Abstract
Background
Penetrating anterior neck injuries are potentially life threatening and the causes vary across countries of the world. Studies in Nigeria have been mainly isolated case reports and few retrospective studies.
Aim
The aim of this study was to assess the causes, severity and management outcome of patients treated in our centre.
Methodology
This is a retrospective study of penetrating anterior neck injuries treated at the Lagos University Teaching Hospital over a 25-year period. The case records were retrieved and demographic data as well as the causes, site, extent of injuries and treatment outcome were analyzed.
Results
The mean age of the 39 patients in this study was 30.5yrs ± 7.9 SD with a male: female ratio of 6.8:1. Inflicted cut throat injuries accounted for 46% followed by vehicular accidents in 21%. Zone II site of the neck was the commonest site of injury 61.6% of the patients; while 71.8% of the patients presented within 24hrs of the injury, 46% of them had immediate blood transfusion. Tracheostomy was the main method of securing the airway. Primary soft tissue repair was performed on all the patients. Laryngopharyngeal repair was done in 61.5%. Peri-operative mortality was 7.7% and 83.3% had prolonged hospital admission with wound infection in 27.8% and laryngotracheal stenosis in 22.2% as the commonest complications.
Conclusion
This study has shown that penetrating anterior neck injuries is not uncommon in Nigeria and commonly due to cut throat and vehicular accidents. Proper documentation and following established management protocols will improve outcome.
Keywords: Anterior neck injuries, Cut throat, Vehicular accidents, Tracheostomy
Introduction
Penetrating neck injuries are associated with a breach in the skin and underlying platysma muscle of the neck and are significantly prone to causing mortality or severe morbidity depending on the cause, site and severity of the injury1, 2. They pose a great challenge to the attending surgeons because of the important structures in the neck that could be affected3.The causes of penetrating anterior neck injuries include gunshot injuries, stab wound injuries, neck laceration from vehicular accidents and inflicted cut throat injuries which could be homicidal or suicidal3. Some authors have classified these injuries as accidental, homicidal and suicidal 2-5. This classification appears simple but in cases of stab injuries to the neck during a fight or a stray bullet injury from a gunshot, it is debatable if these are homicidal or accidental. The anatomic site of injury in the anterior neck is important as this helps to determine the structures that may be affected. The severity of the injury also depends on the structures in the neck that are affected. It is in this regard that the Roon and Christensen’s classification6 of the zones of the neck is useful for ease of assessment. The classification identifies three major zones in the neck. Zone -1extends from the level of the sternal notch to the cricoid cartilage. Zone-2 extends from cricoid cartilage to the angle of mandible and Zone-3 extends from the angle of mandible to the base of the skull.
Penetrating neck injuries have been reported to account for 5 – 10% of trauma cases in some studies7-9. In Nigeria and most sub-Saharan African countries, it is difficult to estimate the incidence or prevalence of penetrating neck injuries as comprehensive trauma registries are few. Studies on penetrating neck injuries in Nigeria have mainly consisted of case reports and they have noted that these cases may be under reported10 - 13. This study is aimed at appraising the pattern of penetrating anterior neck injuries managed at the Lagos University Teaching Hospital, Lagos, Nigeria over a 25-year period in order to assess the causes, types of injury, and management outcome.
METHODOLOGY
This is a 25-year retrospective study of penetrating anterior neck injuries that were managed by the Otorhinolaryngology unit in collaboration with other surgical units and the anaesthesia department of the Lagos University Teaching Hospital, Lagos, Nigeria from January 1992 to December 2016. The records of 58 patients managed for penetrating anterior neck injuries were initially obtained from the operating theatre register. The records of 8 patients treated for anterior neck injuries between January 1992 and December 1995 was obtained from the collated data used for a previously published study14. The discharge summaries of 7 patients treated between January 1996 and December 2004 and the case files of 24 patients treated between 2005 and 2016 were retrieved from the medical records department of the hospital. Patients that were not managed by in collaboration with the Otorhinolaryngology unit in the hospital were excluded.
The data extracted for each patient included the demographic profile, cause of injury, type of injury, extent of injury, treatments and outcome. The causes were classified as gunshot injuries, stab injuries, vehicular accident injuries and inflicted cut throat injuries. The Roon and Christensen’s classification6 of the anatomic zones of the neck was used to assess the site of injury from the documented clinical findings. Treatment was classified as resuscitative measures, airway maintenance technique and repair of wounds. The extent of injuries was identified through the documented operative findings and classified as involvement of the skin, muscles & small blood vessels, involvement of the larynx, pharynx, oesophagus, vascular involvement and neural involvement. Outcome of management was noted as recovery, complications, duration of hospitalization and mortality.
The data collected were documented in a study form and entered into a Microsoft excel worksheet. The data were grouped and analyzed using Microsoft excel statistical package of windows 10. The tables and charts were constructed using Microsoft word software with the results displayed in text, tables and figures. Specimen pictures of some patients were included as figures to highlight the types of injuries.
Results
A total of 58 patients were recorded in the operating theatre register but the data of 39 patients were retrieved for inclusion into the study. The age range of the patients was 6yrs to 65yrs with a mean of 30.5 ± 7.9SD. There were 34 males and 5 females with a male: female ratio of 6.8: 1.
Age-group distribution of the patients
Table 1shows the age group distribution of the patients in relation to the cause of penetrating anterior neck injury. The peak age group affected was the 4th decade (38.5%) while 66.7% were in their 3rd and 4th decades of life.
Table 1. Age group distribution of the study patients in relation to cause of injury.
| Age Groups Yrs. | Gunshot Injury | Stab Wound Injury | Vehicular Accident Injury | Inflicted Cut throat Injury | TOTAL | (%) |
| < 10 | 0 | 0 | 2 | 0 | 2 | 5.1% |
| 10 – 19 | 0 | 0 | 2 | 2 | 4 | 10.3% |
| 20 – 29 | 2 | 2 | 1 | 6 | 11 | 28.2% |
| 30 – 39 | 2 | 4 | 1 | 8 | 15 | 38.5% |
| 40 – 49 | 1 | 0 | 2 | 0 | 3 | 7.7% |
| 50 – 59 | 1 | 0 | 0 | 1 | 2 | 5.1% |
| ≥ 60 | 1 | 0 | 0 | 1 | 2 | 5.1% |
| TOTAL | 7 | 6 | 8 | 18 | 39 | 100% |
Causes of injuries
The causes of injuries were as illustrated in Fig. 1. Inflicted cut throat injuries accounted for 46% of the cases, followed by vehicular accidents (21%).
Fig. 1. Causes of penetrating anterior neck Injuries.
Sites of injury
The zones of the neck that were involved in the injuries are summarized in Table 2
Table 2. Distribution of the anatomic zones of the neck involved in relation to the cause of injury.
| Zones of Neck Affected | Gunshot Injury | Stab Wound Injury | Vehicular Accident Injury | Inflicted Cut throat Injury | TOTAL | |
| Zone I alone | 0 | 0 | 0 | 0 | 0 | 0% |
| Zone II alone | 2 | 4 | 0 | 18 | 24 | 61.6% |
| Zone III alone | 5 | 0 | 0 | 0 | 5 | 12.8% |
| Zones I & II | 0 | 0 | 2 | 0 | 2 | 5.1% |
| Zones II & III | 0 | 2 | 4 | 0 | 6 | 15.4% |
| Zones I, II & III | 0 | 0 | 2 | 0 | 2 | 5.1% |
| TOTAL | 7 | 6 | 8 | 18 | 39 | 100% |
Tissues involved in injury
The skin, muscles and small blood vessels were affected in all the patients and the laryngopharynx was affected in 61.5% of the patients as illustrated in Fig. 2.
Fig. 2. Distribution of the structures involved in the injuries.
Fig. 3 – 13 are pictures of some of the patients
Fig. 3. A 42 year old road transport official with stab wound injury to the anterior neck during an interpersonal violence.
Clinical presentation and resuscitative measures
Table 3 shows the profile of clinical presentation and resuscitative measures that were recorded.
Table 3. Clinical presentation and resuscitative measures applied.
| Clinical Presentation & Resuscitation Measures | Number of Patients (%). n = 39 |
| Duration before presentation | |
| < 12 hrs. | 8 (20.5%) |
| 12 – 24 hrs. | 20 (51.3%) |
| >24 hrs. | 11 (28.2%) |
| Pre-operative Blood transfusion | |
| Not given | 21 (53.8%) |
| Given | 18 (46.2%) |
| Airway maintenance | |
| Nil | 6 (15.4%) |
| Endotracheal Intubation | 0 |
| Tracheostomy | 33 (84.6%) |
| Cricothyroidotomy | 0 |
Surgical treatment
All the patients had surgical treatment with neck wound exploration and primary soft tissue repair. Specific organ repair procedures were done as necessitated such as laryngopharyngeal repair in 61.5%, hemi-thyroidectomy in 10.3%, oesophageal repair in 10.3% and fixation of mandibular fractures in 12.8% of the patients; vascular or neural repairs were not recorded.
Morbidity and mortality profile
Table 4 shows the mortality and morbidity profile of the patients.
Table 4. Morbidity and mortality profile of the patients.
| Mortality & Morbidity Profile | Number of Patients. n = 39 (%) |
| Treatment outcome | |
| Recovery | 36 (92.3%) |
| Mortality at Surgery | 2 (5.1%) |
| Mortality after Surgery | 1 (2.6%) |
| Duration of Hospital Admission | Number of Patients (%). n = 36 |
| < 1 wk. | 4 (11.1%) |
| 1 – 4 wks. | 2 (5.6%) |
| >4 wks. | 30 (83.3%) |
| Tracheostomy decannulation | |
| Successful | 28 (77.8%) |
| Unsuccessful | 8 (22.2%) |
| Complications noted | |
| Wound infection | 10 (27.8%) |
| Fistula formation | 4 (11.1%) |
| Laryngotracheal stenosis | 8 (22.2%) |
Discussion
Penetrating anterior neck injuries varied from minor lacerations or puncture wounds involving the skin, muscles and small blood vessels in the neck to severe injuries that involved the laryngeal framework, pharynx and deeper structures in the neck. The male gender preponderance and the peak age in the 3rd and 4th decades of life seen in the results of this study were highlighted in other published studies2, 10 - 13. Adoga et al in their report of three cases of suicidal cut throat injuries noted that all were males with two in the 3rd and 4th decades of life while Adebola et al reported the case a 24 year old man with inflicted cut throat injury12,13. Onotai et al in a retrospective study, reported on 24 cases of cut throat injuries seen in Port Harcourt over a ten year period and all the patients were males between the ages of 26 and 45 years15.
In our study there were a few females (12.8%). In reports from other developing countries, Panchappa et al reported a m:f ratio of 6.3:1 in a retrospective study of cut throat injuries in India while Gilyoma et al reported a m:f ratio of 2.4:1 in a retrospective / prospective study in Tanzania2, 16. This was attributed to the tendency of young adult males to be more involved in civil strife actions, substance abuse and interpersonal violence. Other reasons adduced were mental illness and frustration from unemployment. Adoga et al noted the link between unemployment and suicide tendency as reported in the study by Shah and Bhandarkar12, 17. The study by Iseh and Obembe also noted that a significant proportion of emergency cases of anterior neck cut throat injuries (52.6%) were from suicidal attempts by people with a background history of psychiatric illness18. The 3rd and 4th decades of life also constitute a relatively high proportion (30.2 %) of the Nigerian population 19.
Some studies estimated that 50 - 95% of penetrating neck injuries result from gunshots and stab wounds and attributed a low incidence of penetrating neck injuries to vehicular accidents5, 7,9, 20. However, the result from this study showed that vehicular accident was a common cause of penetrating neck injury (21%). This may be due to the high rate of road traffic accidents in Nigeria particularly from commercial motorcycle accidents21. On the contrary, the vehicular accident victims in Nigeria may be surviving longer after the injuries than those with gunshot injuries to be able to access hospital care. Gunshot injuries to the neck in this study were few despite the fact that gunshot injuries are common in Nigeria. The relatively few numbers may be due to the fact that high velocity gunshot injuries to the neck are more likely to be lethal. Stab wounds in this study were from assault during interpersonal fights and superficial as they might not be with the intent to kill. Another reason for the relatively few cases of stab wound injuries in this study may be that, deep stab wounds were probably fatal and the patients did not reach the hospital for treatment; forensic studies have shown the fatality of stab injuries to the neck4.
Miller et al (1991) reported that 60-75% of penetrating neck injuries involve zone II22 similar to the finding in this study as zone II alone injuries accounted for 61.6% of cases while zone II both alone and in conjunction with other zones was involved in 83.2% of the patients. Zone II is anatomically the most accessible part of the neck to injuries as Zones I and III are protected by bones and thus less accessible to trauma. Penetrating injury to zone I is likely to be fatal as the main anatomic structures in this zone are the great vessels (subclavian blood vessels, common carotid arteries, aortic arch, brachiocephalic blood vessels and jugular veins), lung apices, trachea and oesophagus and the recurrent laryngeal nerves1. Zone III is in the superior aspect of the neck and the mandible is usually protective. Most patients with zone III injuries (17.9%) were from low velocity gunshot and vehicular accident injuries. Mandibular bone fractures were recorded in 12.8% of patients in this study.
Most (71.8%) of the patients presented within 24 hours of the injury and the peak duration before presentation was 12 – 24 hours. This may be due to the perceived seriousness of penetrating anterior neck injuries among the populace because open neck wounds cause apprehension and panic in individuals leading to early presentation for hospital care23.
Blood transfusion was administered to 46% of the patients as part of resuscitative measures in their initial management while 42% had blood transfusion intra-operatively. This implies that these patients had significant blood loss from the injuries. 12% of the patients were haemodynamically stable on presentation as they had superficial injuries as documented. Tracheostomy was the main route of airway maintenance in this study. A longitudinal study on tracheostomy in Lagos highlighted the use of tracheostomy in the management of upper airway obstruction (UAO) due to external laryngeal trauma in 13% of 177 of patients with UAO14. Ezeanolue documented the importance of tracheostomy in the airway management of severe penetrating neck injuries11. This has also been documented in case reports from Nigeria on penetrating anterior neck injuries10,12, 13. Tracheostomy has been reported to be a good method of securing the airway pre-operatively in severe penetrating neck injuries as endotracheal intubation of open neck wounds could cause more damage to the injury16,18, 20, 23.
The mortality rate in this study was low (7.6%); due to the relatively early presentation of the patients and the policy of early primary wound exploration and repair of affected tissues that was performed in all the patients. The morbidity profile of patients in this study showed that 83.3% of patients had prolonged hospital admission of more than 4 weeks post operatively - a reflection of the severity of the injuries. Tracheostomy decannulation was unsuccessful in 22.2% of the patients that survived. These patients had laryngotracheal stenosis. Wound infection rate was 27.8% despite prophylactic pre-operative parenteral antibiotic administration on all the patients. Fistula formation was noted in 11% of the patients which all healed with conservative management.
Conclusions
This study has shown that penetrating anterior neck injuries is not uncommon in Nigeria and is commonly due to cut throat and vehicular accidents. Proper documentation and following established management protocols will improve outcome.
Fig. 4. The patient after treatment.
Fig. 5. 16 year old student with self-inflicted cut throat injury.
Fig. 6. Injury assessment in the theatre before wound cleaning and tracheostomy.
Fig 7. Repair of the cut throat structures in layers.
Fig. 8. Skin closure.
Fig. 9. Healed cut throat wound awaiting decannulation.
Fig. 10. Successful decannulation.
Acknowledgment
We would like to acknowledge Drs. Najomoh AA, Johnson KJ and Ogunbiyi AA who are resident otorhinolaryngologists in our unit for collating the theatre records and case sorting. We thank Ms Elizabeth Olimah for data input.
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