|Year : 2016 | Volume
| Issue : 2 | Page : 133-135
Management of severe cut throat injury in Zaria, Nigeria
A Bakari, IY Shuaibu, MA Usman
Department of Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
|Date of Web Publication||30-Nov-2016|
I Y Shuaibu
ENT Unit, Department of Surgery, Ahmadu Bello University Teaching Hospital, Shika, Zaria
Source of Support: None, Conflict of Interest: None
Cut throat injury is a potentially life threatening emergency often encountered by ear, nose, and throat surgeons. In recent years, there has been increasing incidence of violence as well as severe injuries from armed robbers and insurgents using sharp knives in Northern Nigeria. The use of knives as a weapon for armed robbery when applied to the neck often results in fatal consequences because of the potential for injury to vital structures. Early appropriate interventions often reduce the morbidity and mortality associated with cut throat injuries. We present a report of a successfully managed case of severe cut throat with complete transection of the larynx and muscles of the posterior neck resulting in near decapitation inflicted using a sharp knife during a robbery incident. Securing airway in the early management of patient with cut throat injury is very important. There is a need for patient and meticulous repair of damaged structures. This may reduce the morbidity and mortality associated with such cases.
Keywords: Armed robbery, cut throat, evaluation of airway, Zaria
|How to cite this article:|
Bakari A, Shuaibu I Y, Usman M A. Management of severe cut throat injury in Zaria, Nigeria. Arch Int Surg 2016;6:133-5
| Introduction|| |
Cut throat injury is a potentially life threatening emergency often encountered by ear nose and throat surgeons. Injury to the anterior part of the neck may be accidental, suicidal, or homicidal in nature. The injuries may be penetrating or nonpenetrating blunt trauma involving the soft tissues, cartilage, bones, and neurovascular bundles. In recent years, there has been increasing incidence of violence as well as severe injuries from armed robbers and insurgents using sharp knives in Northern Nigeria. The use of knives as a weapon for armed robbery when applied to the neck often results in fatal consequences because of the potential for injury to vital structures. For those who survive, the injury may lead to permanent disability such as problem with deglutition, phonation, and subglottic stenosis. Airway compromise, aspiration, or acute blood loss with hypoxemia may be the mode of presentation. Early appropriate interventions often reduce the morbidity and mortality associated with cut throat injuries. Evaluation of the airway is always the first priority in cut throat injury, and this may involve insertion of endotracheal tube directly through the site of the penetrating injury or by doing cricothyroidotomy and subsequently converting it to tracheostomy.
The aim of this study is to report a successfully managed case of severe cut throat with complete transection of the larynx and muscles of the posterior neck resulting in near decapitation inflicted using a sharp knife during a robbery incident. An informed consent was obtained from the patient.
| Case Report|| |
A 27-year-old commercial motor cyclist (locally referred to as okada rider) was brought to the accident and emergency unit of Ahmadu Bello University teaching hospital, Zaria in February 2014, with a 3 hour history of multiple injuries to the neck, face, and hands following assault by an armed robber. The patient was carrying a passenger (armed robber) when he was suddenly attacked by the man using a sharp knife in an attempt to collect his motor cycle. Patient struggled with the armed robber and in the process sustained multiple injuries. No prior resuscitation was offered to the patient before presentation to the hospital. On examination, he was fully conscious and pale but not in respiratory distress. His pulse rate and blood pressure were 98 beats per min and 100/60 mmHg, respectively. His respiratory rate was 28 cycles/min. He had no obvious neck swelling. There was deep laceration across the neck (zone II) with transection of the larynx through the thyrohyoid membrane and involvement of the pharyngeal mucosa. There was also a deep laceration on both sides of the neck measuring approximately 21 cm with transection of the right sternomastoid muscle as well as the involvement of the muscles of the posterior neck to near decapitation. Major vessels of the neck were spared [Figure 1]. He also had multiple lacerations on the face and both upper limbs.
|Figure 1: Deep neck laceration with transection of right sternomastoid muscle as well as involvement of the muscles of the posterior neck to near decapitation|
Click here to view
Resuscitation was commenced by securing intravenous line, and sample for urgent packed cell volume (PCV) and grouping and cross matching was obtained. The airway was secured immediately by intubation through the site of the injury under direct vision. Tracheostomy was then performed immediately and anesthesia was continued via the cuffed tube, as shown in [Figure 2].
Intravenous access was maintained using two wide-bore cannulas. Due to low PCV of 19%, he was transfused with three units of whole blood. He was also placed on IV amoxicillin and clavulanic acid 1.2 g every 12 h, metronidazole 500 mg every 8 h, pentazocine 30 mg every 6 h, and tetanus toxoid. The wound was thoroughly cleaned with normal saline before repair. Nasogastric tube was passed and the repair of hypopharyngeal and laryngeal injuries was effected in layers using vicryl 2/0 and nylon 2/0 to the skin. He was transferred to intensive care unit for close monitoring. Antibiotics were continued postoperatively for 14 days. Patient had normal swallowing, breathing, and phonation before discharge from the hospital. He was weaned off nasogastric and tracheostomy tubes 14 and 21 days after repair, respectively. His follow-up in the clinic has been uneventful for 18 months [Figure 3].
| Discussion|| |
Globally, cut throat injuries account for approximately 5 to 10% of all traumatic injuries, with multiple structures being injured in 30% of the patients., According to Roon and Christensen's classification, neck injuries are divided into three anatomical zones; Zone I, extends from sternal notch/clavicle to cricoid cartilage; Zone II, extends from cricoid cartilage to the angle of mandible; and zone III, extends from angle of mandible to the base of the skull. Zone I and III are more protected by bones and the vital structures in the zone II are not protected by bone; hence the risk of injury is different in these three zones. Zone II is the most common zone of the neck affected in more than 60% of the cases. The wound may be superficial or deep and the causes are varied such as road traffic accident, industrial accident, domestic accidents, sports, suicides, or homicides using different objects. The patient in this study had multiple deep injury from an armed robbery attack. Cut throat injuries pose a great challenge because multiple vital structures are vulnerable to injuries in the small, confined, unprotected area. Up to 30% of the injuries involve multiple structures. This is also the finding in our patient who had transection of the larynx and muscles of the posterior neck, resulting in near decapitation. A thorough knowledge of the anatomy of the neck, physical assessment, and expeditious decision making is often required to prevent catastrophic airway, vascular, or neurologic sequelae. Evaluation of the airway is always the first priority in cut throat injury and may involve insertion of endotracheal tube directly through the site of the penetrating injury or by performing cricothyroidotomy and subsequently converting it to tracheostomy. Our patient had tracheostomy before repair of the wound. Ezeanolue et al. and Okoyeet al. carried out tracheostomy in their patients with cut throat injuries. Exposure of structures such as the larynx hypopharynx require timely and meticulous surgical layer-by-layer repair to restore the continuity of aerodigestive tract without complication. Pharyngeal and laryngeal mucosal laceration should ideally be repaired within 24 h of the injury. The patient in this study had repair of pharyngeal mucosa within 24 h. Pharyngeal and laryngeal stenoses as well as pharyngocutaneous fistula are the common complications following repair of cut throat injuries. Overall mortality because of penetrating neck trauma is as high as 11%. Injury to certain anatomic structures (e.g., the carotid or subclavian vessels) may be fatal in two-thirds of the cases.
Our patient is yet to develop any of these complications 18 months after the treatment.
| Conclusion|| |
The purpose of this report is to emphzsise the role of securing the airway in the early management of such cases and the need for patient and meticulous repair of damaged structures. These may reduce the morbidity and mortality associated with such cases.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Adebola SO, Ologe FE, Ogunkeyede SA, Adedayo GA, Ogundoyin OA. Penetrating anterior neck injury: A multidisciplinary approach. IOSR J Dent Med Sci 2014;13:20-4.
Kundu RK, Adhikary B, Naskar S. A clinical study of management and outcome of 60 cut throat injuries. J Evol Med Dent Sci 2013;2:9444-52.
Biswas A, Gulati SK, Kaushal S. Anesthetic management of a case of suicidal cut throat injury. Anaesth Pain Intensive Care 2015;18:181-3.
Onotai LO, Ibekwe U. The pattern of cut throat injuries in the University of Port-Harcourt Teaching Hospital, Port Harcourt. Niger J Med 2010;19:264-6.
Rao BK, Singh VK, Ray S, Mehra M. Airway management in trauma. Indian J Crit Care Med 2004,8:98-105.
Fagan JJ, Nicol AJ. Neck trauma. In: Scott – Brown's Otorhinolaryngology, Head and Neck surgery. G Michael, editors. Great Britain: Hodder Arnold; 2008. pp. 1766-74.
Iseh KR, Obembe A. Anterior neck injuries presenting as cut throat emergencies in a tertiary health institution in north western Nigeria. Niger J Med 2011;20:475-8.
Manilal A, Khorshed AB, Talukder DC, Sarder RM, Fakir AT, Hossain M. Cut throat injury: Review of 67 cases. Bangladesh J Otorhinolaryngol 2011,17:5-13.
Kendall JL, Anglin D, Demetriades D. Penetrating neck trauma. Emerg Med Clin of N
Ezeanolue BC. Management of the upper airway in severe cut throat injuries. Afr J Med Med Sci 2001;30:233-5.
Okoye BC, Oteri AJ. Cut throat injuries in Port Harcourt. Sahel Med J 2001;4:207-9.
Cherian TA, Rupa V, Raman R. External laryngeal trauma: Analysis of 30 cases. J Laryngol Otol 1993;107:920-3.
[Figure 1], [Figure 2], [Figure 3]