges of this exposure, but if endovascular treatment is not available (or deemed not to be an option), the transverse process below the injury is identified. The vertebral artery runs through the transverse foramina, located centrally in the transverse process (figure 7). Immediately behind the vertebrae is the articular surface. A large needle can be used to ligate the vessel from an anterior approach between the transverse processes. The anterior aspect of the transverse process may need to be removed to better expose the vertebral artery to ligate it.

Most patients with vertebral artery injury will be anticoagulated and placed on antiplatelet therapy, the duration of which depends upon the nature of the injury and repair.

Venous repair or ligation — Patients with isolated asymptomatic jugular venous injuries identified on CT scan can be managed nonoperatively [25]. For symptomatic patients, repair can be attempted, but because the collateral venous network in the neck is extensive, if repair cannot be performed expeditiously or is not feasible, almost all venous injuries in the neck can be ligated. The internal jugular vein can be repaired if the injury is not severe and the patient is stable enough to undergo repair [26]. In the setting of bilateral jugular vein injuries, at least one of the jugular veins should be repaired. The risk of neurologic symptoms or brain edema is higher in the setting of bilateral internal jugular ligation. In an acute setting, the brachiocephalic vein (innominate vein) can also be ligated. While there is concern for possible left upper extremity swelling or neurologic symptoms, few have been reported.

Provided there are no contraindications, systemic anticoagulation is indicated following jugular venous repair or ligation to limit extension of thrombus and risk of thromboembolism. The data are limited for this specific indication, but we maintain anticoagulation for three months with repeat assessment.

Endovascular options — For patients with contained vascular injuries identified on CT angiography, an endovascular approach may be an option. Initially, pressure is held at the site of bleeding with wound packing as indicated. For small wounds, a Fogarty catheter or Foley balloon can be inserted into the wound and inflated to temporarily control hemorrhage. The patient can be transported to an interventional radiology suite or a hybrid operating room suite for endovascular embolization or stent placement. It is important that the patient be monitored closely for any ongoing external bleeding during this procedure.

●Case series have reported management of carotid injuries using urgent endovascular stenting with success [27]. The most common scenario is a contained pseudoaneurysm, which can be managed using a covered stent. High internal carotid artery injury is also best approached this way. However, more work needs to be done before this becomes a standard routine course of management.

●Vertebral artery injury, which is classified based on the affected segment (V1 to V4) (figure 7), is also often best managed with an endovascular approach, typically embolization of the vertebral artery. It is important that both ends of the vertebral artery are evaluated for bleeding and, if necessary, embolized. For injury in the V3 or V4 segment, an endovascular approach is the only option. (See "Vertebral artery revascularization", section on 'Treatment'.)

●Subclavian injuries that are incomplete can be temporized using an endovascular balloon or possibly treated with a covered endovascular stent. (See "Surgical management of severe upper extremity injury", section on 'Revascularization' and "Surgical and endovascular techniques for aortic arch branch and upper extremity revascularization", section on 'Stent-grafting'.)

Complications of vascular repair

Carotid blowout — A serious postoperative complication related to carotid injury is blowout of the carotid repair followed by thrombosis (table 7). Carotid blowout is more common in the setting of infection with a dirty traumatic wound, a concomitant aerodigestive track injury, or a delay in surgical intervention for a missed injury. In this setting, the patency of the airway is the immediate concern since an expanding hematoma can compress and occlude the trachea. Occasionally, the wound may need to be opened at the bedside to relieve the airway obstruction and pressure held over the carotid artery during transport to the operating room.

Most early carotid blowouts can be managed with repair. This may range from simple suture repair to placing a vascular graft (reversed saphenous vein graft or ePTFE). In the setting of delayed blowout (>7 days), the wound may become surgically hostile. In this setting, endovascular stenting may be an option. Most of these emergency carotid stents have been used in the setting of head and neck cancer. Long-term outcomes are generally poor with endoleaks, infection, and stroke. In a series of civilian penetrating cervicothoracic arterial injuries, stroke rates following carotid injury were similar for patients treated between 2000 and 2013 compared with those treated from 1974 and 1988 (2 versus 6 percent) [24]. Yet, there is not enough clear evidence that current management (shunting, endovascular stents, or conservative management) of acute carotid blowouts has improved outcomes.

Vertebral artery bleeding/thrombosis — The two most common postinjury complications related to vertebral artery injury management are bleeding and thrombosis, which can cause stroke.

Vertebral artery bleeding is best managed with endovascular embolization.

For patients with vertebral artery thrombosis and adequate collateral flow via the contralateral vertebral artery, no additional procedure is needed. Patients will commonly be maintained on antiplatelet therapy. The patient should be started on antiplatelet therapy to limit the risk of thrombosis extending beyond the site of occlusion. In the setting of an incomplete neurologic event such as associated with occlusion of the anterior spinal artery, endovascular recanalization has been reported [28]. The current recommendations are no anticoagulation or antiplatelet therapy in the setting of a hemorrhagic stroke. In the setting of embolic stroke, which most commonly occurs with vertebral artery injury, antiplatelet therapy is initiated.

Jugular vein thrombosis — The most common postoperative complication of jugular vein injury is thrombosis. This is usually self-limited and may require no further treatment. In the setting of an infected internal jugular vein, thrombosis with fever, elevated white blood count (WBC), wound infection, and neck swelling, additional management will be required. Blood cultures should be obtained to guide antibiotic management. Empiric antibiotic therapy is directed to cover appropriate skin flora, and in the setting of combined vascular and aerodigestive track injuries, antibiotic therapy must also include coverage of oral flora. Jugular vein excision is rarely indicated. (See "Catheter-related septic thrombophlebitis".)

Tracheal repair and complications — Depending on the injury pattern, the trachea can be exposed via lateral neck incision or via a collar incision. The collar incision provides the best exposure of the entire cervical trachea. It will also provide access to the anterior aspect of the thyroid cartilage. A partial upper sternotomy can provide additional access to the trachea if necessary. (See "Identification and management of tracheobronchial injuries due to blunt or penetrating trauma".)

The blood supply to the trachea and esophagus is segmental via tracheal and esophageal arteries. These come off the inferior thyroid artery, the carotid artery, and the innominate artery in the lower neck. The aorta provides the remainder of the blood supply in the mediastinum. Similar to all injuries, the success of a repair (eg, resection with anastomosis) is dictated by adequate blood supply. Dissection of the trachea should be limited to only that required for adequate debridement and repair or anastomosis.

Tracheal injuries are divided into partial or complete. They are commonly transverse but can be oblique and rarely longitudinal (figure 8). Stab wounds usually do not have any tissue loss and can typically be closed primarily with absorbable suture (eg, Vicryl, PDS). Gunshot wounds to the trachea can result in tissue loss. This requires debridement of the injury site with primary repair. If more than 50 percent of the tracheal lumen has been injured, segmental resection of the injury with mobilization and reapproximation of the trachea will be necessary. The trachea should be mobilized from the mediastinum. A significant tracheal repair should be protected with a vascular muscle pedicle [29]. The ideal muscle pedicle would be the sternocleidomastoid muscle to prevent leaks. Following significant tracheal repairs, the chin will need to be secured to prevent tension on the anastomosis. This can be accomplished by suturing the chin down to the chest for two weeks.

The most common complication of tracheal injury repair is breakdown of the repair (table 7). Ideally, the goal is to quickly wean the patient from positive pressure ventilation since this increases the intraluminal airway pressure causing the air leak. This can become a serious problem for the patient who has respiratory failure. For the patient who requires ongoing mechanical ventilation, tracheostomy below the repair is the best option. Other options include a reinforced endotracheal tube where the tracheal balloon is positioned below the injury. For late-presenting tracheal leak, tracheal luminal stents have been used to help support the repair and allow the trachea to heal [30].

Esophageal repair and complications — The cervical esophagus is only in zone I, and the hypopharynx is in zone II in the neck (table 6). A unilateral stab wound in this area can be exposed via a unilateral neck exploration. A transcervical gunshot wound is best explored via a collar incision to be able to see both sides of the neck. (See 'Neck exposure' above and "Overview of esophageal injury due to blunt or penetrating trauma in adults", section on 'Operative management'.)

If the esophageal injury is not easily identified, a nasogastric tube can be positioned in the cervical esophagus and air blown through it under a pool of saline to identify the injury. Simple esophageal injuries, particularly stab wounds, can be repaired with absorbable suture (eg, Vicryl, PDS) and drained. Gunshot wounds will need debridement and repair. An injury greater than 50 percent of the circumference may require a segmental resection and reanastomosis. The esophagus may need to be mobilized to decrease tension on the repair.

In the setting of a major complex esophageal injury, the intrathoracic esophagus can be freed to be pulled up into the neck. In this setting, a vascularized muscle pedicle should also be used to protect the anastomosis [29]. All esophageal repairs should be drained as a controlled fistula, which is much more easily managed.

Complications following esophageal repair are common (table 7). A small leak will usually heal with time and adequate drainage. In one respective review, 74 percent of the patients who had combined tracheoesophageal injuries from penetrating wounds developed major complications, which included pneumonia, esophageal leak, tracheoesophageal fistula, mediastinal abscess, wound infection, and carotid artery blowout [31].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Penetrating neck injury" and "Society guideline links: General issues of trauma management in adults".)

SUMMARY AND RECOMMENDATIONS

●Penetrating neck injuries can present in a subtle or dramatic fashion. An organized initial approach to neck injury is essential to avoid missed injuries. (See 'Introduction' above.)

●For the hemodynamically stable patient, CT angiography provides the most thorough screening modality to identify specific organ injuries, and the results are useful for aiding surgical planning. (See 'Specific organ injury' above.)

●The unstable patient with neck injury may require an emergency surgical airway or surgical intervention to control neck hemorrhage. Once the airway is secured, initial damage control consists of controlling bleeding (ligation, possible shunt placement) and limiting contamination. (See 'Airway emergency' above and 'Active neck hemorrhage' above.)

●Once the airway is secured and vascular injuries are controlled, repair of specific injuries (eg, carotid, esophagus, trachea) can be undertaken, each handled according to their severity. If specific aerodigestive structures are not directly visualized, their integrity must assessed before leaving the operating room using bronchoscopy and esophagoscopy. (See 'Specific organ injury' above and 'Repair of penetrating injuries' above.)

●Exploration of zone II neck injuries (figure 1 and table 6) can be approached using a unilateral (ie, oblique) or bilateral (ie, collar) incision, depending upon the suspected or proven location(s) of vascular or aerodigestive tract injuries. Additional exposure (median sternotomy, clavicle resection) may be required to provide adequate exposure to control, identify, and repair zone I injuries. The surgical management of specific vascular, esophageal, and tracheobronchial injuries is discussed above. (See 'Approach by zone of injury' above and 'Surgical approach' above.)