Abstract
Background
Selective conservative management of penetrating neck trauma is a commonly adopted procedure to manage patients of such trauma. However, at places where trauma services are inadequate on different counts and a low-intensity military conflict is on, relevance of this approach without compromising the safety and well-being of the patient remains to be evaluated.
Objectives
The study aimed to address the relevance of selective conservative management of penetrating neck trauma in a low-intensity military conflict of Kashmir.
Patients and Methods
This was a prospective case study of patients presenting to the ENT Head & Neck Surgery department with penetrating neck trauma for a 2-year period from June 2003 to May 2005. After a careful physical examination in the emergency room, immediate surgical intervention or a careful observation is planned. Relevant investigations in the latter group if indicated by clinical examination determined whether to operate or to continue such approach. The data were collected and analyzed.
Results
Forty-six patients fulfilled the criteria to be included in the study. Eight patients (17.4%) underwent immediate surgical intervention, whereas the remaining patients (78.26%) were carefully observed for a minimum of 24 hours. Two patients of the active observation group required delayed exploration because of the close proximity of projectile to vessels. None of the patients in either group died. There was significant difference between the 2 groups in terms of hospital stay, use of diagnostic tests, and complications.
Conclusions
Selective conservative management is a cost-effective approach for penetrating neck trauma even in areas where there is relative paucity of advanced trauma services. These results further reinforce the validity of careful physical examination as a reliable tool to guide further management without necessarily resorting to expensive and at times difficult to do diagnostic tests.
1
Introduction
Trauma represents an unfortunate event in the life of a person; but with global development in all spheres of human activity, the likelihood of such an event occurring has increased. This trend is primarily attributed to the rapid industrial development. Nevertheless, in recent decades, low-intensity military conflicts happening across different parts of the globe also have significantly contributed to it. In the present-day world, the outlook for trauma patients is much favorable owing to better understanding of the pathophysiology and improved management of trauma victims despite the increasing magnitude and complexity of the challenges. The presenting feature in such a case may range from a trivial injury to a life-threatening one requiring exigent management.
In the case of the neck, optimum management of wounds that violate platysma has generated lot of debate among clinicians dealing with this subject. Some favor mandatory surgical exploration of all penetrating neck wounds while others deny this approach, citing a high rate of negative explorations in most series as their main argument . Proponents of the latter approach also termed as selective conservative management prefer to observe the patient carefully with judicious use of ancillary diagnostic tests to diagnose clinically undetectable significant internal neck damage. In today’s world of escalating health care costs, this approach has gained support of most of the health care professionals in developed countries. However, in a developing country like India where trauma services, except in metropolitan cities, are generally inadequate, the relevance of this approach is debatable. In Kashmir, low-intensity military conflict has compounded this problem where different diagnostic test facilities may not always be available for continuing this approach. Therefore, this prospective study was undertaken to evaluate the relevance of selective conservative management of penetrating neck trauma in Kashmir over a 2-year period.
2
Patients and methods
All patients who reported to the ENT Head & Neck Surgery department with penetrating neck trauma of any etiology as an isolated injury or as part of multisystem trauma were considered eligible for study. Patients who were dead on arrival were excluded from the study.
On the arrival of patient, the management was prioritized according to Advanced Trauma Life Support guidelines. All patients with evidence of platysmal penetration were admitted. In local neck examination the wound localization was classified into different trauma zones . Treatment differed from continuous careful observation to delayed or immediate (within 6 hours) surgical intervention. Severe active bleeding, shock not responding to treatment, large expanding hematoma, absent or weak peripheral pulse, air bubbling through the wound, major hemoptysis, and respiratory distress required immediate surgical intervention. Diagnostic studies such as plain neck radiographs, CT scan, Doppler ultrasound imaging, barium swallow, upper aerodigestive endoscopy, and so on, were done on a case-to-case basis depending on the clinical findings.
Those patients in whom intervention was deemed necessary were taken to the operation theater where the procedure was done under general anesthesia. Injured vessels were repaired or ligated. Primary repair and closed drainage (wounds above cricopharynx) or nothing per orally for 2 weeks (wounds below this level) managed pharyngo-esophageal injuries. Repair of soft tissues, evacuation of large hematomas, fixation of unstable fractures, and so on, managed laryngeal injuries. Soft tissue intervention included repair of muscles, ligaments, fascia, subcutaneous tissues, and skin in layers with drainage, if deemed necessary.
Periodic examination of the patient was done in the postoperative period to detect any complication of the injury or the operation. Serial chest and neck radiographs wherever indicated were done to access the progress of the patient. Daily wound dressing ensured fewer wound infections. Nasogastric decannulation was done after 10 days when barium swallow demonstrated absence of fistula. Tracheostomy was removed after a variable interval depending on the degree of initial airway insult and the progress of the patient as adjudged by the tolerance of tracheostomy tube withdrawal on a temporary basis each day. The patient was discharged once he or she was free from tracheostomy and tolerated orals well with strong instructions to follow-up as advised depending on individual case.
2
Patients and methods
All patients who reported to the ENT Head & Neck Surgery department with penetrating neck trauma of any etiology as an isolated injury or as part of multisystem trauma were considered eligible for study. Patients who were dead on arrival were excluded from the study.
On the arrival of patient, the management was prioritized according to Advanced Trauma Life Support guidelines. All patients with evidence of platysmal penetration were admitted. In local neck examination the wound localization was classified into different trauma zones . Treatment differed from continuous careful observation to delayed or immediate (within 6 hours) surgical intervention. Severe active bleeding, shock not responding to treatment, large expanding hematoma, absent or weak peripheral pulse, air bubbling through the wound, major hemoptysis, and respiratory distress required immediate surgical intervention. Diagnostic studies such as plain neck radiographs, CT scan, Doppler ultrasound imaging, barium swallow, upper aerodigestive endoscopy, and so on, were done on a case-to-case basis depending on the clinical findings.
Those patients in whom intervention was deemed necessary were taken to the operation theater where the procedure was done under general anesthesia. Injured vessels were repaired or ligated. Primary repair and closed drainage (wounds above cricopharynx) or nothing per orally for 2 weeks (wounds below this level) managed pharyngo-esophageal injuries. Repair of soft tissues, evacuation of large hematomas, fixation of unstable fractures, and so on, managed laryngeal injuries. Soft tissue intervention included repair of muscles, ligaments, fascia, subcutaneous tissues, and skin in layers with drainage, if deemed necessary.
Periodic examination of the patient was done in the postoperative period to detect any complication of the injury or the operation. Serial chest and neck radiographs wherever indicated were done to access the progress of the patient. Daily wound dressing ensured fewer wound infections. Nasogastric decannulation was done after 10 days when barium swallow demonstrated absence of fistula. Tracheostomy was removed after a variable interval depending on the degree of initial airway insult and the progress of the patient as adjudged by the tolerance of tracheostomy tube withdrawal on a temporary basis each day. The patient was discharged once he or she was free from tracheostomy and tolerated orals well with strong instructions to follow-up as advised depending on individual case.
3
Results
3.1
Patients
A total of 46 patients (38 male and 8 female) fulfilled the eligibility criteria with a mean age of 35.25 (range, 2–80 years). Reporting time varied from less than 2 to 24 hours. Zone I was involved in 3 (6.5%), zone II in 27 (58.7%), zone III in 4 (8.7%), and multiple zone affliction occurred in 12 (26%) of patients. Injuries resulting from projectiles (splinters, shrapnel, and bullets), knives, animal encounters, and motor vehicle accidents are shown in Table 1. Clinical features on admission are enumerated in Table 2.
| Cause of injury | No. of patients (immediate intervention) | No. of patients (active observation) |
|---|---|---|
| Projectile injury | 4 | 20 |
| Knife inflicted | 5 | 4 |
| Animal assaults | 1 | 8 |
| Motor vehicle accidents | 0 | 4 |
| Symptom/sign | No. of patients |
|---|---|
| Hemoptysis | 14 |
| Hoarseness of voice | 13 |
| Odynophagia/dysphagia | 26 |
| Hematemesis | 1 |
| Subcutaneous emphysema | 9 |
| Active bleeding not responding to conservative measures | 3 |
| Shock | 3 |
| Expanding hematoma | 1 |
| Respiratory distress | 3 |
| Mild discomfort | 20 |
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