Open cervical trauma is relatively common and can result from both firearm injuries and non-firearm injuries (e.g., incised or stab wounds). Incised wounds, such as those from self-inflicted throat-cutting, often damage the larynx and trachea. Penetrating injuries, on the other hand, typically affect the soft tissues of the neck, including blood vessels, nerves, the pharynx, and the esophagus. Due to their deceptively small external wounds, penetrating injuries are frequently underestimated, leading to delayed recognition and potentially severe consequences.
Open Vascular Injury
Open vascular injuries are often caused by direct trauma to the neck. The hematoma formed by vascular damage may compress nerves, resulting in neurological deficits. Based on the severity of the injury, vascular damage can be categorized into three types:
- Traumatic arterial spasm
- Damage to the vascular wall, primarily involving the intima or media while the adventitia remains intact
- Partial or complete rupture of the blood vessel
Clinical Manifestations
Hemorrhage
The injured site may exhibit significant bleeding or hematoma formation, with severe cases leading to hemorrhagic shock. In cases where large blood vessels are injured but the external wound is small, significant internal bleeding may occur with minimal external bleeding, a situation that can easily be overlooked. Closely monitoring the patient's blood pressure and pulse is important to assess for potential internal bleeding.
Neurological Impairment
Neurological symptoms often accompany damage to the vagus, hypoglossal, glossopharyngeal, or facial nerves. Manifestations include hoarseness, tongue deviation during extension, choking, and facial paralysis.
Cerebral Ischemia
Carotid artery injuries can result in ischemia in the injured side of the brain, leading to symptoms such as coma, hemiplegia, and aphasia.
Respiratory Distress
Carotid artery injuries are often associated with trauma to the larynx or trachea, causing respiratory difficulty. Hematomas formed after carotid artery injuries may also compress the larynx or trachea, exacerbating the respiratory distress.
Air Embolism
When the internal jugular vein is damaged, air may enter the venous system through the ruptured venous wall during inspiration due to negative intrathoracic pressure, causing air embolism. This can lead to damage to critical organs, such as the brain, liver, and kidneys. A large amount of air entering the bloodstream may result in rapid death.
Injuries to Other Cervical Organs
Commonly affected structures include the larynx, trachea, esophagus, and thyroid gland.
Hematoma Formation
Symptoms of a pseudoaneurysm may develop. Hematomas caused by arterial damage often appear on the second day after the injury and are characterized by noticeable pulsation and systolic murmurs on auscultation. These murmurs often radiate along the arteries and may be accompanied by ipsilateral headache and referred ear pain. Internal carotid artery hematomas may present with optic disc edema, hyperemia, venous dilation, and vision loss. Symptoms of arteriovenous hematomas usually appear earlier, often within a few hours after the injury, and are associated with more pronounced murmurs. These murmurs can be heard not only along the blood vessels but also in areas far from the injury site, accompanied by persistent local thrills upon palpation.
Diagnosis
A history of open neck trauma, accompanied by signs such as local bleeding or hematoma formation with noticeable pulsation, and systolic murmurs on auscultation, along with symptoms of cerebral ischemia, nerve compression, and systemic blood loss, should suggest vascular and nerve injuries in the neck. Diagnostic assistance can be provided by digital subtraction angiography (DSA) and cervical ultrasound. If necessary, exploration of the cervical wound may be performed to determine the location and severity of the injury, but this must be conducted with adequate blood reserve and vascular reconstruction preparations.
Treatment
The treatment principles include bleeding control, shock management, maintaining airway patency, and infection prevention.
Bleeding Control and Shock Management
For active bleeding, immediate pressure should be applied to control the bleeding. Blood transfusion and fluid replacement are employed to restore blood volume and correct acidosis. Close monitoring of vital signs such as blood pressure, pulse, and respiration is essential, along with observation for signs of ongoing internal bleeding.
Maintaining Airway Patency
In cases of respiratory distress, endotracheal intubation or tracheostomy is performed, followed by clearance of secretions and blood from the airway to ensure that it remains open.
Infection Control
The use of adequate doses of sensitive antibiotics is necessary to control infection, and tetanus antitoxin should be administered.
Repair of Damaged Blood Vessels and Nerves
For severe injuries with significant blood loss and active bleeding suggesting potential major vascular damage, surgical exploration is performed after blood volume restoration, shock correction, and relief of respiratory difficulty. Appropriate repair methods are selected based on the extent of the injury.
Open Tracheal Injuries
These are typically caused by sharp instrument injuries in the midline of the neck and are relatively easy to diagnose.
Clinical Manifestations
Air Leakage
Air escapes through the tracheal rupture during breathing. If the skin defect is relatively small, the escaping air may not exit smoothly and can accumulate in the subcutaneous tissues of the neck, chest wall, or abdominal wall, resulting in extensive subcutaneous emphysema. If the air enters the cervical fascial spaces, it may extend to the mediastinum, leading to mediastinal emphysema.
Irritative Cough
Inhalation of blood, vomitus, or saliva into the trachea can trigger an irritative cough.
Respiratory Distress
Tracheal mucosal injury accompanied by swelling, cartilage damage, mediastinal emphysema, pneumothorax, blood clots, or secretions blocking the trachea can cause respiratory distress and cyanosis, which tend to progressively worsen. Dislocation of tracheal cricoid cartilage can lead to severe respiratory distress, possibly resulting in asphyxiation and death.
Injury to Adjacent Organs
Tracheal injuries are often associated with laryngeal contusions, which may present as hoarseness or even voice loss. Thyroid or vascular injuries can cause significant bleeding. Injury to the pleura can lead to pneumothorax, exacerbating respiratory distress. Pain during swallowing may indicate esophageal injury, which, if present, can result in tracheoesophageal fistulas and, in severe cases, mediastinal infections.
Diagnosis
A diagnosis of tracheal injury is established with a history of anterior cervical open trauma, the presence of air leakage at the injury site, and the development of subcutaneous emphysema. In addition to close observation of respiratory status and preparation for tracheotomy or endotracheal intubation, cervical and thoracic CT scans are crucial to determine the extent of tracheal injury, the presence of mediastinal emphysema, or pneumothorax. If required, fiberoptic bronchoscopy or rigid bronchoscopy may clarify the location, extent, and depth of the injury.
Treatment
The treatment principles include relieving respiratory distress, ensuring airway patency, controlling bleeding, and repairing the injury.
Relieving Respiratory Distress
Insertion of a tracheal tube at the rupture site is performed to suction out secretions and blood clots from the trachea. Once the situation stabilizes, tracheotomy is performed.
Maintaining Airway Patency
After respiratory distress is relieved, close observation and effective measures are required to maintain continuous airway patency. Further airway obstruction caused by ongoing bleeding, secretion blockage, mucosal edema, local compression, or displacement of the tracheal cannula should be prevented.
Controlling Bleeding
Injuries to major neck vessels or the thyroid gland may result in significant bleeding. Hemostasis should be performed promptly while ensuring airway patency.
Repairing the Injury
Once the condition stabilizes, timely debridement and suturing are indicated. Small defects may only require simple alignment and suturing, while larger defects involve proper alignment and suturing of the cartilage after reduction and repair of the surrounding soft tissues. For cases with completely fractured or severed cartilage, the upper and lower ends of the trachea are mobilized and reapproximated for end-to-end anastomosis. In cases where postoperative tracheal stenosis is likely, a dilatation tube is placed after realignment. Thoracic tracheal injuries are treated with thoracotomy. Injuries often coexist with laryngeal trauma and should be managed concurrently. Proper primary repair is highly critical as it serves as the most important approach to preventing or avoiding laryngeal or tracheal stenosis.
Open Injuries to the Pharynx and Esophagus
The pharynx and esophagus lie deeper and are softer in structure. Isolated open injuries to these structures are relatively rare and are usually associated with injuries to other regions.
Clinical Symptoms
Pain during swallowing is common, and saliva, food, or air escaping through the rupture may occur during swallowing. Symptoms may also include hematemesis, blood-tinged vomitus, subcutaneous emphysema, or mediastinal emphysema.
Diagnosis
Larger ruptures are easier to detect, whereas smaller ruptures may be challenging to identify. Instructing the patient to swallow air may reveal air leakage through the cervical wound. Swallowing methylene blue may help locate the pharyngeal or esophageal rupture through blue staining at the injury site.
Treatment
Once a diagnosis is confirmed, timely treatment is initiated. Patients are instructed to abstain from oral intake and are placed on a nasal feeding tube with liquid nutrition. Broad-spectrum, sensitive antibiotics are administered to prevent infections in the deep cervical layers and mediastinum. Timely debridement and suturing are recommended as part of the treatment strategy.