Pharyngeal injury

Hypopharyngeal injury should be suspected in Zone II penetrating injuries, particularly in

the presence of dysphagia, odynophagia, voice change, haemoptysis, haematemesis, and
surgical emphysema. Flexible nasopharyngoscopy may reveal oedema, blood in the pharynx,
or the perforation may be visible if located in the superior hypopharynx. Direct
pharyngoscopy should reveal all injuries, but oesophagography is unreliable.
upper hypopharyngeal injuries may be managed non-operatively; this part of the
hypopharynx is capacious, has a lowintraluminal pressure and is enveloped by both the
middle and inferior constrictor muscles. The lower hypopharyngeal funnels into the
cricopharyngeus segment and is less capacious, has higher intraluminal pressure and is
surrounded only by the inferior constrictor muscle; it should explored, repaired and drained
 Oesophageal injury
Early recognition and treatment of oesophageal perforation is the key to
favourable outcome. Missed oesophageal injury has high morbidity and
mortality. Intervention delays of > 12 hours for iatrogenic oesophageal injury
has a mortality rate of 40% as opposed to 9% if < 12 hours
Dysphagia, haematemesis and odynophagia are symptomatic of penetrating
oesophageal injury. Clinical evidence includes surgical emphysema and a
salivary leak. X-ray may reveal retropharyngeal air, retropharyngeal oedema,
haematoma, tracheal deviation, and a pneumomediastinum.
combination of oesophagography and oesophagoscopy had a sensitivity of
100%.
Because barium, if aspirated, may induce serious pulmonary problems, it
should not be used in trauma patients and an appropriate water-soluble contrast
agent (e.g. gastrograffin) should be used.
 Oesophageal injury
Treatment of oesophageal injury varies from observation, to simple repair of the wall +/-
drainage of deep neck spaces, to primary diversion of salivary flow to the skin by means of
partial or total exteriorization procedures. All high-kinetic injuries should be explored. The
management of stab wounds and low-kinetic energy GSWs is more consrvative.
Generally it is recommended that, should barium swallow be positive or equivocal, one
should proceed to rigid oesophagoscopy; if positive, then the oesophagus is explored
marily. The remainder are repaired by resection and anastomosis, or are simply drained.
Intravenous antibiotics and enteral or parenteral nutrition should be instituted.
Barium swallow is done on day 5–7, as 50% of post-operative oesophageal fistulae are
asymptomatic and detected only on contrast study
 Vascular injury
The gold standard investigation remains 4-vessel arch angiography with selective catheterization.
Angiography has the following benefits:
identifies the site of injury;
identifies subclinical vascular injury including vertebral artery trauma;
serves as a roadmap for the surgeon;
delineates the extent of crossover circulation through the Circle of Willis;
identifies injuries amenable to endovascular intervention.
Helical CT angiography is largely replacing conventional angiography and has a 90–100%
sensitivity and specificity to detect arterial injury
Colour flow duplex Doppler (CFD) imaging, when combined with clinical examination, had a
sensitivity of 91% and specificity of 99% to detect vascular injury.
Vascular injuries in Zone II are readily exposed
Vascular injuries in Znes I and III do pre-operative angiography.
 Venous injury

The external jugular vein may be ligated if injured. The internal jugular vein
may be repaired by lateral venorrhaphy, or ligated. Should both internal jugular
veins have been injured, then at least one vein should be repaired to prevent
facial swelling, and sequelae of raised intracranial pressure such as blindness,
SIADH and even death. A remnant of the contralateral internal jugular vein or
saphenous vein can be used should a graft be required.
 Chylous injury

Patients with Zone I injuries rarely develop a chylothorax due to injury to the
thoracic duct or right lymphatic duct. Although one can attempt a diet of
medium-chain triglycerides, Worthington et al. reported that conservative
treatment is uniformly unsuccessful, and advocate early ligation via
thoracotomy.
 Neurological injury

Significant brachial plexus nerve injury should be repaired within 24–72 hrs.
 SUMMARY
Management of penetrating injuries of the neck remains controversial.
All three zones contain major vascular, and aerodigestive structures.
vascular and oesophageal injuries can be missed when the neck is
explored without the assistance of pre-operative angiography,
oesophagography
diagnostic studies do not have 100% sensitivity to detect oesophageal
and vascular injuries
patients are assessed individually according to:
the severity of the clinical signs: Hard signs VS soft signs.
the direction of the injury tract :away OR towards major viscera.
selective non-operative management of penetrating neck injuries is
effective and safe.
EXPLORATION OF THE NECK: GENERAL PRINCIPLES
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