Letter to the editor: an isolated midline zone 1 neck injury, with a tracheooesophageal fistula

To the Editor,

We have read the article ‘Bilateral pneumothoraces secondary to an isolated midline zone 1 cervical stab injury’ by Kasturi et. al., who note the rarity of such an injury [1], and we write regarding a similar case of a 76-year-old lady who presented with a self-inflicted zone 1 knife injury to the neck, which also resulted in bilateral pneumothoraces. In contrast to the patient discussed in Kasturi et. al.’s case report, our patient’s injury extended to involve the posterior wall of the trachea and anterior oesophagus. We managed this injury conservatively.

In the UK, penetrating neck injuries are relatively uncommon, and approximately half of these injuries are a result of self-inflicted injury [2]. Much of the guidance on their management is derived from the USA, South African and battlefield guidelines [2, 3]. A 2016 UK study of 63 penetrating neck trauma patients over 6 years notes a general shift towards conservative management, with only 35% progressing to general anaesthetic and open exploration. However, this trend towards conservative management may reflect the fact that the UK has a higher proportion of low velocity neck injuries compared to other countries such as the USA where firearm regulations are less stringent [3].

The patient had presented to our accident and emergency department approximately 1 week prior with a suicide attempt by suffocation. At her second presentation to the emergency department, she was found to have a zone 1 neck injury with the knife no longer in situ (Fig. 1A). She showed minimal signs of respiratory distress and was haemodynamically stable and haemostasis had largely been achieved by the prehospital paramedic crew. Kagimoto et al. describe an 84-year-old female with low mood and self-inflicted neck injury who was also haemodynamically stable, though in contrast, the knife was still embedded in the neck and was tamponading the bleeding [4].

Fig. 1.

A Photograph of zone 1 neck injury. B CT scan demonstrating zone 1 neck injury with subcutaneous emphysema, pneumomediastinum and bilateral pneumothoraces. C CT scan with anterior tracheal injury appreciable. D Contrast swallow showing extravasation of contrast from the oesophagus into the trachea

Initial computed tomography (CT) scan demonstrated an anterior tracheal injury with subcutaneous emphysema confined to the neck and upper chest, pneumomediastinum with bilateral pneumothoraces and small to moderate pleural collections (Fig. 1B and C). An oesophageal injury could not, however, be ruled out. A contrast swallow confirmed the presence of a tracheooesophageal fistula (Fig. 1D), a fluoroscopy-guided nasogastric tube was inserted to allow enteral feeding. The knife wound was covered with an occlusive dressing and allowed to heal by secondary intention, while the larger right-sided pneumothorax was managed with an intercostal chest drain. The chest drain was connected to a digital suction device and this progressively reduced the surgical and mediastinal emphysema. The chest drain was removed after 9 days allowing sufficient time for healing of the tracheal and oesophageal injuries. A repeat contrast swallow on day 12 showed that the tracheo-oesophageal fistula had healed, although the patient now demonstrated aspiration of contrast during the swallow (Fig. 2).

Fig. 2.

Contrast swallow showing resolution of the trachea-oesophageal fistula, though with new aspiration

This unsafe swallow resulted in two episodes of aspiration pneumonia both of which were managed with a course of appropriate antibiotics. Much of the remaining inpatient stay was a result of poor mental health as the patient struggled to engage in swallow training exercises. The psychiatric team reviewed her regularly and ultimately, the patient was transferred to a psychiatric unit under section following resolution of her swallowing issues.

The original article [1] notes the varied presentation of penetrating neck injuries, and in keeping with recent peer-reviewed literature, our case follows the trend towards conservative management in the UK. Initial prompt advanced trauma life support (ATLS) assessment is key. In addition, our case highlights the importance of an individualised approach to such injuries and a holistic approach to manage the complex relationship between physical and mental health.

Author contribution

Not applicable.

Funding

The authors received no financial support for the research, authorship, or publication of this article.

Data availability

Not applicable.

Code availability

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Declarations

Ethics approval and consent to participate

Informed consent was given by the patient to publish this case and associated images.

Conflict of interest

The authors declare no competing interests.