Cut Neck, Department of E.N.T in a Tertiary Centre: How We Approach

Abstract

Cut neck injury needs prolonged hospitalization, high cost care, reduced quality of life and above all death. Proper exploration is a must in preventing co-morbidities like shock, sepsis, laryngotracheal stenosis or fistula formation. Neck trauma can involve muscles, vessels, nerves, bone and hollow viscera. Though the repair of neck means planning and skill for repair of the structure, the tracheal repair needs special attention to avoid tracheal stenosis. 12 patients were included in the prospective study of 8 months. Management plan was undertaken which were thoroughly studied and discussed with respect to two tracheoplasty cases done in ENT OT, AMCH. Apart from haemodynamic stability all patients were assessed for injury to hollow viscera and planned accordingly as this centre is an important centre for airway reconstruction. Male female ratio was 11:1. Suicidal cut neck injury was the most common cause. Two cases were of tracheal stenosis post tracheostomy. One of the case had associated neurovascular injury but with patent airway. Rest of the cases were repaired under general and/or local anaesthesia. Primary aim should be to maintain airway and to look for the extent of injury to reduce morbidity. Expertise of surgeons’ skill is developing every day hence the successfulness of repair will be tested by least of morbidity. From this institute which is skilled in airway reconstruction we could comment that airway reconstruction team should be an integral part of surgeons’ team.

Introduction

Cut neck injury is always an emergency as it is associated with many vital structures which if damaged and not timely managed can lead to long term morbidities like hoarseness, stenosis, fistula formation, shock, sepsis and even death [1]. The individual with cut throat injury presents with airway compromise, aspiration or acute blood loss with hypoxemia because of the airway injury and the injury to major vessels in the neck. Management of the wounded airway is essential in cut neck injury, by instituting an airway using endotracheal intubation or through tracheostomy. The main idea is to first secure the airway and then go for repair by estimating the extent of injury. Cut neck injuries requires interdisciplinary treatment; the anaesthetist, nurses, speech therapist and clinical-psychologist working as a team with the Otolaryngologist are needed for the good and effective patient`s care.

India and China alone account for 49% of global suicides. The World Health Organization (WHO) estimates that of the nearly 900,000 people who die from suicide globally every year, 170,000 are from India. But this number may vary because of under-reporting of suicide by the NCRB [2].

Laryngotracheal trauma constitutes less than 1% of all trauma cases, but accounts for more than 75% cases of immediate mortality [3]. These injuries are less common in the paediatric population because of the higher position and elastic nature of the larynx. The vital structures involved in ventilation, phonation, and swallowing are present in a more compact space in the neck and are more prone to injury as they are not protected by a bony covering.

One area that particularly lacks clear guidance is therapeutic decision making, including whether to mandatorily or selectively explore the neck. However, advances in imaging studies have provided a valuable tool for treatment planning in trauma cases. The restoration of phonatory and the sphincter function of the larynx depend on the proper alignment of the cartilaginous framework, muscles, ligaments, as well as mucosal integrity following injury [4].

The study was conducted in the department of Otorhinolaryngology, Assam Medical College and Hospital, Dibrugarh.

The aims of this study were to describe the clinical presentation, management, and outcomes in patients who presented with cut neck injuries.

Materials and Methods

Data was categorized according to name, age, sex, mechanism of injury, extent of injury, socio demographic pattern and duration of hospital stay, treatment given and the final outcome of the patient [4]. The data is represented in the form of tables and charts.

The evaluation of a patient with cut throat injury should start with advanced trauma life support (ATLS), which begins with a primary survey giving importance to the airway, breathing, circulation, disability and exposure [4].

Primary survey is followed by secondary survey which includes head to foot examination of the patient. Further investigations are required in stable patients to plan the management of a cut throat injury.

Preliminary factors to be dealt at first are hypoxia, hypovolaemia secondary to haemorrhage, shock, airway obstruction, tension pneumothorax and to rule out any associated head injury. Patient is examined for the evidence of any airway obstruction which may present as stridor and use of accessory muscles of respiration is looked upon [4]. An endotracheal or tracheostomy tube should be kept at hand to be inserted directly into the trachea through the site of a penetrating cut neck injury to prevent aspiration.

In case of a shock patient, start with normal saline and/ or haemaccel and proceed to emergency blood transfusion. Active bleeding from a cervical wound may be controlled with compressive dressing or digital pressure [4]. Estimated blood loss was calculated on the basis of number of gauze fully soaked in blood and amount of blood clots. A fully soaked gauze piece was equivalent to 20 ml blood and blood clots of the size of fist were 300 ml. Hence any major vessel injury was suspected on the basis of blood loss.

Patients with superficial injuries involving only the skin and subcutaneous tissue are repaired under local anaesthesia by infiltrating the margins with 2% lignocaine with adrenaline. Superficial cut throats were managed with the simple layered closure of wound 2-0 or 3-0 vicryl suturing under aseptic conditions. Deep laryngotracheal injuries were repaired with Prolene.

All patients received tetanus toxoid and antibiotics. Dirty wounds were cleaned first with a lot of saline followed by betadine and antibiotic solution. After thorough cleaning, the injury is properly examined for any pharyngeal, oesophageal, laryngeal and/or tracheal injuries. Care must be taken to examine for any vascular injury. Any vascular or aero digestive tract injuries should be repaired in an operation theatre under general anaesthesia either through endotracheal intubation or through the tracheostomy site.

Results

A total of 12 patients with cut throat injury were included in the study, in which 11 were male (92%) and 1 female (08%). Male to female ratio was 11:1. Age ranged from 20 to 50 years (mean age 32 years). Most of the patients were from tea garden community. The symptoms with which the cases presented are depicted in Fig 1 and Table 1.

Fig. 1.

Symptoms of cases

Table 1.

Symptoms of cut neck patients

Symptoms	Cases
Bleeding from site	10
Associated psychiatry illness	7
Aphonic	6
Respiratory distress	4
Dysphonia	3
Unconsciousness	1

In our study 2 (17%) cut necks were superficial and 10 (83%) were deep. Out of 10 patients 06 patients were tracheotomised. Post repair, 3 patients out of 8 were kept under intubation (Table 2,  Fig. 2).

Table 2.

Extent of injury in cut neck patients

Sl. no	Extent of injury	No. of patients
1	Skin and subcutaneous tissue	2
2	Strap muscles and thyrohyoid membrane	2
3	Larynx and trachea	6
4	Neurovascular injury	2
5	Other structures	3

Fig. 2.

Extent of injury

04 patients were mentally sound and 08 patients were found to have some mental illness. Socio economic status revealed that most of the patients belonged to upper lower strata (Table 3).

Table 3.

Socioeconomic status of cut neck patients

Socioeconomic status	No. of patients
Upper	0
Upper middle	1
Lower middle	2
Upper lower	7
Lower	2

The most common cause of cut neck was suicidal 07 (58%) followed by homicidal 03 (26%), RTA 01 (08%) and accidental 01 (08%) (Fig. 3, Table 4).

Fig. 3.

Mode of injury

Table 4.

Mode of injury

Mode of injury	Total	Male	Female
Homicidal	3	3	0
Suicidal	7	6	1
RTA	1	1	0
Accidental	1	1	0

Severity of laryngeal injury (Schaefer Fuhrman's classification) [5] when applied upon the cases, it was found that 6 cases were category III, 3 were category II and 1 of them was of category I. (Table 5)

Table 5.

Schaefer Fuhrman's classification of severity of laryngeal injury

Group	Injury
I	Minor endolaryngeal hemotoma without detectable fracture
II	Edema, hematoma, minor mucosal disruption without exposed cartilage, and nondisplaced fractures
III	Massive edema, mucosal disruption, exposed cartilage, vocal fold immobility, and displaced fracture
IV	Group III with disruption of anterior larynx, unstable fractures, two or more fracture lines, or massive trauma to laryngeal mucosa
V	Complete laryngotracheal seperation

Neck zones: The neck has been divided into 03 zones anatomically, namely (Table 6).

Table 6.

Number of cases with respect to neck zones

Neck zones	No. of cases
Zone I	08
Zone II	04
Zone III	00

ZONE I: from clavicle/sternum to cricoid cartilage. It is a dangerous area and injuries are potentially lethal due to involvement of:

• Great vessels in the neck

• Mediastinum

• Cervical and thoracic esophagus

ZONE II: from cricoid cartilage to angle of mandible. It’s the largest of all neck zones and most common zone to be injured

ZONE III: from angle of mandible to skull

Two of the cases had developed tracheal stenosis. First case was a 5 months old RTA case with neck injury. Preliminary treatment and emergency tracheostomy was done in another tertiary care centre. We received the patient with grade II tracheal stenosis as per COTTON MYER grading and grade III tracheobronchial injury as per SCHAEFER FUHRMANS classification. Second case was a case of self-inflicted cut neck injury repaired and tracheostomised in another tertiary care centre. We received the patient having tracheal stenosis and trachea-esophageal fistula. Both these cases were explored under general anaesthesia.

Below mentioned is Cotton Mayer staging for sub-glottic stenosis [6] (Fig. 4).

Fig. 4.

Cotton Mayer staging for sub-glottic stenosis

In the first patient with RTA four tracheal rings had to be excised followed by end to end anastomosis (Fig. 14). The other patient had glotto-glotic stenosis with tracheo-esophageal fistula where tracheothyroplasty with cricoid repair was done along with repair of TEF. Thyroid ala was supported by the rings of trachea and arytenoids were sutured to upper tracheal edges. In both the cases before exploration low tracheostomy was done which was replaced by armoured endotracheal intubation during OT procedure. Both of them were kept under nasotracheal intubation post OT.

Fig. 14.

Post-op X-ray soft tissue neck (A-P & Lateral view) of tracheoplasty case where end to end anastomosis was done

Tracheoplasty

Two cut neck cases had to be planned for tracheoplasty. In both the cases we had used cuffed armoured tube in the tracheostomy site and had fixed it on to the chest. Previous tracheostomy site was used to explore the neck. Proper dissection was carried out after raising superior and inferior flaps. Following dissection stenosis part was removed. For better anastomosis laryngeal drop was achieved by dissecting the thyrohyoid muscle. In the case with trachea-esophageal fistula drilling was carried out by diamond burr over the posterior lamina of cricoid to delineate the fistula and primary repair was done to close it with prolene. By this time endotracheal tube was inserted nasally and kept just above the resected part. End to end anastomosis was carried out first in the posterior wall and then the anterior wall with vicryl 3-0. Before the anterior wall was repaired, the endotracheal tube was inserted pass the repaired zone. Following this the repair was continued in layers. Endotracheal tube was kept in situ for 10 days during which proper suctioning was carried out. Submento-sternal suture was put to keep the neck in flexed position in post-operative period. Tube was removed on 10^th post-operative day and submento-sternal suture on 14th day. The tracheoplasty procedural images has been depicted in below images (Figs. 5, 6, 7, 8, 9, 10 and 11). 

Fig. 5.

Raising superior flap

Fig. 6.

Armoured tube in situ with resection of superior end of stenosed part

Fig. 7.

Lower end of stenosed part being dissected. Endotracheal tube has been inserted nasally

Fig. 8.

Repair of posterior wall

Fig. 9.

Repair of anterior wall

Fig. 10.

Stenosed portion after excision

Fig. 11.

Drilling of posterior lamina of cricoid cartilage for delineating the TEF

Another patient had come with cut neck injury following A/H/O fall over bamboo stick. Patient was referred from another tertiary centre to AMCH. During exploration it was found that patient had injury over left sternocleidomastoid, left IJV, left lateral border of esophagus, left sympathetic trunk, a rent in left internal carotid artery and also left RLN. He was subjected to immediate exploration under GA. Post repair patient was shifted to ICU where he was kept under endotracheal intubation for 10 days. The reason for keeping him in ICU was that the patient had developed blood dyscrasia due to massive blood transfusion (Fig. 12).

Fig. 12.

Post operated patient coming for check-up after 01 month. a Pre-ryles tube removal. b Post-ryles tube removal. An oblique scar is noted in left supraclavicular region

One patient from Arunachal Pradesh with past history of psychiatric illness was brought to AMCH with A/H/O suicidal cut neck injury. In casualty when wound was explored it was noted that a stoma had been created over the inferior aspect of thyroid cartilage involving the first tracheal ring. Emergency cuffed tracheostomy tube was inserted through the stoma to prevent aspiration. Patient was shifted to OT where re tracheostomy was done followed by repair of the injured thyroid lamina (Fig. 13).

Fig. 13.

A pre stoma noted (left) and immediate post repair a cuffed tracheostomy tube in situ (right)

Rest of the patients had injury over thyroid cartilage and cricothyroid membrane where subsequent tracheostomy and repair was done in OT.

All patients who had a tracheotomy were eventually de-cannulated. Mean time to decannulation was 15 days with a range of 5–30 days (Table 7).

Table 7.

Duration of hospital stay

Duration of hospital stay (in days)	No. of patients
0–10	04
11–20	06
21 and more days	02

Voice outcomes were satisfactory in almost all cases except for the patient who sustained injury to left RLN. He had developed change in voice in initial post-operative period due to paresis of left RLN. But after 1 month no obvious change in voice was noted.

Radiological Investigations

All patients were subjected to radiological investigation which included X-RAY and CT SCAN. Most of them were done post op period (Fig. 14). Few of them were done prior to de-cannulation period showing tracheostomy tube in situ. Few of the findings included loss of cervical lordosis, surgical emphysema around the operated wound. Below depicted is the post-operative X- ray image of one of the tracheoplasty cases showing patency of the airway.

Prognosis

One of the patient expired post repair period due to cardiorespiratory failure. Due to heavy blood loss in the pre-operative period. Another patient (05 months old RTA case where tracheoplasty was done) was able to speak after a period of 5 months.

Discussion

The above study was done from a viewpoint of preliminary management of cut neck patients and it was found that the main aim should always be to secure the airways. Once the airway is managed it should be followed by repair of cut neck. We have noticed that if a stoma is already made due to cut neck, than that particular stoma can be used for putting tracheostomy tube or for intubation purposes provided other parameters are feasible. Once we have secured the airway we can than shift the patient to OT for further evaluation. If no previous stoma has been made than as per our study we can do emergency tracheostomy using BJORK flap so as to reduce the chances of post tracheostomy stenosis as found in 2 of our cases.

Post operatively it is advisable to keep head in flexed position. We have used submento-sternal suturing to keep head in flexed position.

Conclusion

Neck trauma whether open and/or blunt are in a rise due to road traffic accidents and modern day induced stress giving neck surgeon the challenge of getting equipped not only to settle the patient haemo-dynamically but also to decrease the morbidity with the use of modern skill of vascular, airway and visceral repair.

Therefore preliminary treatment in cut neck includes making patient haemo-dynamically stable and securing the airway but not at the cost of life long morbidity due to hastened emergency management. Aim should always be to restore the functions at par to its normal state, for which proper anatomical and physiological knowledge is a must.

Compliance with Ethical Standards

Conflict of interest

No conflict of interest.

Ethical Approval

Ethical clearance taken from ethical committee of the college.

Informed Consent

Written and informed consent taken from the patients in the study.