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Face and neck trauma

Section: Trauma Curriculum: Curriculum, page 78

Zones of the Neck

  • I - Sternal notch to lower border of Cricoid cartilage
  • II - Cricoid cartilage to angle of mandible
  • III - Angle of mandible to base of skull

Contents

  • Zone 1 (6 structures)
    • Vascular - Great vessels
    • Aerodigestive - Trachea, Lung apices, Oesophagus
    • Other - Thoracic duct, Upper mediastinum
  • Zone 2 (7 structures)
    • Vascular - Carotid and Vertebral A’s, Jugular V’s
    • Aerodigestive - Pharynx, Larynx, Oesophagus, Trachea
  • Zone 3 (4 structures)
    • Vascular - Distal Extracranial Carotid A and Vertebral A, Jugular V segments
    • Aerodigestive - Pharynx

When to explore

  • Penetrating neck injury with hard signs of vascular or aerodigestive injury
  • Modern day thinking is the “no zone approach” i.e if no indication for straight to theatre then all patients should be imaged
    • Old thinking was mandatory zone 2 exploration
  • Other Broad Principles
    • Zone 1 - Angiography to aid operative planning due to potential vessel injury at the thoracic outlet
    • Zone 2 - Angiography not as important but if suspicions of vertebral vessel injury then yes, often miss oesophageal injury with these
    • Zone 3 - Angiography important to identify vascular injury near base of skull → Embolization

Access to Zones of the Neck

  • Preparation
    • Neck extended
    • Rotate head away from site of injury
    • Prep wide - including Chest

Zone 1 access

  • Unstable patient
    • For right
      • Median sternotomy - exam answer as can get proximal control
          • Supraclavicular extension
    • For Left
      • DSCT say anterolateral thoracotomy as subclavian vessels are lower on the left
      • But sternotomy and + Supraclavicular extension an option
  • Stable
    • Trans-clavicular
      • Cut skin down on the clavicle
      • Remove all muscle of clavicle
      • Jiggly saw medial and then rotate lateral (can save) then wire it back
      • This can be extended down the arm or sternotomy
    • Infra-clavicular
    • Supra-clavicular

Zone 2 access

  • Incision
    • Longitudinal at Anterior border of SCM
      • Can extend all the way from the mastoid process down to the clavicle if needed
      • Can be extended up and down or into a sternotomy
    • Through subcutaneous tissue and platysma to reach muscle.
  • Retract sternocleidomastoid laterally
  • Omohyoid only strap to cross Carotid Sheath → CCA landmark
  • Expose IJV
    • Landmark for the carotid bifurcation - facial vein, which dives off the anterior border of the Internal jugular vein
    • Divide fascial vein to take you on to the common carotid
  • Lateral retractiopn of IVJ takes you to common carotid
    • Beware of vagus nerve which is running in carotid sheath
  • Lateral retraction of Carotid Sheath to access Trachea/Oesophagus/Thyroid
  • Medial retraction to access Prevertebral Fascia and Vertebral Artery

Zone 3 access

  • Principles
    • Nasotracheal tube if possible
    • Neurosurgery
    • Temporize by using Fogarty catheters via neck
  • Incision
    • Longitudinal at Anterior border of SCM
    • Divide the sternocleidomastoid muscle at the mastoid if required
      • Mindful of the Accessory Nerve, which is going to enter into the sternocleidomastoid about 3 centimetres distal to that
    • Retractor on the mandible and pull that anteriorly to open up the space.
      • Dislocate the mandible or divide the mandible in order to get you increased access if needed
    • Same as zone 2
      • Ligate the middle thyroid and the common facial veins, retract the sternocleidomastoid muscle and internal jugular laterally
      • Careful of the vagus nerve in the carotid sheath.
    • Find carotid artery proximal and follow superiorly
    • Can divde posterior belly of diagastric
    • Hypoglossal Nerve will run anterior to the artery at this point

Axillary injury

  • Can do supraclavicular incision to get proximal control

    • Excise supraclavicular fat bad
    • Get on to scalenus anterior
    • Divide Scalenus Anterior
    • Then can access the subclavian artery which is sitting behind it

  • What are the operative priorities in neck trauma

    • #1 - AW control
    • #2 - Stop bleeding - Pressure, Fogarty

Facial fractures

  • Zygomatic Arch #
    • Trismus and Infraorbital Nerve injury with paraesthesia
      • Impinged Coronoid Process to cause trismus
    • Requires maxfax repair within 10 days – Important for mastication
  • Maxillary/Le Fort #
    • Classification Le Fort 1 | 2 | 3 - progressively more involvement of the orbits
    • Can cause dentition issues
    • CT assessment requires thin slices - 1-2mm
    • Repair by maxfax within 10 days
  • Nasal # → ENT | Plastics | Maxfax
    • Can get CSF leak
    • Septal haematoma - drainage urgently to prevent septal cartilage necrosis
      • Drain under LA/Topical anaesthetic
    • Can be associated with orbital blow out #’s
    • Can be reduced or complex #’s may need maxfax recon
  • Orbital # (Assess all eye functions)
    • Common to get diplopia with inferior rectus dysfunction (peri-muscular tissue entrapment)
    • Irritation of infraorbital nerve
    • Complications
      • Injury to globe, optic nerve, infraorbital nerve
      • Blindness, diplopia
      • Lid malposition and poor function
    • General mx principles
      • Restore normal anatomy
      • To prevent early and late complications including
      • Vision loss, diplopia, cosmesis issues
    • AW protection | Abx | ? Steroids | No nose blowing | No valsalva

C-Spine

  • High risk of neck injury
    • High speed MVA
    • Death at the scene of MVA
    • Fall from height > 3m
    • Significant closed head injury or CT proven ICH
    • Neurological sx/signs referred to the cervical spine (UL neurology)
    • Pelvic or multiple extremity #’s
  • Low risk factors - can clear c-spine clinically and without radiology
    • No posterior midline cervical tenderness
    • Normal level of alertness
    • No evidence of intoxication
    • No abnormal neurological findings
    • No painful distracting injury
  • Clearance
    • If can’t clear clinically - Image and ortho
    • Keep collar on
  • Xray C-spine = 3 views
    • AP | Lateral | Open mouth (Odontoid/peg view)

ABCs of Cervical Spine Imaging Evaluation

  • A - Alignment & Anatomy
  • B - Bony integrity
  • C - Cartilage (Joint) spaces
  • S - Soft Tissues

A - Alignment & Anatomy

  • Visually trace 4 lines
    • Look for disrupted Anterior or Posterior Vertebral Body Lines
    • Look for disruption of the Spinolaminar Line
    • Look for Posterior Spinous Line
    • Look for asymmetry of the facets
    • Look for widening of the spaces between the individual vertebrae
    • Look for widened the predental soft tissue space

B – Bony abnormalities

  • Overt fracture lucencies/ deformities
  • Once one fracture is seen, be sure to look for others
  • Disruption of the ring of C1 (Odontoid Fx)

C – Cartilage (Joint) abnormalities

  • Widened or narrowed disc space/facets

S – Soft tissue abnormalities

  • Widened prevertebral space

  • 7mm should prompt high suspicion for injury

Hard and Soft Signs

  • Invx options in Neck Trauma
    • CT - with IV and PO contrast (GG swallow on table) - arterial and portal venous phase
    • Scopes - OGD and Bronchoscopy
    • Interventional angiography in hybrid theatre - Stent/embolise
  • Mx Options
    • If unstable or hard signs should explore all
  • If stable
    • If stable all zones should be imaged
      • Zone 1 - Prefer imaging (Great vessels, Trachea, Oesophagus)
        • If imaging positive → Median Sternotomy and Neck exploration
    • Zone 2 - If no hard signs and stable → CT IV/PO 2 phase
    • Zone 3 - Should image —> Difficult access
      • Need help - Maxfax
        • May need to disarticulate the jaw
      • Start in zone 2 for proximal control

Laryngeal Trauma

  • If need emergency airway likely need a surgical cricothyroidotomy

Oesophageal Injury

  • Access dependent on location
  • Need to dissect off trachea
  • Repair in 2 layers - mucosal with 3.0 vicryl sutures in and 3.0 prolene or PDS muscular layer out

Blunt cerebrovascular injuries

  • Definition
    • Non-penetrating injury to the carotid or vertebral arteries.
  • Pathophysiology
    • Stretching or impingement of the vessel wall as the head and neck are forcefully moved in flexion extension or rotation.
  • Causes
    • Intimal tears and exposure of the subintimal layers to blood flow
    • Leads
      • Thrombus formation
      • Dissections in the vessel wall
      • Pseudo aneurysms
      • Complete occlusion of the vessel
      • Transection of the vessel.
      • Strokes
  • Denver grading system

  • Signs and symptoms
    • Arterial hemorrhage from the neck, nose or mouth
    • Expanding neck hematoma
    • Cervical bruit in a patient less than 50 years old
    • Focal neurological deficit that may indicate an ischemic injury to the brain
    • Horner’s syndrome
    • Stroke seen on imaging
  • If any of the above
    • CT angiogram
      • Low threshold
        • High energy neck trauma
        • Displaced facial fractures, mandibular fractures, complex base of skull fractures, a severe traumatic brain injury, cervical spine fractures, a near hanging with hypoxic brain injury, a clothesline type injury or a seatbelt sign on the neck, significant scalp degloving, significant chest, upper rib or abdominal injuries.
  • Treatment
    • Medical
      • Antiplatelets or heparin
        • Grade 1, 2 and 3
        • If survive in grade 4 then for life long antiplatelet therapy
    • Endovascular
      • Grade 1 - No role, self resolve
      • Grade 2 - Consider in 2 if progresses on repeat imaging at 7-10 days
      • Grade 3 - Consider in 3, often based on size (>1cm)
      • Grade 4 - No role in grade 4
      • Grade 5 - Can attempt in 5 but high mortality rate/stroke rate regardless.
    • Surgery
      • If hard signs
  • Follow up
    • In medical management at 2 weeks and 3 months re-image

Carotid Artery Repair

  • IR option available for stenting but not always amenable
  • Contraindications to repair
    • Ischaemic Infarct > 4hrs old

    • 4hrs of interrupted flow with coma

    • No back flow from carotid stump
  • Repair options
    • Shunt if needing to temporise
    • Repair - Suture +/- Patch
    • Replace - Graft - Interposition (reversed GSV)
    • Bypass - Graft
    • Transposition Graft - for ICA → replumb onto ECA
    • Ligation - for high injuries, if no neurology or > 48 hrs neurology
  • Access
    • As above - depends on zone

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