Closed cervical trauma is often caused by blunt force injuries such as punching, strangulation, or vehicular accidents. Compared to open injuries, closed trauma does not involve visible wounds on the skin. As a result, symptoms and signs may remain subtle in the early post-injury period, and the condition is often overlooked. Many patients experience severe complications such as respiratory distress and hypovolemic shock. The specific area of injury generally corresponds to the direction of the blunt force: blunt trauma to the anterior neck often affects the larynx, trachea, and thyroid gland, while lateral blows may primarily damage blood vessels, nerves, the esophagus, muscles, and cervical vertebrae. Injuries to the larynx, thyroid gland, and cervical vertebrae have been discussed in relevant chapters or covered by other specialties. This section primarily addresses closed tracheal trauma, closed pharyngeal and esophageal trauma, and traumatic arterial embolism.
Closed Tracheal Trauma
Closed tracheal trauma is relatively rare but can lead to severe consequences when it occurs.
Etiology
The trachea is protected anteriorly by the sternum and posteriorly by the spine. Its mobility and unique histological structure contribute to a lower likelihood of injury. However, violent trauma to the neck or chest may generate extreme intraluminal airway pressure, leading to tracheal damage. Severe injuries can result in tracheal rupture or Grade III-IV inspiratory airway obstruction, posing a life-threatening risk.
Clinical Manifestations
Closed tracheal trauma often occurs in conjunction with laryngeal contusions. Symptoms include:
Pain at the Site of Tracheal Injury
Pain worsens during swallowing or head movement and may radiate to the ipsilateral ear.
Cough and Hemoptysis
Damage to the tracheal wall allows blood to enter the airway, causing paroxysmal irritant cough and frothy blood-streaked sputum. Injury to larger blood vessels may result in significant hemoptysis.
Respiratory Distress
Swelling of the tracheal mucosa, cartilage damage, or complications such as mediastinal emphysema or pneumothorax can cause progressive respiratory distress. Tracheal-ring dislocation involving the cricoid cartilage may lead to severe respiratory obstruction or even rapid asphyxiation and death.
Emphysema
Air escaping through a ruptured tracheal wall into the surrounding subcutaneous tissues results in emphysema, which is a key clinical sign of tracheal injury. Emphysema may remain localized or spread progressively within a short time to the head, neck, and chest, or even the entire body. Severe cases are frequently accompanied by mediastinal emphysema and pneumothorax.
Hoarseness
Symptoms such as hoarseness or, in severe cases, loss of voice may occur if the injury involves the larynx or recurrent laryngeal nerves.
Diagnosis
Swelling, bruising, tenderness of the anterior cervical skin, cough, hemoptysis, and subcutaneous emphysema, with or without respiratory distress following blunt force trauma to the neck, are highly suggestive of tracheal injury. Observation of respiratory status is critical, and preparations should be made for tracheostomy or endotracheal intubation if necessary. For patients without severe respiratory distress who can tolerate further evaluation, cervical and chest CT imaging is recommended to identify tracheal injuries and assess for mediastinal emphysema or pneumothorax. Flexible bronchoscopy can be performed if needed to confirm the diagnosis. For patients with significant respiratory distress, prophylactic tracheostomy is often advised to secure the airway before conducting further diagnostic procedures.
Treatment
Management aims to maintain a patent airway and perform primary repair of laryngotracheal injuries to prevent tracheal stenosis.
Conservative Management
Mild tracheal injuries without respiratory distress are closely monitored. Treatment includes the use of antibiotics and corticosteroids.
Tracheostomy
Respiratory distress may not be apparent in the early stages of tracheal injury but can develop a few hours later due to wound bleeding and mucosal swelling. If respiratory distress develops, prompt low-level tracheostomy is typically required.
Injury Repair
Treatment strategies are selected based on the extent and location of the injury. Small tracheal mucosal injuries do not require suturing, while longer mucosal lacerations are sutured. Cases involving tracheal cartilage fractures and displacement are treated with reduction and proper suturing of the injured cartilage and mucosa. In severe crush injuries to the tracheal cartilage or complete transection where the trachea retracts superiorly and inferiorly, the injured tracheal ends are mobilized and repaired through end-to-end anastomosis. Thoracic tracheal injuries require thoracotomy for repair after alleviating respiratory distress with measures such as low-level tracheostomy or bronchoscopy. The key to managing acute tracheal injuries is ensuring airway patency and performing primary repair to address injury-related deformities.
Tracheal injuries are often associated with laryngeal damage, which must be addressed simultaneously. Primary repair of laryngotracheal injuries is critical for successful treatment. Failure to achieve primary repair increases the likelihood of developing intractable laryngotracheal stenosis, which significantly impacts the patient’s prognosis.
Closed Injuries of the Pharynx and Esophagus
Etiology
Injuries to the pharynx and esophagus caused by blunt force can result in compression injuries when the pharynx and esophagus are squeezed against the spine. More commonly, injuries occur due to sharp foreign bodies, such as fish bones or chicken bones, which can perforate the pharyngeal or esophageal mucosa. This risk is particularly heightened when individuals attempt to swallow forcefully after accidentally ingesting such objects.
Clinical Manifestations
Pain
Localized tenderness is noticeable, with pain worsening during swallowing. Patients may be unable to eat due to the severity of the pain.
Hematemesis or Vomiting of Blood
Subcutaneous Emphysema and Pneumothorax
Air, saliva, and food can enter the subcutaneous and deep cervical fascial spaces through the ruptured pharynx or esophagus, causing subcutaneous emphysema, mediastinal emphysema, pneumothorax, deep cervical, or mediastinal infections. Patients may experience varying degrees of respiratory distress and symptoms of infection.
Diagnosis
In cases of neck trauma followed by localized pain, aggravated pain during swallowing, and the presence of subcutaneous emphysema, pharyngeal or esophageal injuries should be suspected. Examination of the neck and chest with CT imaging may help assess the extent of emphysema. Esophageal X-ray imaging can reveal the location and size of esophageal perforation. If necessary, flexible esophagoscopy or rigid esophagoscopy can further clarify the diagnosis.
Treatment
The treatment principle includes infection prevention and early repair of the injury.
Infection Prevention
Maintaining cleanliness of the oral cavity and pharynx, removing oral secretions, maintaining strict fasting, and providing nutritional support through nasal feeding or intravenous infusion are recommended. Effective antibiotics are used to manage infection.
Repair of the Wound
For larger injuries, early primary suturing is performed.
For wounds that are already infected, active measures to combat infection are applied. Abscesses should be incised and drained promptly, followed by antibiotics irrigation. Secondary suturing may be performed.
Traumatic Carotid Artery Embolism
This condition is relatively rare and most commonly occurs in the internal carotid artery. When it does occur, the consequences can be severe and warrant significant attention.
Etiology and Pathogenesis
Trauma to the carotid artery caused by external traction or direct contusion often spares the elastic outer layer while damaging the intima and media. Tears or injuries to the intima can lead to thrombus formation at the site of the injury, which may gradually expand and cause complete carotid artery occlusion. If the intima and media are torn or interrupted due to contusion, high arterial pressure may cause extensive detachment of the intima, leading to the formation of a dissecting aneurysm. This condition is more likely to occur in the presence of pre-existing arteriosclerosis.
Clinical Symptoms
Cervical Hematoma
Following neck trauma, hematomas commonly form in the carotid triangle.
Symptoms of Nerve Compression
Enlarging hematomas may compress the cervical sympathetic nerve, vagus nerve, hypoglossal nerve, or glossopharyngeal nerve, resulting in conditions such as Horner’s syndrome, hoarseness, tongue deviation, and loss of the gag reflex.
Cerebral Ischemia
Vascular spasms, thrombus formation, arterial occlusion, and arteriosclerosis following neck trauma can all result in cerebral ischemia. This is characterized by monoplegia or hemiplegia, though consciousness remains preserved.
Diagnosis
The possibility of carotid artery embolism should be considered when there is a hematoma in the carotid triangle following neck trauma, with or without accompanying symptoms of nerve compression or cerebral ischemia. Digital subtraction angiography (DSA) is considered the most reliable diagnostic method. Typical signs of carotid embolism include vascular narrowing in a bundled or conical shape. CT, MRI, and cerebral blood flow imaging can assist in diagnosis. It is important to note that carotid artery embolism often coincides with trauma to other areas of the head, neck, or chest, requiring timely diagnosis and management.
Treatment
The treatment principle involves relieving vascular spasms, preventing thrombus formation and progression, and ensuring adequate cerebral blood supply.
Conservative Treatment
Patients are required to strictly maintain bed rest and limit head and neck movement. Vasodilators such as tolazoline and lidocaine may be used, along with cervical sympathetic chain block or severing procedures. Appropriate anticoagulants may reduce thrombus formation but are contraindicated in cases of cerebral hemorrhage.
Surgical Treatment
Surgery may be considered if conservative treatment fails, the thrombus continues to enlarge, or serious complications such as cerebral ischemia occur due to carotid artery occlusion. Thrombus removal can be performed, although the procedure carries significant risks, including high mortality and disability rates.