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 Table of Contents  
ORIGINAL ARTICLE
Year : 2013  |  Volume : 3  |  Issue : 2  |  Page : 119-123

Penetrating neck injuries: A study from IBN-Alnafis hospital for thoracic and cardiovascular surgery, Baghdad, Iraq


1 Senior Registrar, Department of Thoracic and Cardiovascular Surgery, IBN-Alnafis Hospital, Baghdad, Iraq
2 Head of Department of Thoracic and Cardiovascular Surgery, University of Sulaimania, School of Medicine, Sulaimania, Iraq
3 Consultant Surgeon, Department of Thoracic and Cardiovascular Surgery, PAR Hospital, Irbil, Iraq

Date of Web Publication13-Dec-2013

Correspondence Address:
Abdulsalam Y Taha
Sulaimania, Iraq. P. O. Box 414
Iraq
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-9596.122930

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  Abstract 

Background: The optimum management of penetrating neck injuries (PNIs) is controversial. The initial trend was a mandatory exploration once the platysma is violated. It has changed over time into a selective approach with surgery done to patients with overt clinical features or abnormal investigations. This study aims to test the usefulness and safety of an individualized approach to the management of patients with PNIs.
Materials and Methods: The management of PNIs deployed over the period from June 1, 2009 to June 30, 2012 at IBN-Alnafis Hospital, Baghdad, Iraq, was retrospectively reviewed. The demographic features of patients, presenting symptoms and signs, location of injuries in term of neck zones, associated injuries, diagnostic work up and methods of treatment (surgery vs. conservative), morbidity and mortality were determined.
Results: Sixty-eight patients (64 males and 4 females) were studied. The peak incidence was in the third decade. The mean age was 29.7 ΁ 12.9 years. Shells were the main causative agents (45.6%). The most frequently injured neck zone was the second (41.7%). Vascular injuries headed the list (8 cases). The majority of patients (56%) were managed surgically while 26.5% were managed conservatively. Other patients were either referred to other hospitals for further treatment or discharged against medical advice. Two patients died in this series (2.9%).
Conclusions: In circumstances like ours, a selective approach to management of PNIs seems to be preferable. It can be safely applied if a high index of suspicion is maintained to overcome the known shortcomings of our health system.

Keywords: Cervical vascular Injuries, mandatory vs. selective exploration, neck injuries, penetrating wounds


How to cite this article:
Suleiman AM, Taha AY, Alissa MA. Penetrating neck injuries: A study from IBN-Alnafis hospital for thoracic and cardiovascular surgery, Baghdad, Iraq. Arch Int Surg 2013;3:119-23

How to cite this URL:
Suleiman AM, Taha AY, Alissa MA. Penetrating neck injuries: A study from IBN-Alnafis hospital for thoracic and cardiovascular surgery, Baghdad, Iraq. Arch Int Surg [serial online] 2013 [cited 2024 Mar 29];3:119-23. Available from: https://www.archintsurg.org/text.asp?2013/3/2/119/122930


  Introduction Top


Penetrating neck injuries (PNI) have the potential to challenge the skill of even the most experienced trauma care provider. [1] The neck contains multiple vital structures with little anatomic protection from overlying bones, muscles, and soft tissues. Most severe neck injuries are the result of penetrating wounds and may present an immediate threat to life due to airway compromise or hemorrhage, therefore accurate and aggressive initial evaluation and treatment is required to optimize the outcome. [2] Mass casualties may not allow for routine exploration of all stable cervical blast injuries. [3] Improvements in the diagnostic modalities allow evaluation of potentially injured structures, providing an alternative to those who favor a nonoperative approach. [4] The therapy of PNIs has evolved from no treatment, to nonoperative management, to routine exploration, and to selective exploration. [5] A high index of suspicion must be maintained and multiple diagnostic modalities may be required to exclude occult injuries. [6]

The aim of this study was to test the usefulness and safety of an individualized approach to the management of patients with PNI in a busy surgical center with limited resources taking into account the ongoing controversy regarding the optimum management strategy of this common and serious emergency.


  Materials and Methods Top


This is a retrospective study of 68 patients (64 males and 4 females) with PNIs who were admitted and treated in IBN-Alnafis Teaching Hospital for Thoracic and Cardiovascular Surgery from June 1, 2009 to June 30, 2012.

The patients' case sheets were reviewed to collect information relevant to their management. Age, sex, and mechanism of injury (shell, bullet, and stab wounds) were recorded. Presenting symptoms and signs like pain, bleeding, expanding hematoma, thrill or bruit, shortness of breath, odynophagia, surgical emphysema, hemoptysis, hematemesis, hoarseness of voice, and any neurological deficits were also noted. The location of the injury in term of neck zones I, II, and III was observed as well as injuries in other parts of the body. The neck is divided into three zones. Zone I includes the thoracic inlet (clavicles to the cricoid cartilage). Zone II includes the structures of the mid-neck (cricoid cartilage to the angle of the mandible). Zone III includes the structures near the skull base (angle of the mandible to the base of the skull). [1] The diagnostic techniques employed in these patients were reviewed including plain neck and chest radiographs, barium swallow, Doppler ultrasound examination of neck vessels, bronchoscopy, and esophagoscopy.

The management policy was an individualized one. Two main methods of treatment could be recognized: Surgery vs. conservative. Patients who were unstable for a hemodynamic or respiratory cause or with overt clinical evidence of vascular, aero-digestive or neurologic injuries were managed surgically. In contrast, stable patients were managed conservatively, that is, admitted for observation. If signs and symptoms developed during the period of hospitalization, relevant investigations were ordered. Surgery was then elected for the suspected or proven injuries. Patients who do not deteriorate during the period of observation or have normal investigations were discharged home and asked to come for follow-up. When surgery was needed, it was performed after an adequate resuscitation. Enough cross-matched blood was made ready as well as an antibiotic cover and tetanus prophylaxis. A team approach was used for the multiple injured patients with prioritization of the injuries.

In this study, the term major operation referred to exploration of major vessels of the neck or aero-digestive tract (larynx, trachea, pharynx, and esophagus). Surgery was considered a positive exploration when an injury was found and repaired, otherwise, it was reported as negative if no structural injury was discovered. Most of the injuries in the neck were approached via the standard incision parallel to the sternocleidomastoid muscle, though laryngo-tracheal injuries were approached via the anterior collar incision. Adjuvant procedures like tracheostomy were done when needed. The associated injuries were dealt with accordingly. Chest tubes were placed for hemothorax or pneumothorax. Limb fractures were initially stabilized and then definitely treated by orthopedic surgeons.

Patients who were clinically stable but had retained shells, bullets, or pellets were subjected to minor operations for removal of these foreign bodies and debridement of associated wounds and drainage of small hematomas if present. Postoperatively, the critical patients were admitted to the intensive care unit (ICU). Some of the postoperative morbidities can be life-threatening like retained chest secretions; thus bronchoscopic pulmonary toilet was done for such cases. The complications following surgery for PNIs were noted. Any follow-up information available to us from the doctors in charge of these patients was recorded.


  Results Top


Sixty-eight patients (64 males and 4 females) with PNIs were included in this study. Male to female ratio was 16:1. The youngest patient was a boy of 5 years and the oldest was a man of 72 years. The mean age was 29.7 ± 12.9 SD years. The age and sex distribution is shown in [Table 1]. Though PNIs occurred in all age groups from young boys to elderly men, the peak incidence was in the third decade. The majority of patients (94.1%) were aged less than 40 years. Males constituted the majority (94.1%). The penetrating agents are shown in [Table 2].
Table 1: Age and sex distribution of patients with penetrating neck
injury


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Table 2: Penetrating agents

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The neck zones injured are shown in [Table 3]. In nearly half the patients, the zone of injury was not documented. The most frequently injured region was zone II followed by zone I, whereas zone III was the least common. The important injuries encountered in the neck and the associated body injuries are shown in [Table 4]. Vascular injuries headed the list followed by salivary glands and laryngo-tracheal injuries. Thoracic and extremity injuries predominated the associated injuries.
Table 3: Distribution of patients according to neck zones

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Table 4: Details of Injuries

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Some of the patients were directly brought to the hospital from the trauma field when they were injured in a nearby area while others were referred from other hospitals after an initial resuscitation when facilities to treat such injuries did not exist there. Most of the patients were admitted to the hospital soon after the injury, however, the exact time interval between injury and presentation at hospital was unfortunately not mentioned in the patients' case sheets.

The diagnostic tools employed in this study included plain radiographs of neck and chest, barium swallow and esophagoscopy for patients that presented with dysphagia or subcutaneous emphysema raising suspicion of esophageal injury, bronchoscopy for suspected tracheobronchial injuries, Doppler ultrasonography of neck vessels (carotid arteries and internal jugular vein) for the stable patient in whom vascular injuries were suspected. It was performed for 13 such patients. But no patient had angiography. We can recognize two groups of patients based on type of management provided to them:

  1. Operative group
  2. Observation (conservative) group.


The method of treatment is shown in [Table 5]. Majority of the patients were managed surgically. Formal neck exploration done in 11 cases proved to be positive in 8 and negative in 3. Most of the major operations were for vascular injuries while most of the minor operations were for removal of shells or bullets. Eight patients had vascular injuries on surgical exploration. The external carotid artery (ECA) or its branches were safely ligated in four cases. Two cases of false aneurysm of common carotid artery (CCA) were encountered. Aneurysmectomy was performed but the method of arterial repair was not mentioned. Two patients had subclavian artery injuries; one had safe ligation of a friable artery after aneurysmectomy while the second died intraoperatively due to uncontrolled bleeding resulting from an apparently improper surgical approach. Operations for associated injuries consisted of thoracotomy (n=1), tube thoracostomy (n=5), and tendon repair (n=1). Thoracotomy was done for massive hemothorax and lung laceration due to a bullet injury to the chest. The patient survived the operation.
Table 5: Methods of management and outcome of PNIs

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The mean duration of stay in hospital was 3.6 days ranging from 1 to 18 days. Most of them stayed for 1-7 days. Some of the morbidities in these patients include cranial nerve palsy in six, retained chest secretions in five, and hemothorax in six. In this series two patients died (2.9%). Unfortunately, a long-term follow up was not available. The longest follow-up was 3 months for a case of subclavian artery false aneurysm.


  Discussion Top


Penetrating injuries to the neck are a diagnostic and therapeutic challenge. Meticulous attention to physical signs and clinical symptoms is crucial. [7] Demographically, the vast majority of our patients (64, 94.1%) were males. Most of them (64, 94.1%) were aged under 40 years. The peak incidence was in the third decade. This is consistent with other studies. [7],[8] This particular age and sex predilection reflects the usual exposure of young males to civilian violence and terrorist attacks in our society. Shells were on the top of the list of causative agents. This is probably due to high rate of explosions.

In nearly half the patients, the injured neck zone was not documented in the case sheets. This indicates a poor medical documentation, which should be corrected. This significantly undermines the role of nonoperative treatment of these patients. In addition, it may have a significant medico-legal effect. The most frequently injured zone was the second. This finding is similarly reported by other studies. [7],[8] This is because zone II is the most exposed part of the neck. [8] Vascular injuries in this series headed the list, a finding similarly reported by Haba et al. [8] and Elhassani et al. [7] In contrast, Albadri et al. reported laryngotracheal injuries on the top followed by pharyngeal and esophageal injuries, whereas vascular injuries came next to them. [9] This finding may be explained by the difference in the specialties of the authors as well as the mechanism of injury. The most frequently associated injury was thoracic followed by extremity injuries. This finding is similar to other studies. [7],[8],[10] Most of the patients (93.1%) in this study stayed for 1-7 days. This is due to the fact that only 25% of patients had major operations, which required a longer stay.

The mandatory approach to management of PNIs dictates the routine surgical exploration of any case in which the platysma muscle is violated. Such a policy ensures detection of all injuries but, in contrast, results in a significant number of unnecessary operations and a burden on hospital resources in the face of mass casualties common during terrorist attacks. To be applied in this series of patients, for example, all 68 patients should have been explored! The limited number of doctors and nursing staff as well as the cost incurred to the health system make it clearly impractical in our situation. The selective approach, in contrast, directs our efforts toward those who really are in need of surgery and avoids unnecessary operations. To be safe and successful, a close observation of the victims of PNIs by doctors and paramedics is essential, aided by efficient diagnostic tools whenever needed. In this study, about one-quarter of patients were managed this way. By looking at their case sheets and reading the daily follow up notes we got unpleasant by the lack of observation and very poor documentation. The follow up was also lacking. It is difficult to exclude missed injuries in this series of patients. The following case is a good example:

An 18-year-old male patient presented himself with shortness of breath of one week duration. He gave a history of a stab wound to left neck 2 months earlier. At that time, he was operated upon for repair of vertebral and esophageal injuries (as written in his case sheet) via a left neck incision. It was not evident for us where he had this operation. In the second admission, a diagnosis of an infected false aneurysm of first part of left subclavian artery (most probably missed at first hospitalization) was made. It was repaired by a supraclavicular approach, claviculectomy (of the medial two-thirds), aneurysmectomy and ligation of the artery (as attempts of anastomosis failed due to friability of vessel). The outcome of ligation was good.

Indeed, it is very strange to miss such an injury as the patient was already explored! It should not be missed if he was just adequately examined clinically or thoroughly investigated by Doppler ultrasound or angiography. The situation would be more embarrassing if he was first admitted to the same hospital.

For safe application of the selective approach, patients were managed conservatively and discharged home after a period of observation and should be followed up adequately. In this series, there was no recordable follow up. Therefore, it is possible to have missed injuries. Our study has the same limitations as that of Ahmed from Northern Nigeria, [11] namely lack of long-term follow-up, which precludes detection of late complications in many patients.

One of the rationales for using the selective approach is to operate on the indicated patients only and thus avoid unnecessary operations. In this series, formal neck exploration was done in 11 cases; proved to be positive in 8 and negative in 3. One of the three negatively explored patients had no preoperative Doppler ultrasonography of the neck vessels or angiography. It also deserves to note that none of the patients in this series had angiography, although the study was performed in a specialized vascular center and vascular injuries were the top PNIs. Eight patients had vascular injuries on surgical exploration in this series. Safe ligation was done for four cases of ECA or its branches and for one subclavian artery false aneurysm. Many studies emphasized the safety of ligation of these arteries especially when adequate collaterals exist. [7],[9],[12] In this study, out of the 17 patients managed by major operations, 15 (88.2%) had their injuries in zone II, a finding similar to another study. [11] This was probably because injuries in this region are often associated with major vascular injuries and blood loss because of lack of anatomical protection of the major vessels and limited tamponade. [11] Brennan et al. reported zone II injuries in 77% of 112 neck explorations for PNIs due to high velocity projectiles in Operation Iraqi Freedom, a finding very comparable to those seen in civilian centers managing low-velocity PNI. [13]

There were no deaths in the conservative group while two patients (2.9%) in the group of major surgery died. The cause of death in one patient was uncontrolled bleeding due to an improper surgical approach. The second patient was a 70-year old man with a laryngeal injury who died 3 days after repair probably due to respiratory insufficiency. This mortality goes with the reported figures in the literature. [8] One study reviewed 24 series adopting the selective approach. The calculated average mortality rate for this series was 3.74% with a range of 0-9.8%. [8]


  Conclusions Top


In circumstances like ours in Iraq, a selective approach to management of PNIs seems to be preferable. The high casualty rate and limited health resources make mandatory exploration of all cases impractical. In contrast, the selective strategy can be safely applied only if vigilant observation is provided to the victims, so that no injuries are missed. Moreover, modern diagnostic tools should be available to aid in the detection of such injuries.

 
  References Top

1.Vance ES, Randall SF, editors. Penetrating Neck Trauma. In: Wilson WC, Grande CM, Hoyt DB, editors. TRAUMA-Emergency Resuscitation, Perioperative Anesthesia, Surgical Management, Volume 1. Zug, Switzerland: Informa Healthcare; 2007;24:447-58.  Back to cited text no. 1
    
2.Hoyt DB, Coimbra R, Potenza B, editors. Management of Acute Trauma. In: Townsend CM Jr, Beauchamp DR, Evers MB, Mattox KL. Sabiston Textbook of Surgery, 17 th ed., Vol. 20. Philadelphia: Elsevier; 2004. p. 498-502.  Back to cited text no. 2
    
3.Fox CJ, Gillespie DL, Weber MA, Cox MW, Hawksworth JS, Cryer CM, et al. Delayed evaluation of combat-related penetrating neck trauma. J Vasc Surg 2006;44:86-93.  Back to cited text no. 3
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4.Siegrist B, Steeb G. Penetrating neck injuries. South Med J 2000;93:567-70.  Back to cited text no. 4
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5.Cheng E, Selivanov V. Penetrating neck trauma, 1996. Available from: http://www.reference.medscape.com/public/about text/html. [Last updated on 2006 Dec 19; cited 2012 Aug 11].  Back to cited text no. 5
    
6.Wilson RF, Diebel L. Injuries to the neck. In: Wilson RF, Walt AJ, editors. Management of Trauma: Pitfalls and Practice. 2 nd ed. Baltimore, MD: Williams and Wilkins; 1996. p. 270-87.  Back to cited text no. 6
    
7.Uday HJ, Elhassani NB. Penetrating neck injuries: Approach and management in the light of controversies, A thesis submitted to The Scientific Council Of Thoracic And Cardiovascular Surgery in partial fulfilment of the requirement of the degree of fellowship of Iraqi Commission for Medical Specialization, Baghdad, 2008.  Back to cited text no. 7
    
8.Ibrahim FF, Haba FM. Penetrating neck injuries, analysis of seventy cases, A Thesis submitted to The Scientific Council Of Thoracic And Cardiovascular Surgery in partial fulfilment of the requirement of the degree of fellowship of Iraqi Commission For Medical Specialization, Baghdad, 2001.  Back to cited text no. 8
    
9.Albadri M, Albeiruty U, Mousa A. Penetrating injuries of the neck. Iraqi Postgrad Med J 2009;8:196-203.  Back to cited text no. 9
    
10.Ramadan F, Rutledge R, Oller D, Howell P, Baker C, Keagy B. Carotid artery trauma: A review of contemporary trauma centre experiences. J Vasc Surg 1995;21:46-55.  Back to cited text no. 10
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11.Ahmed A. Selective observational management of penetrating neck injury in Northern Nigeria. S Afr J Surg 2009;47:80-5.  Back to cited text no. 11
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12.Taha AS. Penetrating carotid artery injuries. Iraqi Postgrad Med J 2013;12:96-103.  Back to cited text no. 12
    
13.Brennan J, Lopez M, Gibbons MD, Hayes D, Faulkner J, Dorlac WC, et al. Penetrating neck trauma in Operation Iraqi Freedom. Otolaryngol Head Neck Surg 2011;144:180-5.  Back to cited text no. 13
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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