Abstract
Penetrating neck injuries are defined as injury to the neck associated with breach in the platysmal muscle layer. All penetrating neck injuries are potentially dangerous and require emergency intervention due to its proximity to airway, important blood vessels, nerves and other organs in the neck. A complete evaluation, rapid airway intervention and proper surgical repair are highly essential to prevent complications. Clinical evaluation and management of penetrating neck injuries at a tertiary care hospital. In this study, 66 cases of penetrating neck injuries who presented to the emergency department from October 2018 to September 2020 were included. The particulars of the insult like type of instrument causing injury and zone of injury were compared. An analysis of the management of penetrating neck injury with respect to exploration and wound repair and the need for tracheostomy, vascular repair, esophageal repair, laryngeal framework repair and pharyngeal repair was made. The maximum incidence was observed for the age group between 21 and 30 years. The object causing the maximum number of neck injuries was knife, in 36 cases. The distribution of cases according to zone of injury revealed that the zone II was most commonly affected in 43 cases. The structures injured in the study indicated that platysma was involved in all the cases, followed by thyroid cartilage in 33 cases. Wound exploration and repair was done in all cases and tracheostomy was done in 44 cases. Complications were vocal cord palsy in 19 patients, 15 had tracheal stenosis, 13 had hoarseness of voice, 7 developed pharyngocutaneous fistula and 1 developed pharyngeal stenosis. There were 2 deaths. 16 patients who attempted suicide had depression. All penetrating neck injuries are potentially dangerous and require emergency treatment because of the presence of important vessels, nerves andorgans in the neck. Thorough knowledge of the anatomy of neck, clinical assessment and diagnostic and therapeutic interventions are necessary for appropriate management.
Keywords: Penetrating neck injury, Airway, Tracheostomy, Neck zones
Introduction
Penetrating neck injuries is defined as injury to the neck associated with breach in the platysmal muscle layer. All penetrating neck injuries are potentially dangerous and require emergency intervention due to its proximity to airway, important blood vessels, nerves and other organs in the neck. Risk of significant injury to vital structures in the neck is dependent on the type of penetrating object. Thorough knowledge of the anatomy of neck, clinical assessment and diagnostic and therapeutic interventions are necessary for appropriate management [1].
Neck is divided horizontally into three zones. Zone I extends between the cricoid cartilage and clavicle, and injury to this zone carries the highest mortality because of involvement of the thoracic structures, vascular injury and difficult surgical exploration. Zone II extends from angle of mandible to cricoid cartilage. Injury to this area is more common but mortality is less due to better surgical exploration compared to other zones. Zone III extends from base of the skull to the angle of mandible. Although zones I and III are protected by bones, penetrating trauma of these areas are more dangerous than in zone II because of proximity of thorax and skull base [2].
Knowledge about the common consequences of each zone of injury gives an idea about the most likely injury and expected surgical management. However, any patient with obvious signs or symptoms of a major vascular or tracheo-oesophageal injury, regardless of anatomical zone, should be explored as an emergency [3].
Neck is densely concentrated with aero digestive, vascular and nervous system within a relatively small and unprotected anatomical region, making it one of the most vulnerable areas of the body for all types of injuries. Penetrating neck injury constitutes 5–10% of all emergency cases. The surge in urban violence leads to the proportional rise in the number of cases these days. Penetrating neck injuries may be homicidal, suicidal and accidental (RTA) in nature. Objects which can cause penetrating neck injuries are knife, gun, pencil, glass pieces and metal objects. The accurate documentation helps us to determine whether the injury is homicidal or suicidal [4].
Objectives
To evaluate different clinical presentation of penetrating neck injuries,
To assess the management and outcome of penetrating neck injuries.
Methods
This prospective study included Sixty-six (66) patients with penetrating neck injury. Patients attending to casualty ENT department at Sri Venkateshwara ENT institute and ENT department of Bowring and Lady Curzon hospital attached to Bangalore medical college and Research institute, Bangalore during period November 2018–May 2020 were enrolled for the study after the ethical committee clearance.
Inclusion Criteria
Patients more than 18 years of age.
Patient who are coming to the hospital for the first time or referred from others hospital or institute with history of penetrating neck injury.
Patients/relative who are willing to participate and ready to give written informed consent.
Exclusion Criteria
Patients less than 18 years of age.
Patients or relatives who are not willing to give informed written consent.
Initially, for all patients, primary survey (survival assessment) was done which includes airway patency, breathing and adequacy of circulation. Resuscitation was performed according to Advanced Trauma Life Support (ATLS) principles. The neck was stabilized with a cervical collar or sandbags until cervical spine injury excluded.
Patients with Glasgow coma scores (GCS) of ≤ 8 were intubated to protect the airway. In few patients, endotracheal tube was inserted directly into the trachea when it was exposed in a penetrating cervical injury. The chest was examined to rule out tension pneumothorax and haemothorax. The patients were examined for clues to indicate damage to vital structures like gross bleeding or presence of hematoma (seen in arterial injury), hematemesis, odynophagia, subcutaneous emphysema, blood in saliva or in the aspirate of the nasogastric tube (seen in indirect aero digestive injuries) etc.
Depending on symptoms and signs suspicious of oesophagus, pharyngeal injuries and other injuries, standard procedures were done (i.e. Fibre-optic Nasoendoscopy, pan-endoscopy). Detailed head to toe examination was done to look for any associated injuries if present, were managed accordingly. Patients were subjected to standard haematological studies, imaging studies and other supplementary studies.
Patients analysed individually with respect to zone of the neck trauma, traumatized viscera, mechanism of trauma and presence of any complications and were managed accordingly. Our treatment protocol included selective management based on the neck zones and angiography, barium swallow, and endoscopic analysis.
According to the type, timing and severity of injury and patient comorbidities, the surgical management was determined. Surgical management including endoscopic approach and open approach were individualized according to patient. The options for acute management of the threatened airway included routine endotracheal intubation and tracheostomy under local anesthesia or general anesthesia which was followed by exploration of neck wound and it’s repair, vascular repair, Oesophageal repair, laryngeal framework repair and pharyngeal repair were made eventually. Surgery was aimed at airway preservation, prevention of secondary sequelae of healing and restoration of function via repair of endolaryngeal and other concomitant injuries such as neurovascular damage, or thoracic injuries, and stabilization of fractures of laryngeal framework.
The non-operative management of the patients included admission to an intensive care unit for airway monitoring for at least 24 h and treatment with constant humidification, head-end elevation, nil- by mouth and voice rest, head end elevation, naso-gastric feeding and suctioning, antacids, steroids and antibiotics. The complications of penetrating neck injury such as hoarseness of voice, tracheal stenosis, vocal cord palsy, trachea-esophageal fistula (TEF), and prognosis of penetrating neck injury to different zones were recorded systematically.
Follow Up
A regular post-operative follow up was done after a month, after two months, after three months and after six months for all patients. Psychiatric assessment and counselling was done.
Statistical Analysis
The data has been statistically analyzed by Software SPSS Statistics 24.0 and presented in the form of tables, figures, graphs, diagrams wherever necessary.
Results
Sixty-six (66) patients with penetrating neck injury were enrolled for this study irrespective of age and sex. The study population showed male preponderance with 51(77%) males and 15(23%) females (Table 1). Most common age group was between 21 and 30 years (51%) (Fig. 1).
Table 1.
Gender distribution of patients
| Sl. No | Gender | Frequency (n = 66) | Percentage (%) |
|---|---|---|---|
| 1 | Male | 51 | 77 |
| 2 | Female | 15 | 23 |
Fig. 1.
Distribution of patients according to age group
Our study showed higher incidence in lower class (48%) and lowest in upper class (6%) according to Kuppuswamy socio-economic scale. Majority of patients in our study belong to homicidal group (62%) followed by suicidal group (28%) and accidental group (10%) which included one patient with bull gore injury.
Table 2 depicts distribution of patients according to the structures injured in which thyroid cartilage was found to be involved in 50% of cases.
Table 2.
Depicting distribution of patients of according to structures injured
| Sl. No | Structures injured | No. of patients (n = 66) | Percentage (%) |
|---|---|---|---|
| 1 | Platysma | 66 | 100 |
| 2 | Sternocleidomastoid | 13 | 19 |
| 3 | Thyroid gland | 03 | 05 |
| 4 | Thyroid cartilage | 33 | 50 |
| 5 | Trachea | 10 | 15 |
| 6 | Major vessels | 02 | 03 |
| 7 | Accessory nerve | 03 | 05 |
| 8 | Pharynx | 11 | 16 |
| 9 | Laryngeal structures | 19 | 29 |
| 10 | Cricoid cartilage | 04 | 06 |
| 11 | Oesophagus | 01 | 1.5 |
Out of the sixty-six (66) patients with penetrating neck injury studied, zone II (Figs. 2 and 3) was involved in 43 (65%) patients, followed by zone I (Fig. 4) in 19 (29%) patients and zone III in 4 (6%) patients.
Fig. 2.
Penetrating neck injury of Zone II in the midline cutting through thyroid cartilage and exposing the thyroid gland
Fig. 3.
Penetrating neck injury of zone II above the level of hyoid bone exposing bilateral submandibular glands
Fig. 4.
Penetrating neck injury of Zone I in the midline showing tracheal breach at 2nd–3rd rings
The object causing the maximum number of neck injuries was knife, in 36 cases (Fig. 5).
Fig. 5.
Distribution of patients according to instrument causing injury
Wound exploration and repair was done in all cases and tracheostomy was done in 44 cases. (Fig. 6).
Fig. 6.
The distribution of patients according to their management
In this study, 32 (48.5%) patients had complications. Among them, 19 (28.8%) had vocal cord palsy, 15 (22.7%) had tracheal stenosis, followed by hoarseness of voice in 13 (19,6%) patients and the least was pharyngeal stenosis seen in 1 (1.5%) patient.
In our study, 25 cases had poor prognosis accounting for 37.8%. Best prognosis was seen in zone II injuries with 1.5% mortality, death occurred in 2 patients with mortality rate of 3%.
In this study, 16 patients had depression. Among 16 patients with depression, 5 had Schizophrenia, 5 had substance abuse, 1 had adjustment disorder and 1 had psychotic disorder. For these patients, psychiatric opinion was taken and appropriate medication and counselling done. Majority of the patients had a hospital stay of 11–20 days.
Discussion
Penetrating neck injuries (PNIs) are serious injuries as there is a high concentration of vital structures in close proximity to each other in a compressed anatomical area and can be immediately life threatening due to massive bleeding from vascular structures or airway compromise. Injury to the digestive tract in the neck may also result in delayed and potentially life-threatening conditions. The clinician caring for such a patient therefore requires a structured and comprehensive approach to managing these injuries and be able to manage competing priorities [5].
In our series, male preponderance was noted as study group consisted of 51(77%) males and 15(23%) females. This is in correlation with studies by Chappidi et al [6], Adoga et al [7] and Jain et al. [8].
On analyzing the age distribution of the study patients, it was observed that the mean age of the patients was 30 years. The ages of youngest and oldest patients in our series were 22 years and 65 years respectively. Majority of patients in our series belonged to age group between 21- 30 years (51%) followed by 31–40 years age group (30%). According to study by Manilal et al [9] with 67 cut throat cases, mean age was 28.82 years and majority of victims were 41 (61.19%) patients in between 21 and 30 years of age group.
Our study showed higher incidence of PNI in low socio-economic group (51%) than in middle class group (43%). Suicides were more commonly seen in middle class group and homicides were more in low socio-economic group. This is in comparable with studies by manilal [9] showing 79.10% patients belonged to low socioeconomic class and chappidi [6] showed 56.6% patients belonging to low socioeconomic class.
Majority of patients in our series belonged to homicidal group (62%) followed by Suicidal group (28%) and accidental group (10%) which included one patient with bull goar injury. The homicides were due to property disputes, fights and sexual offences. The most common cause of suicidal injuries was psychosocial stressors (familial disharmony) or psychiatric illness like depression, schizophrenia, bipolar disorder etc.Modi et al [10] observed that in India, suicidal wounds of the throat are rare. In contrast, cut throat injuries were reported to be caused by suicide attempts in majority of cases in western countries. [10–12] In developing countries, homicide is the most common cause of cut throat injury. Since, India is a developing country; homicide is the most common cause of cut throat injury. This is in correlation with our study. Males dominated in both homicidal and suicidal cut throat injury.
The most common mechanism of injury was stab wounds. Among 66 patients with PNI, Knife was most commonly used instrument accounting for 36 (55%) patients, followed by razor blade in 13 (20%) patients, iron rod in 6 (9%) patients, sword in 5 (7.5%) patients, sickle in 5 (7.5%) patients, and bull hit in 1 (1.5%) patient. In a study by Lochowski et al [13], 90% patients had injury with knife and 10% had gunshot injury. The most common mechanism of injury was cut wounds.
Out of the sixty-six (66) patients with penetrating neck injury studied, zone II was involved in 43 (65%) patients, followed by zone I in 19 (29%) patients and zone III in 4 (6%) patients. In a study by Peralta and Hurford [14], the location of injury was Zone I (lower neck) in 20 cases (15%), Zone II (midportion of neck) in 108 (81%) cases and Zone III (upper neck) in 5 (4%) cases14. Viswanatha et al. [3] reported injuries in zone I involving (14.2%) patients, zone II involving 80% patients and with 4.7% patients involved in zone III.
In our series, all the cases (100%) skin, soft tissue and small vessels were severed and platysma was breached. Thyroid cartilage was involved in 33 (50%) patients, laryngeal structures in 19 (29%) patients, sternocleidomastoid muscle in 13 (19%) patients, pharynx in 11 (16%) patients,
trachea in 10 (15%) patients, cricoid cartilage in 4 (6%) patients, thyroid gland in 3 (5%) patients, accessory nerve in 3 (5%) patients, major vessels in 2 (3%) patients, and oesophagus in 1 (1.5%) patient. In a study by Vishwanatha et al [3] with 42 patients of PNI, Thyroid cartilage was involved in 28.5% patients, laryngeal structures in 14.2% patients, pharynx in 21% patients, trachea in 14.2% patients, cricoid cartilage in 4.7% patients and oesophagus in 4.7% patients.
In our study, wound repair was done in all cases (100%). Tracheostomy was done in 44 (67%) patients, laryngotracheal repair was done in 44 (67%) patients, neck exploration was done in 11 (16%) patients, pharyngeal repair was done in 11 (16%) patients, vascular repair was done in 04 (6%) patients, and oesophageal repair was done in 01(1.5%) patient.
In our study, 32 (48.5%) patients had complications. Among them, 19 had vocal cord palsy, 15 had tracheal stenosis, 13 had hoarseness of voice, 7 had pharyngocutaneous fistula, 5 had hypertrophic neck scar, and 1 had pharyngeal stenosis.
In our study, 25 cases had poor prognosis accounting for 37.8%. Best prognosis was seen in zone II injuries with 1.5% mortality. In our study, suicidal injuries showed 89% recovery, homicidal injuries showed recovery rate of 51.2%, and accidental injuries had recovery rate of 71.5%. In present study, death occurred in 2 patients accounting to mortality rate (3%). Steward Fogelman et al. reported 6% mortality in PNI [3]. Demetriades et al [15] reported 2.7% and D Progmet [16] reported 2.1% which is comparable with our study.
Our study analysis showed hospital stay on an average less than 3 weeks. In our study 57 (86.5%) patients had stay of around 10–21 days, 6(9%) patients staying for 0–10 days, and only 3 (4.5%) stayed more than 21 days. In study by chappidi et al. [6], 12 (40%) patients had stay of around 0–10 days and with only 10 (33.33%) patients staying for 10–21 days, 8 (26.66%) stayed more than 21 days.
The increasing prevalence of psychiatric disorders has resulted in increasing incidence of suicidal PNI as observed in our study. Out of 66 patients, 16 patients had depression. Among 16 patients with depression, 5 had Schizophrenia, 5 had substance abuse, 1 had adjustment disorder and 1 had psychotic disorder. Psychiatric illness is the strongest predictor of suicide [17]. Suicide occurs 20.4 times more frequently in individuals with psychiatric illness than the general population. In attempted suicidal cases, there is a possibility of second attempt [18].
Conclusion
All penetrating neck injuries are potentially dangerous and require emergency treatment because of the presence of important vessels, nerves and organs in the neck. Thorough knowledge of the anatomy of neck, clinical assessment and diagnostic and therapeutic interventions are necessary for appropriate management.
Management of laryngeal injuries depends on their severity. In minor injuries, simple repair without tracheostomy is sufficient. Repair of major injuries (large mucosal lacerations, displaced fractures of larynx, laryngeal instability, vocal cord injuries) may require thyrotomy with reduction of displaced fractures or tracheostomy. Major injuries tend to have worse voice results.
Funding
None.
Declarations
Conflict of interest
No potential conflict of interest.
Ethical Approval
The study was approved by the Institutional Ethics Committee.
Informed Consent
Informed consent were obtained from all the participants.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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