Trauma to the neck

  Cut throat

In the majority of cases admitted to accident and emergency centres the wound does not involve important neurovascular structures but only skin, platysma and sternocleidomastoid or strap muscles. It is, however, prudent to explore all of these wounds formally.

  Wounds above the hyoid bone

The cavity of the mouth or pharynx may have been entered and the epiglottis may be divided via the pre-epiglottic space. These wounds require repair with absorbable sutures on a formal basis under a general anaesthetic. If there is any degree of associated oedema or bleeding, particularly in relation to the tongue base or laryngeal inlet, it is advisable to perform a tracheostomy to avoid any subsequent respiratory distress.

 

Wounds of the thyroid and cricoid cartilage

Blunt crushing injuries or severe laceration injuries to the laryngeal skeleton can cause marked haematoma formation and rapid loss of the airway. There may be significant disruption of the laryngeal skeleton. These patients should not have an endotracheal intubation for any length of time, even if this is the initial emergency way of protecting the

airway. The larynx is a delicate three-tiered sphincter and the presence of a foreign body in its lumen after severe disruption gives rise to major fibrosis and loss of laryngeal function. These injuries are frequently an absolute indication for a low tracheostomy, following which the larynx can be carefully explored and damaged cartilages repositioned and sutured, and the paraglottic space drained. An indwelling stent of soft sponge shaped to fit the laryngeal lumen and held by a nylon retaining suture through the neck may be left in place for approximately 5 days. This stent can be removed endoscopically after cutting the retaining suture and as the laryngeal damage heals the patient may then be decannulated.

 

Division of the trachea

 

Wounds of the trachea are fortunately rare but they should all be formally explored, and in order to obtain adequate exposure it is usually necessary to divide and ligate the thyroid isthmus. A small tracheostomy below the wound and then repair of the trachea with a limited number of submucosal sutures is appropriate. In self-inflicted wounds the recurrent laryngeal nerves, which lie protected in the tracheo-oesophageal grooves, are rarely injured. However, in stab wounds to the neck any nerve may be involved including the vagus, recurrent laryngeal nerve or cervical sympathetic chain. Primary repair is rarely possible but may be undertaken at the time of formal exploration of a major neck wound.

Vascular complications of cut throat

 

In contrast to nerve damage, vascular damage can be severe. Major haemorrhagic shock may occur as a consequence of injury to the common carotid, external or internal carotid, or a venous air embolism as a result of damage to one of the major veins, most commonly the internal jugular. Infection of large neck wounds is not uncommon, and cellulitis may supervene and spread inferiorly to the mediastinum. Surgical emphysema may result if damage to the trachea is not recognised and air escapes into the neck. Oesophageal and pharyngeal fistula may occur but usually heal spontaneously. Aphonia or dysphonia may follow injury to the vocal folds or division of the recurrent laryngeal nerves. Stenosis of the trachea or larynx may be caused by scarring from major injuries due to road traffic accident or attempted hanging.

 

Wounds of the cervical portion of the thoracic duct

 

Wounds to the thoracic duct are fortunately rare and most often occur in association with dissection of lymph nodes in the left supraclavicular fossa. When damage to the duct is not recognised at the time of operation, chyle may subsequently leak from wound in amounts up to 2 litres/day and, as a result, the patient may waste rapidly.

 

Treatment

 

Should the damage be recognised during an operation, the proximal end of the duct must be ligated. Ligation of the duct is not harmful because there is a number of anastomotic channels between the lymphatic and venous system in the lower neck. If undetected, chyle usually starts to discharge from the neck wound within 24 hours of the operation. On occasions firm pressure by a pad and bandage to the lower neck may stop the leakage but frequently this is unsuccessful and it is best to re-explore the wound and locate and ligate the damaged duct. If the patient is given some cream to drink 2 hours before the operation the cut end of the duct is more easily found just lateral to the lower 4 cm of the left internal jugular vein. If it proves impossible to find the duct, particularly in an area of oedematous and fragile tissue, the wound can be packed firmly with a Whitehead’s varnish pack and allowed to heal by granulation.