1. Farrah Siddiqui, M.D.
Discussion: Francis B. Quinn, Jr., M.D., FACS
University of Texas Medical Branch
Department of Otolaryngology
Grand Rounds Presentation
March 31, 2010
http://www.utmb.edu/otoref/grnds/GrndsIndex.html

2. ‫رب زدن ي علـلما‬
ً‫ـِ مْ ا‬ ِ‫َ ِّ ـِ مْ ـ‬
Overview
Background: History of management of PNI
Anatomy classification of neck zones
Epidemiology
Morbidity types of injury
Diagnosis
Management
Clinical cases
Conclusions

3. Background: History
 1944: Bailey—early exploration if deep to platysma
 1956: Fogelman Stewart—6% mortality in early exploration vs. 35% if
delayed
 1979: Roon Christensen—immediate exploration for middle zone vs.
angiogram for stable high or low zones 81% surgery with 53% negative
exploration rate
 1980s +: Selective management
 Clinical Exam
 Adjunctive tests: Endoscopy, swallow study
 Arteriography
 Duplex Ultrasound
 Computerized tomography angiography (CTA)
With mandatory exploration, mortality decreased from 15-18% pre WWII to 3-7% during WWII.
However, negative exploration increased dramatically—40-60%
Roon AJ, Christensen N. Evaluation and treatment of penetrating cervical injuries. J Trauma 1979; 19:
391-7.

4. Background: History
 Meyer et al 1987: prospective zone II study, n = 120
 5.8% immediate exploration
 94.2% had endoscopy arteriography before surgery
 6% morbidity, 0.8% mortality
 Biffl WL et al 1997: 18 year prospective study showed selective
management of PNI safe
 1973-1978: mandatory exploration  56% negative
 1978-1996: selective  66% observed
 1 missed esophageal injury
 16% negative exploration
 3 % mortality; 10% morbidity
Biffl WL et al. Selective management of penetrating neck trauma based on cervical level of injury; Denver since 1978

5. Sniper injury to neck from Spanish Civil War left him with vocal cord paralysis

6. Anatomy: Zones I - III
Zone I: sternal notch 
cricothyroid membrane
Zone II: cricothyroid
membrane  angle of
mandible
Zone III: angle of
mandible  skull base
Is this classification
outdated?
Zone I is treated like thoracic injury
Anterior neck area classification ant to pos B of SCM; posterior neck
not further divided
Often patients have multiple wounds or GSW tract can involve
multiple zones, so some question importance of this classification
Superficial wound does not correspond well to deeper structures
injured.

7. Anatomy: Facial planes
 Hematomas, air tracks
 Bullet, metal tracks
 Carotid space: Carotid, IJV, CN X
 Retropharyngeal space: behind
pharynx, anterior to prevertebral
muscles
 Perivertebral space: muscles
soft tissue around vertebrae
Bleeding that displaces prevertebral muscles anteriorly is
associated with vertebral body fractures.
Retropharyngeal carotid artery important for presurgical
planning
Esophageal injury can track air into RP, prevertebral space
Missed esophageal injuries can present as retropharyngeal
abscess, mediastinitis, sepsis www.medscape.com

8. Epidemiology: Adult PNI
Gun shot (GSW) Stab (SW) Shotgun
45% 40% 4%
 1% of all trauma patients in USA
 Demetriades et al 1993 GSW more clinical signs injuries (35% vs.
19% for SW)
 Structures injured: 40% no significant damage
 Major vein 15-25%
 Major artery 10-15%
 Digestive tract (pharynx, esophagus) 5-15%
 Respiratory tract (larynx, trachea) 4-12%
 Major nerves 3-8%
Brywczynski JJ et al. Management of penetrating neck injury in the emergency department: a structured literature review.
Emerg Med J 2008; 25: 711-715
metaanalysis of 20 studies
Demetriades prospective study; 97 GSW, 89 SW

9. Epidemiology: Pediatric PNI
 40% mortality—zones I III more common
 60% zone I—multiple wounds
 29% zone II
 56% zone III—multiple wounds
Mandatory Neck Exploration Selective Neck Exploration
Hoarseness, aphonia, airway Change in neck exam
Shock, continued bleeding Abnormal diagnostic tests
Blood in aerodigestive tract
Subcutaneous air
Neurologic deficits  86% positive exploration
Multiple major injuries
 100% positive exploration
Kim MK et al. Penetrating neck trauma in children: An urban hospital’s experience. Otolayngol Head Neck Surg 2000; 123:
439-43.
Upenn n = 35 1990-97
Firearm injuries second leading cause of mortality in age 15-24.

10. Morbidity: Vascular injury
Major Signs
Active bleeding
Unstable/hypotension
Expanding hematoma
Pulsatile swelling
Bruit, thrill
Unilateral CNS deficit
Pulse deficit
 Minor Signs
 Parasthesias
 Nonexpanding hematoma
 C spine or skull base
fractures in MVAs

11. Morbidity: Vascular injury
Carotid artery injury Vertebral artery injury
 22% vascular injuries  10%
 10-20% mortality in  2/3 major neck trauma,
hospital especially C spine
 Repair preferred unless esophagus
comatose patient  Isolated  1/3 no signs
 Ligate or embolize if high  Sepsis due to missed
carotid injury esophageal injury
 Minor injury (intimal flap)  Endovascular
 endovascular repair, ? embolization if bleeding
Anti-platelet Tx  Ligation low risk
 Anticoagulate blunt injury  Anticoagulate blunt injury

12. Morbidity: Esophageal Injury
 Odynophagia, dysphagia,
hematemesis
 Airway injury  25% have
esophageal injury
 Transcervical trajectory
 Saliva in wound, subcutaneous
emphysema
 Prevertebral air on lateral neck
X ray
Kietdumrongwong P Hemachudha T 2005
Kietdumrongwong P Hemachudha T. Pneumomediastinum as initial presentation of
paralytic rabies: A case reportBMC Infectious Diseases 2005, 5:92.

13. Morbidity: Esophageal Injury
 Most commonly missed
 Weigelt JA et al 1987: 30% no signs or symptoms
 Wood J et al 1989: most common cause delayed morbidity
 Asensio JA et al 2001: 34 center study of 405 patients with penetrating
esophageal injuries
 56% cervical esophagus
 19% mortality—most common exsanguination
 82% primary repair with 16% requiring muscle flaps
 11% drainage
 3-4% complex: resection/diversion or resection/anastomosis
 41% esophageal complication in delayed repair (vs. 19%)
 Empyema, abscess, mediastinitis
Weigelt JA et al. Diagnosis of penetrating cervical esophageal injuries. Am J Surg, 1987; 154 (6): 619-22.
Asensio JA et al. Penetrating esophageal injuries: multicenter study of the American Association for the Surgery of
Trauma. J Trauma-Injury, Infection Critical Care. 2001; 50(2): 289-96. 34 centers retrospective
Wood J et al. Penetrating neck injuries: recommendations for selective management. J Trauma 1989; 29: 602-5.

14. Morbidity: Esophageal Injury
Srinivasan et al 2000: flexible esophagoscopy safe
accurate
 Sensitivity = 92.4%, specificity = 100%
 PPV = 33.3%, NPV = 100%  no injuries missed
 Low PPV because incidence of injury low (3.6%)
Imaging
 Water soluble contrast (gastrograffin): ½ missed
 aspiration pneumonitis: not use if poor gag reflex/cough
 Barium: ¼ missed
  increased mediastinitis
Srinivasan R et al. Role of Flexible Endoscopy in the Evaluation of Possible Esophageal
Trauma After Penetrating Injuries. AJG 2000; 95(2): 1725-29.
Start with gastrograffin if negative, repeat swallow with barium

15. Morbidity: Esophagram
Nel L et al. Imaging the oesophagus
after penetrating cervical trauma using
water-soluble contrast alone: simple,
cost-effective and accurate. Emerg Med
J. 2009;26:106–108
Nel L et al 2009

16. Morbidity: Esophageal Injury
Treatment
Observe 24 hrs if high suspicion but studies negative
Pharyngeal injury  NPO, IV antibiotics, NGT
Esophageal injury  primary repair vs. drainage/
resection/diversion
 Early diagnosis  primary repair
 Late diagnosis with sepsis/inflammation  drainage

17. Morbidity: Airway Injury
 More common in blunt trauma
 5-15% PNI will have laryngotracheal trauma
 Hoarseness, stridor, hemoptysis, difficulty breathing, pain
 Air leak in wound, difficult airway  surgery!!!
 Majority airways managed by rapid sequence intubation (RSI) at scene or ED
Mandavia DP 2000 Retrospective N = 748 11% emergent intubation
-67% RSI with  100% success
-33% fiberoptic  91% success
-3 fiberoptic failures  RSI
Eggen JT N = 114 60% intubated, 22% ED
1993 No intubation complications
Shearer VE N = 107 83% RSI with DL  100% success
1993 6% surgical airway  100%
7% awake fiberoptic 98%
4% blind nasotracheal 75%
•Eggen JT et al. Airway management, penetrating neck trauma. J Emerg Med 1993: 11: 31-5.
•Mandavia DP et al. Emergency airway management in penetrating neck injury. Ann Emerg Med 2000; 35: 221-5.
•Shearer VE et al. Airway management for patients with penetrating neck trauma: a retrospective study. Anasth Analg 1993; 77: 1135-8.
•Mandavia et al
•Shearer et al

18. Morbidity: Airway Injury
High index of suspicion—avoid paralytic agent!
Trachea most commonly involved (2/3) vs. larynx (1/3)
25% have esophageal injury
Esophageal injury  chances of airway injury double
Unstable airway  Be prepared for surgical airway
 tracheotomy safest option
Stable airway  Flexible laryngoscopy, bronchoscopy
 CT shows fractures, tracheal injury
 OR for endoscopy if suspect injury
 Steroids, oxygen, IV Abx, humidified air if no fractures, mucosal
disruptions or progressive edema/hematoma

19. Morbidity: Airway Injury
 Laryngeal fractures in PNI
 Thyroid cartilage most common
 Should not delay fixation for 24 hours since increased risk of scarring
Group Laryngeal Injury Treatment
I Minor endolaryngeal hematoma; Observe; steroids, PPI,
No fracture; Good airway humidity
II Hematoma/edema compromising airway; OR for tracheotomy, DL
Laceration without exposed cartilage; esophagoscopy
Nondisplaced fracture(s)
III Massive edema, exposed cartilage, immobile vocal OR for repair tracheotomy
cord(s), displaced fracture(s)
IV Group III + more than 2 fracture lines OR for repair trach
V Laryngotracheal separation OR for repair
Gold SM et al. Blunt laryngeal trauma in children. Arch Otolaryngol Head Neck Surg 1997; 123: 83.

20. Morbidity: Airway Injury
Groups III- V: OR for repair
Repair anterior commissure, TVC lacerations
Cover exposed cartilage
Repair fractures with stainless steel wire or suture
 Some prefer absorbable (PDS), others prolene
 Nonabsorbable absorbable miniplates also used
Stent indicated if unstable larynx after fracture fixation
or lacerations involving anterior commissure
 Remove 10-14 days with endoscopy, remove granulation with
CO2 laser

21. Morbidity: Airway Injury Baisakhiya N et al 2009
Baisakhiya N et al. Laryngotracheal Trauma . The Internet Journal of Otorhinolaryngology. 2009 Volume 9 Number 1
CT shows right thyroid cartilage fracture air escape suggesting tracheal tear. Extensive subQ air.
Patient managed with tracheostomy, reduction of fracture + fixation with 4-0 prolene. Tracheal partially excised with primary
repair of trachea.

22. Morbidity: Airway Injury
Outcomes of penetrating laryngotracheal injury
1/3 delayed diagnosis
10% preventable mortality
Many suffer permanent voice swallowing problems

23. Diagnosis: Clinical exam
 Rivers et al 1988  Biffl et al 1997, n = 312
 no vascular injury missed by physical  105 positive exam  OR
exam 16% negative exploration
 207 negative exam  observed
 Demetriades et al 1993, n = 335
 1 esophageal perforation
 269 negative exam observed
 Sekharan J et al 2000, n = 145
 2 later required intervention for
 0.7% vascular injury missed
vascular injury
 Azuaje R et al 2003
 Demetriades et al 1996, n = 223  93% sensitive, 97% PPV
 All patients with negative clinical exam  Inaba K et al 2006, n = 91
had arteriogram  100% sensitive, 93.5% specific
 No vascular injury requiring
 Tisherman SA et al 2008
intervention  Clinical exam protocol up to 95% sensitive
 NPV of clinical exam 100% injury
Demetriades Br J Surg 1993; World J Surg 1996, all prospective
Biff et al, Am J Surg 1997, prospective
Tisherman SA et al. Clinical practice guideline; penetrating zone II neck trauma. J Trauma 64: 1392-1405, 2008.
Inaba K et al. Prospective evaluation of screening multislice helical computed tomographic angiography in the evaluation of
penetrating neck trauma. J Trauma 61: 144-149, 2006. n = 91, prospective
Azuaje RE et al. Reliability of physical examination as a predictor of vascular injury after penetrating neck trauma. The Am
Surg. 2003; 69: 804-7.
Sekharan J et al. Continued experience with physical examination alone for evaluation and management of penetrating zone
2 neck injuries: rests of 145 cases. J Vasc Surg 1988; 8: 112-6.

24. Diagnosis: Clinical Exam
 Fogelman MJ Stewart RD 1956: 43% positive explorations were
hemodynamically stable 70% had no bleeding
 Carducci et al 1985: 1/3 patients with positive exploration had no
signs/symptoms on clinical exam
 Scalafani et al 1991: 61% sensitivity for vascular injury
 Apffelstaedt et al 1994: n = 335 SW; 30% positive explorations had no clinical
signs
 Eddy VA et al 2000: low sensitivity NPV with clinical exam but improved in
patients when CXR added to physical exam
Fogelman MJ and Stewart RD, Am J Surg 1956, 91: 581.
Carducci et al, Ann Emerg Med 1985 15:208
Apffelstaedt World J Surg, 1994, 18: 917
Scalafani SJ et al. The role of angiography in penetrating neck trauma. J Trauma 31: 557-62, 1991.
Eddy VA et al. Is routine arteriography mandatory for penetrating injuries to zone I of the neck? J
Trauma 2000; 48: 208.

25. Diagnosis: Arteriography
Gold standard for vascular injury
Diagnostic therapeutic
Zones I III difficult to assess clinically
Zones I III often involve complex surgery
Eddy VA et al 2000
 N = 138, retrospective review vs. mandatory zone I angio
 No arterial injuries on arteriogram if normal exam CXR
Demetriades et al 1993
 Cost-effective for zones I III
 Decreased surgery rates to 5% in zone I 13% in zone III

26. Diagnosis: Arteriography
Modrall JM et al 1995 meta-analysis: Diagnosis of vascular
trauma
23% positive zones I III
2.2 to 28% positive zone II  only 1% needs surgery
94-100% sensitive
90-98% specific
54-66% PPV  high false positive rate
100% NPV  no false negatives
0-3% complication, mostly minor
$66,420 per positive arteriogram due to high FP
Modrall JM et al. Diagnosis of vascular trauma. 9(4) 1995.

27. Munera F et al 2000
Left carotid artery occlusion seenin angiogram on right as well as parasagittal helical CTA
on left

28. Diagnosis: Arteriography
 Specialized team
 Expensive
 0.16-2.0% complication:
hematoma, pseudoaneurysm,
spasm, thrombosis, emboli,
thrombi, arterial dissection
  permanent CNS sequelae
Morris C. Vascular and Solid Organ Trauma
- Interventional Radiology.
www.emedicine.com 2008.
Digital subtraction left cervical carotid
angiogram demonstrating traumatic injury of
the left internal carotid artery, manifested by
pseudoaneurysm formation and an intimal
dissection
Morris C 2008.

29. Diagnosis: Arteriography
Endovascular therapy
 Covered stent graft:
pseudoaneurysm,
lacerations, AVF
 Embolization or coiling:
pseudoaneurysm, AVF
 Endovascular occlusion:
injured vertebral arteries
 Test balloon occlusion prior
to ligation
Munera F et al 2000 2005.
www.medscape.com

30. Diagnosis: Arteriography
www.findmeacure.com
Dong Z et al. Endovascular repair for a huge vertebral
artery pseudoaneurysm caused by Behcet’s disease.
Dong Z et al 2006. Chinese Medical Journal, 2006, Vol. 119 No. 5 : 435-437

31. Diagnosis: Duplex U/S
 Bynoe RP et al 1991, n = 198
 95% sensitive, 99% specific
 Demetraides D et al 1995 (82)
 91% sensitive, 98.6% specific
 100% sensitive for clinically significant injuries
 Montalvo BM et al 1996 (52)
 Detected all serious injuries
 Limitations
 Operator dependent
 No soft tissue/bony detail
 Not useful in zone I III
•Bynoe RP et al. Noninvasive diagnosis of vascular trauma by duplex
ultrasonagraphy. J VAsc Surg 14: 346-52, 1991. prospective
•Demetraides D et al. Penetrating injuries of the neck in patients in
stable condition: Physical examination, angiography or color flow
Doppler imaging. Arch Surg 130: 971-75. 1995. prospective
•Montalvo BM et al. Collor Doppler sonography in penetrating
injuries of the neck. Am J Neuroradiol. 17: 943-951, 1996.
prospective
•Picture shows Pseudoaneurysm (arrow) of the femoral artery on
angiography and on (B) color duplex ultrasound demonstrating
communication and flow between the false aneurysm (FA) and the
common femoral artery (CFA) via a neck. (C) Characteristic to-and-
fro Doppler waveform in the neck of the pseudoaneurysm. (D)
Absence of flow within the false aneurysm after successful thrombin
injection

32. Diagnosis: CTA
 Method:
 Nonionic contrast in peripheral IV, care in renal or diabetic
 Exam takes 1 min., postprocessing takes 15 min.
 Axial usually enough; add multiplanar + 3D for OR plan
 Direct signs
 Irregular vessel margins, filling defects
 Contrast extravasation, lack of vascular enhancement
 Vessel caliber changes
 Indirect: indistinct perivascular fat plane, bullet/bone fragments
within 5 mm of major vessel, hematoma close to vessel
 Associated Injuries: C spine, bullet track, aerodigestive
Munera F et al. Penetrating injuries of the neck: use of helical computed tomographic angiography.
J Trauma. 2005; 58: 413-18.
University of Miami, prospective 2 yr. n = 60

33. Diagnosis: CTA
 Munera F et al 2000 (2005) (p)  Gonzalez RP et al 2003 (p)
 Sensitivity 90% (100%)  Physical exam missed 2 esophageal
 Specificity 100% (98.6%) injuries seen on CTA
 PPV 100% (92.8%)  Recommend as initial for zone II
 NPV 98% (100%)  Mazolewski PJ et al 2001 (p)
 Inaba K et al 2006 (p)  100% sensitive, 91% specific
 Sensitivity 100%  operative findings in zone II
 Specificity 93.5%  Gracias VH et al 2001 (r)
 Nondiagnostic 2.2%  Initial test in zones I – III
 Woo K et al 2005 (r)  Decreased overall adjunct studies
 CTA decreased negative exploration  MRI/MRA logistics difficult, no bony
adjunct tests information
(1st number compared to arteriography; 2nd number compared to actual intervention—surgery or endovascular or observation)
Munera F et al. Diagnosis of arterial injuries caused by penetrating trauma to the neck: comparison of helical CT angiography and
conventional angiography. Radiology 2000; 216 (2) 356-62.
Inaba K et al. Prospective evaluation of screening multislcine helical CTA in the initial evaluation of penetrating neck injuries. J
Trauma, Injury, Infection and Critical Care. 2006; 61 (1): 144-56
Gracias VH et al. Computed tomography in the evaluation of penetrating neck trauma: a preliminary study. Arch Surg. 2001; 136:
1231-1235.
Mazolewski PJ et al. Computed tomographic scan can be used for surgical decision making in zone II penetrating neck injuries. J
Trauma. 2001: 51: 315-19.
Gonzalez RP et al. Penetrating zone II neck injury: does dynamic computed tomographic scan contribute to the diagnostic sensitivity
of physical examination for surgically significant injury? A prospective blinded study. J Trauma 2003; 54: 61-4.

34. Diagnosis: CTA
 Woo K et al 2005 Retrospective 1994 – 2004
Patient n= Surgery Negative Angio- Esopha- CF
130 Exploration graphy gram Doppler
CTA 34 1 0 4 4 13
(3%) (12%) (12%) (39%)
No CTA 96 32 22% 19 17 21
(33%) (66%/32) (29%) (26%) (32%)
No CTA 1994-1998: 34% angiogram, 24% esophagram
41% CTA 1999-2004: 11% angiogram, 16% esophagram
Woo Karen et al. CT angiography in penetrating neck trauma reduced the need for
operative neck exploration. The American Surgeon 2005.

35. Diagnosis: Cost-effectiveness of CTA
Seamon MJ et al: extremity CTA
versus arteriogram saved $12,922
in patient charges $1,166
hospital cost
Decreased negative exploration
rate cuts OR patient cost
A Prospective Validation of a Current Practice: The Detection of Extremity Vascular Injury With CT
Angiography. Original Article
Journal of Trauma-Injury Infection Critical Care. 67(2):238-244, August 2009. Seamon, Mark J.

36. Diagnosis: CTA—stab wound
Munera F et al. Multidetector row computed tomography in the management of penetrating neck
injuries. Seminals in Ultrasound CT and MRI. 2009.
Multiple stab wounds to neck; axial CT (c) shows right skin defect with extension down to jugular vein,
no hematoma; B) is maximum intensity projection A) is color 3D volume rendered image  patient
taken to OR for debridement small injury to right IJV repaired

37. Munera F et al 2009.
Self-inflicted GSW to right neck; axial CTA shows large hematoma with contrast extravasation. MIP
3D show facial artery branching from ECA running into hematoma,most likely source of bleeding

38. Munera F et al 2005
Right common
carotid
pseudoaneurysm

39. Munera F et al 2000
Axial CT images from inferior to
superior shows progressive narrowing
of right ICA; no contrast enhancement
seen in superior most (bottom)

40. Munera F et al 2000
Left common carotid pseudoaneurysm with
fistula to IJV: left = proximal axial CT, right
= at bifurcation; see increased collection of
contrast into left IJV as compared to normal
right; sagittal recon shows extravasation of
contrast and increased enhancement of left
IJV

41. Munera F et al 2009.
Direct injury with thrombosis of right IJV

42. Munera F et al 2005.
Axial CT shows bullet tract through left neck, close to esophagus; esophagus
replaced by large posterior mediastinal hematoma

43. Diagnosis: CTA—esophageal injury
Rathlev NK et al 2007
Rathlev NK et al. Evaluation and management of neck trauma. Emerg Med Clin N Am 2007;
25: 679-694.
Free air adj to esophagus, traumatic perf

44. Diagnosis: CTA
Limitations
 1.1 – 2.2% nondiagnostic
 Large patients: shoulder
obscures neck
 Streak artifacts from
bullets/metal
 Normal variants may look like
injuries
 Subclavian arteries
 Large volume contrast: renal,
diabetic patient
Munera F et al 2009.
Munera F et al 2009.
GSW to neck, bullet fragments in right carotid space cause streak artifact 
nondiagnostic CTA  required angio which showed dissection

45. Management Summary
Unstable Stable w/ symptoms Stable without
symptoms
Airway injury Hematoma, hemoptysis,
Hemodynamic instability hematemesis, dysphagia,
Uncontrolled bleeding dysphonia, peripheral neuro
Evolving CVA deficit, subcutaneous air
Mandatory Exploration CTA in all Observe 12 hrs
Selective testing: endoscopy, CTA in all
esophagraphy Arteriography
Arteriography I III Esophagraphy in zone
Foley tamponade I
? Mandatory exploration ? exploration
South Africa: Foley catheter balloon tamponade for life-threatening hemorrhage in
penetrating neck trauma. Navsaria P et al. World J Surgy 2006 30: 1265-1268

46. Case 1
24 M, GSW to right neck
Intubated at scene
Vitals currently stable
Right neck swelling, no
bruit/thrill
SubQ air
CTA done
 What next?
Woo K et al 2005. CTA allows
visualization of bullet tract; carotids are
fine; bullet fragments + air in prevertebral
+ parapharyngeal space  esophagram
done, no injury noted Woo K et al 2005

47. Case 2
35 M
Injury to neck with
working with axe
chip flew into midline
1 week ago
c/o pain, dysphagia
Vitals stable, no dysphonia
No fever
Wound between thyroid
Gulia J et al 2009
cricoid, no saliva or air
•J. Gulia, S. Yadav, K. Singh A. Khaowas : Penetrating Neck Injury: Report Of Two Cases. The Internet
Journal of Emergency Medicine. 2009 Volume 6 Number 1
•Gulia J et al 2009

48. Case 3:
40 M, stray shot to neck
c/o pain, some bleeding
Wound anterior neck
No exit wound
No swelling
Mild dysphonia
No airway distress
Sari M et al 2007.
Vitals stable
Sari M et al 2007. Atypical penetrating laryngeal trauma. European Journal of Emergency
Medicine 2007, 14:230–232

49. Case 3 Sari M et al 2007.
Flexible laryngoscopy showed airway stable, bilat TVC mobile, right supraglottic edema with bullet lodged
OR for DL, bullet removed, no further intervention needed, observed x 24 hrs.

50. Conclusions
Immediate exploration for patients with hard signs
Hemodynamic instability
Uncontrollable bleeding, expanding hematoma
Worsening neurological status
Air bubbling in wound, need for surgical airway
Brywczynski JJ et al 2008: meta-analysis shows C
spine injury less common in penetrating trauma
 Remove C collar to examine neck !!!
Selective management of stable patients

51. Conclusions: Selective Management
Method Logistics Reliability Adjunct Bonus
($, ease) Tests
Physical Exam Cheap Large X rays No
Quick trauma Esophagram
centers Endoscopy
Duplex Cheap Operator No
Ultrasound Quick Zone II only
Arteriography Expensive Gold Endovascula
Time standard r Treatment
Specialized vascular
injury
CTA Mid price Good Lower rate Bony, tissue,
Quick Streak aerodigestive
C spine,
artifacts
bullet tract

52. Conclusions
Zone I Zone II Zone III
CTA CTA CTA
Esophagram/flexible esophagoscopy if suspect/see injury on CT
Flexible laryngoscopy if suspect/see injury on CT
Arteriogram if CTA nondiagnostic, need more information for OR
or plan endovascular intervention
OR if injury needs to be surgically assessed/repaired
? Usefulness of whole body CTA in multiple GSW/SW
 Neck Zones Obsolete???

53. Conclusions
Zone I-III classification still works for operative
management of vascular injuries
Zone II easy to get proximal distal control  surgery
Zone I III may try endovascular therapy
 Difficult proximal control zone I: median sternotomy
 Difficult distal control zone III: skull base

54. Munera F et al.
Munera F et al. Penetrating injuries of the neck: use of
helical computed tomographic angiography. J Trauma.
2005; 58: 413-18.
University of Miami, prospective 2 yr. n = 60

55. Discussion: Francis B. Quinn, Jr., MD
Doctor Siddiqui has given an excellent and up‐ to‐ date summary of the diagnosis and treatment of
penetrating injuries of the neck, with emphasis on the wide range of approaches made possible by
newer imaging techniques. She has pointed out that the earlier zone protocol may be soon
overwhelmed by the more modern selective management strategies.
The question of evaluating various series of cases is made complicated by the several mechanisms
of injury as drawn from different cultures and environments. We note that 75% of South African
patients present with incised wounds, 50% of U.S. urban patients seek treatment for gunshot
wounds, and our military casualties suffer wounds from low‐ velocity shell fragments, as well as high
velocity small caliber rifle bullets, often accompanied by substantial loss of tissue.
Thus, reports of treatment results should allow us to picture the biomechanics of injury, for as has
been shown in a previous Grand Rounds(1,2,3), the high velocity projectile creates instantaneous and
extensive tissue expansion with shearing stress leading to delayed devitalizationand unanticipated
late complications. Further, even low velocity (800 fps) bullets are known to tumble and fragment,
causing tissue injury far from the missile track. In contrast, stabbing or cutting injury causes tissue
injury limited to the track of the weapon.
Doctor Siddiqui's presentation has shown us that the newer treatment methods have laid upon
faculty of resident training institutions the requirement to distill the reports of these methods into a
doctrine suitable for the instruction of those aspiring young surgeons under our direction, a doctrine
which takes into account the local weapons culture as well as the technical and imaging support
available.

56. Discussion: Francis B. Quinn, Jr., MD
REFERENCES:
1. Dr. Quinn's Online Textbook of Otolaryngology,
http://www.utmb.edu/otoref/Grnds/GrndsIndex.html
2. LeBoeuf, Herve J, MD. Penetrating Neck Trauma. University of Texas Medical
Branch, Department of Otolaryngolgy. Online[Available]:
http://www.utmb.edu/otoref/Grnds/Pen‐neck‐trauma‐9901/Pen‐neck‐trauma‐
9901.html. SLIDES: http://www.utmb.edu/otoref/Grnds/Pen‐neck‐trauma‐
9901/Pen‐neck‐trauma.pdf. January 27, 1999.
3. Reddy, Shashidhar S, MD. Management of Penetrating Neck Trauma.
University of Texas Medical Branch, Department of Otolaryngolgy.
Online[Available]: http://www.utmb.edu/otoref/Grnds/Penetrat‐NeckTrauma‐
2002‐0905/Penetrat‐Neck‐Trauma‐020905..pdf. SLIDES:
http://www.utmb.edu/otoref/Grnds/Penetrat‐NeckTrauma‐2002‐
0905/Penetrat‐Neck‐Trauma‐2002‐0905‐slides.pdf, September 6, 2002.