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The neck is a small anatomical area with complex anatomic features and dense concentration of numerous vital structures, not always amenable to easy clinical examination. The radiological evaluation of these injuries has undergone major changes in the last few years and shifted from invasive diagnostic procedures to noninvasive methods. The selection of the most appropriate investigation remains a controversial issue. The surgical exposure of some neck structures may be difficult and can challenge the surgical skills of even the most experienced surgeons. The surgical management of some of these injuries, such as carotid injury in the presence of neurological deficits or blunt carotid trauma, still remains controversial. The advancement of interventional radiology has revolutionized many aspects of the management of some complex vascular injuries.

In an urban environment with short prehospital times, “scoop and run” to the nearest trauma center is the only acceptable policy and offers the best chance of survival in patients with neck vascular injuries or airway compromise. Attempts to resuscitate the patient with intravenous fluids or perform a prophylactic endotracheal intubation for airway protection are ill-advised and potentially dangerous. Prehospital endotracheal intubation in patients with injuries of the neck should be attempted only in patients with anticipated prolonged transport times who are in respiratory distress or imminent cardiac arrest.

The airway management is the first and most challenging priority in the management of patients with severe neck trauma. The technique of airway management should be determined taking into account many factors, such as the severity of respiratory distress, the hemodynamic condition of the victim, the nature of the local neck injury, and the experience of the trauma team. Alternative approaches should be planned in advance and be immediately available in case the initial attempt is not successful.

In the presence of active bleeding the patient should be placed in the Trendelenburg position to reduce the risk of air embolism. Intravenous lines should be avoided in the arm on the side of the neck wound. External bleeding can be controlled successfully by direct pressure or digital compression with a gloved finger through the wound or balloon tamponade.

Many patients with major injuries to the neck vessels reach the hospital in cardiac arrest or imminent cardiac arrest. These patients may benefit from a resuscitative thoracotomy for cardiac resuscitation and aspiration of the right ventricle for air embolism.

Physical examination, preferably according to a written protocol, remains the most reliable diagnostic tool. “Hard” signs highly diagnostic of significant laryngotracheal trauma include respiratory distress, air bubbling through the neck wound, and major hemoptysis. In the presence of any of these findings an operation is indicated without any specific diagnostic studies. “Soft” signs suggestive of laryngotracheal trauma include subcutaneous emphysema, hoarseness, and minor hemoptysis. Patients with these signs need further diagnostic evaluation to identify those with significant injuries requiring surgical repair. Hard signs of significant vascular trauma include severe active bleeding, large expanding hematoma, absent or diminished peripheral pulse, bruit on auscultation, and unexplained hypotension. Soft signs of vascular trauma include stable small to moderate size hematomas, minor bleeding, mild hypotension responding well to fluid resuscitation, and proximity wounds. Patients with soft signs need further investigations. There are no hard signs that are diagnostic of pharyngoesophageal injuries. Soft signs that require evaluation of the pharynx and esophagus include painful swallowing, subcutaneous emphysema, and hematemesis.

The neurological clinical examination should include assessment of the Glasgow Coma Scale (GCS) score, localizing signs, pupils, cranial nerves, spinal cord, brachial plexus, the phrenic nerve, and the sympathetic chain (Horner syndrome). Clinical examination according to a tested protocol reliably diagnoses or highly suggests all significant injuries. The absence of any clinical signs or symptoms suggestive of vascular or aerodigestive injury reliably excludes significant injuries to these structures requiring therapeutic intervention.

The mechanism of injury and clinical examination will determine the need and type of specific investigations in the evaluation of neck trauma. Patients with hard signs of major vascular or laryngotracheal injuries should undergo an operation without any delay for definitive investigations.

Angiography has largely been replaced by less invasive studies, such as color flow Doppler and computed tomography (CT) angiogram. Angiography should be reserved only for selected cases with specific diagnostic or therapeutic indications, such as nondiagnostic ultrasound scan or CT angiography or shotgun injuries or for therapeutic purposes, such as embolization or endovascular stenting.

Helical CT angiography has been used successfully for the evaluation of the major neck vessels and has become an excellent initial investigation for suspected vascular injuries. A brain CT scan is indicated in patients with neck trauma and unexplained central neurological deficits to evaluate for a possible anemic infarction secondary to a carotid artery injury or an associated direct brain injury.

Esophageal studies are recommended in stable patients with suspicious clinical signs, such as painful swallowing, hematemesis, or subcutaneous emphysema and in cases with a CT scan that suggests a bullet trajectory near the esophagus. Indications for laryngotracheal evaluation by means of fiberoptic endoscopy or CT scan include proximity injury with soft clinical signs suspicious of airway injuries (eg, minor hemoptysis, hoarseness, subcutaneous emphysema).

The old policy of mandatory operation for all penetrating injuries that violated the platysma has now been abandoned by most trauma centers in favor of a policy of selective nonoperative management. The selection of patients for operation or observation should be based on clinical examination and appropriate investigations. Failure to follow written protocols and algorithms, especially in low-volume trauma centers or by an inexperienced surgeon, may result in the missing of significant injuries or performing unnecessary operations.

Patients with gunshot wounds, including transcervical gunshot wounds, can also safely be managed nonoperatively, after careful clinical examination and appropriate investigations.

Many patients with penetrating injury to the carotid artery die before reaching a hospital or present to the emergency department in full cardiac arrest or severe hypovolemic shock. In some cases, especially in blunt trauma, the patient may be asymptomatic or present in coma or hemiplegia secondary to carotid artery occlusion. Although some minor penetrating carotid injuries, such as small asymptomatic intimal defects or pseudoaneurysms, can safely be managed nonoperatively, the vast majority of penetrating injuries will require surgical repair or endovascular treatment. Although carotid reconstruction is indicated in most patients with severe injuries, there is still controversy regarding reconstruction versus ligation or nonoperative management in the patient with established coma or dense contralateral neurologic deficits. We believe that the best chance for neurologic recovery, even in the patient who presents in coma, is urgent revascularization unless some other contraindication to operation is present. However, the patient who has been in a prolonged (>4 hours) established coma due to a carotid injury has an extremely poor prognosis regardless of treatment, and revascularization often exacerbates cerebral edema and intracranial hypertension. Carotid ligation should never be performed, even in the hemodynamically unstable or multiply injured patient, because of the high risk of ischemic neurological complications. In these patients placement of a temporary intraluminal carotid shunt and delayed reconstruction should be considered. If the injury or dissection extends into the distal internal carotid artery, exposure and repair are significantly more difficult, and neurosurgical or maxillofacial consultation may be required to assist with exposure of the internal carotid at the skull base as previously described. In selected cases angiographically placed stents may be a good option.

Blunt carotid trauma is rare (approximately 0.1% of blunt trauma). These injuries often present with early or late neurologic deficits, although in many cases the patient remains asymptomatic. Blunt trauma patients with unexplained neurological symptoms or seatbelt marks or hematomas in the neck or major craniofacial injuries, or major cervical spine fractures, should be screened with CT angiography or ultrasound scan for carotid injuries. The vast majority of blunt carotid artery injuries are not amenable to surgical intervention. In the rare surgically accessible lesion, operative repair should be undertaken for all significant lesions. In most patients the management decision will involve whether to administer some form of anticoagulation or place an endovascular stent.

Many vertebral artery injuries, especially due to blunt trauma, are asymptomatic and most of them do not require any treatment, although some authorities recommend treatment with interventional angiography or anticoagulation. In penetrating trauma the artery is often thrombosed and there is no need for any treatment. In the presence of active bleeding, depending on the hemodynamic stability of the patient, the therapeutic options are either angiographic embolization or operative intervention.

Many victims with subclavian vascular injuries die before reaching medical care.^. Only selected patients with short prehospital times and contained hemorrhage due to thrombosis or local hematoma reach the hospital in fairly stable condition. The majority of patients are in severe shock on admission and require immediate operation, without any specific diagnostic studies. The operation is difficult and often requires the division or excision or dislocation of the clavicle. Ligation of the subclavian artery should never be considered, even in critically ill patients. Temporary shunting with definitive repair at a later stage should be considered, instead of arterial ligation. Endovascular stent-grafts have been used successfully in selected patients with subclavian artery false aneurysm, arteriovenous fistula, or arterial stenosis.

Injuries to the larynx and trachea resulting from trauma are fairly uncommon but potentially lethal because of the risk of airway compromise. The clinical presentation may include subcutaneous emphysema, hoarseness, hemoptysis, air bubbling through the wound, or stridor and impending airway obstruction. In patients with suspected blunt laryngotracheal trauma, in addition to fiberoptic endoscopy, a CT scan of the cervical region is extremely valuable for the evaluation of the structures of the larynx. Many patients with minor blunt laryngotracheal trauma can safely be managed nonoperatively. Penetrating injuries or complex blunt injuries require surgical repair.

Pharyngoesophageal trauma is relatively uncommon. Flexible esophagoscopy is the investigation of choice for stable patients with signs or symptoms of pharyngoesophageal injury. Although small penetrating injuries of the pharynx can safely be managed nonoperatively, all injuries to the cervical esophagus should be repaired without any delay.

Injuries to the thoracic duct are exceedingly rare and are usually seen in left-sided penetrating injuries to zone I. These injuries are often missed at the initial operation, manifesting postoperatively as chyle leak. Almost all leaks can safely be managed nonoperatively with low-fat diet and somatostatin or its analog, octreotide. Surgical intervention for ligation of the duct is rarely necessary, but should be considered in patients with persistent leaks.

Brachial plexus injuries due to blunt trauma are often associated with vascular injuries and in these cases the prognosis is poor. Evaluation with CT myelography or magnetic resonance imaging (MRI) may help in determining the optimal treatment and prognosis. The necessity and timing of surgical treatment for brachial plexus injuries depend on the mechanism and severity of the injury.

There have been some significant advances in the evaluation and management of patients with penetrating injuries of the neck. Selective nonoperative management of penetrating injuries, including transcervical gunshot wounds, is an important advancement. The replacement of angiography with color flow Doppler or CT angiography is a major diagnostic advancement. The introduction of angiographic stenting in selected cases with carotid or subclavian artery injuries may revolutionize the management of these injuries and eliminate the need for complex surgery in many patients. The optimal management of blunt carotid trauma is still an unresolved issue that requires intensive investigation.