Trauma - Neck, Larynx

Question 1

Discuss the initial basic approach to trauma

Answer 1

1. ABCDE
2. GCS (E4, V5, M6)
3. C-spine immobilization and X-ray

Question 2

Describe the zones of the neck with respect to blunt/penetrating neck trauma

Answer 2

1. Zone 1: From the clavicle to the inferior border of the cricoid
2. Zone 2: Inferior border of cricoid to the angle of the mandible
3. Zone 3: Above the angle of the mandible to the level of the skull base

Bailey’s uses inferior border of cricoid, resident trauma manual uses horizontal line dividing cricoid

Kevan Trauma Pg 26

Question 3

How are neck injuries generally classified? Name two different classification ways.

Answer 3

1. By Zone (I/II/III)
2. Penetrating vs. Non-penetrating

Penetrating = passes through platysma
Non-penetrating = does not violate platysma

Question 4

How are penetrating neck injuries classified?

Answer 4

Classified based on velocity:

1. Low-Velocity Penetrating Neck Trauma (LVPNT)
   - < 610m/s (< 2000feet/second)
   - Examples: stab wounds, handgun wounds
2. High-Velocity Penetrating Neck Trauma (HVPNT)
   - > 610m/s (>2000 feet/second)
   - Examples: Rifle wounds, wounds from bombs/Improvised explosive devices (IEDs)/grenades

Note: Bailey’s uses < 1000ft/sec and > 10000ft/s

Question 5

What determines the kinetic energy imparted on tissues during traumatic penetrating injury?

Answer 5

KE = 1/2 M (V1-V2)^2

KE = Kinetic energy of the missile
M = Missile mass
V1 = Entry velocity
V2 = Exit velocity

The highest kinetic energy is thus associated with a heavy projectile with a high entry velocity and an exit velocity of 0 (that is, it doesn’t leave the body)
- Examples of these would include expanding or explosive bullets

Question 6

What 2 mechanisms that mediate gunshot wound injury?

Answer 6

1. Direct tissue injury
2. Temporary cavitation (creation of a pulsating temporary cavity surrounding the bullet path)

Kevan Trauma Pg 27

Question 7

What are the indications for vascular evaluation (e.g. Angiography) in penetrating wounds to the face?

Answer 7

P’s mnemonic:
1. Proximity to major vascular structures
2. Posterior to the MANDIBULAR ANGLE PLANE (MAP)
- MAP is a vertical line drawn at the angle of the mandible

Kevan Trauma 27

Question 8

What are the regions of potential injury in neck trauma, their associated signs and symptoms, and methods of investigation?

Answer 8

A. VASCULAR INJURY
1. Signs and Symptoms:
- Shock
- Hematoma
- Hemorrhage
- Pulse deficit
- Neurologic deficit
- Bruit or thrill in neck

2. Tests:
   - Angiogram
   - CT angiogram
   - Doppler ultrasound
   - Neck exploration

B. LARYNGOTRACHEAL INJURY
1. Signs and Symptoms:
- Subcutaneous emphysema
- Airway obstruction
- Sucking wound
- Hemoptysis
- Dyspnea
- Stridor
- Hoarseness or dysphonia

2. Tests:
   - Laryngotracheoscopy
   - Neck exploration
   - CT scan

C. PHARYNX/ESOPHAGUS INJURY
1. Signs and symptoms:
- Subcutaneous emphysema
- Hematemesis
- Dysphagia or odynophagia

2. Tests:
   - Contrast esophagogram
   - Esophagoscopy
   - Neck exploration

Question 9

Describe the classes of hemorrhagic shock

Answer 9

Average adult blood volume = 4500-5700mL (about 5L)

1. CLASS I: Up to 15% blood loss
   - Approx 750mL
   - Hemodynamically normal (No tachycardia, normal BP, RR)
   - Normal urine output > 30ml/hr
   - Mental slightly slightly anxious but normal
   - Skin and cap refill: normal < 2 s
2. CLASS II: 15-30% blood loss
   - 750-1500mL
   - HR elevated (100-120)
   - No hypotension - Normal sBP, decreased pulse pressure, slightly elevated RR (20-30)
   - Urine output slightly lower 20-30ml/h
   - Mildly anxious
   - Skin and cap refill: > 2s, clammy skin
3. CLASS III: 30-40% blood loss
   - 1500-2000mL
   - Tachycardic 120-140
   - HYPOTENSION - sBP decreased, pulse pressure decreased
   - RR increased 30-40
   - Urine output decreased 5-15mL/h
   - Anxious and confused
   - Skin and cap refill: > 3s, cool pale skin
4. CLASS IV: >40% blood loss
   - More than 2000mL blood loss
   - Very tachycardic (>140), hypotensive, tachypneic >35
   - Negligible urine output
   - Confused, lethargic
   - Skin and cap refill: >3s, cold mottled skin

Question 10

What are 7 indicators of major vascular injury following penetrating neck injury on chest x-ray (CXR)?

Answer 10

1. Widened mediastinum
2. Obscured aortic knob
3. Deviated trachea
4. Apical cap (blood at lung apex)
5. NG tube deviation
6. Hemothorax
7. Hemopericardium
8. Pleural effusion
9. Pneumothorax/mediastinum

“WEAPON”
W - Widened mediastinum
E - Effusion (pleural)
A - Apical cap
P - Pneumothorax/mediastinum
O - Obscured aortic knob
N - NG or trachea deviated

Question 11

What are the hard signs / Immediate surgical indications for penetrating neck trauma?

Answer 11

VASCULAR SIGNS (5)
1. Shock or hemodynamic instability
2. Pulsatile bleeding / massive bleeding
3. Expanding hematoma (or hemothorax or hemomediastinum)
4. Unilateral loss of extremity pulse
5. Audible bruit or palpable thrill

“BEEPS”: Bruit or thrill, Extremity loss of pulse, expanding hematoma, pulsatile bleeding, shock

AIRWAY SIGNS (3)
1. Airway compromise
2. Extensive subcutaneous air / wound bubbling
3. Stridor/hoarseness

“ASS”: Airway compromise, subcut air, stridor

NEUROLOGIC SIGNS (1)
1. Lateralizing neurologic deficits (stroke signs)

Question 12

Describe the management of a Zone I injury

Answer 12

Zone I Injury = clavicle to cricoid

1. Immediate OR if hard signs/unstable
2. If no hard signs, EVERYONE GETS:
   - Vascular evaluation (CT angiogram)
   - Esophageal evaluation
3. If above investigations all negative, then observation
4. If investigations above positive, then vascular OR neck exploration (Especially for vascular)

Options for esophageal evaluation:
1. Esophagoscopy
2. Barium or gastrograffin swallow
3. CT Neck

Barium vs. Gastrograffin:
- Barium: Thicker, thus more sensitive for esophageal injury, but can lead to infection if leaks into neck
- Gastrograffin: Thinner, thus less sensitive, but less likely to lead to infection with a leak

Surgical exposure options:
1. Left - Anterior thoracotomy
2. Right - Median sternotomy

Question 13

Describe the management of a Zone II injury

Answer 13

Zone II injury = Cricoid to mandible

1. Immediate OR if hard signs or unstable
2. If no hard signs:
   - If stable with symptoms (e.g. hematoma, subcutaneous emphysema) = selective neck exploration
   - If stable with NO symptoms = directed exam (ie. vascular evaluation ± laryngoscopy ± endoscopy ± esophagoscopy depending on projectile path and examination

• If directed exam positive = neck exploration
• If directed exam negative = observation

Historically mandatory neck exploration in Zone II injuries was the standard of care, but now with advancements in imaging, a selected approach as described above is more common

Surgical exposure option:
- Hockey stick incision along anterior border of SCM

Question 14

Describe the management of a Zone III injury

Answer 14

Zone III Injury = Mandible to base of skull

1. Immediate OR if hard signs/unstable
2. If stable = CT Angiography
   - If CT angio positive = Vascular intervention (intravascular or open, usually more feasible to access via intravascular approach)
   - If CT angio negative = observation

Surgical Exposure options:
- Extension of Zone II (hockey stick incision) to include mandibulotomy or mandible subluxation

Question 15

Describe the management approach of penetrating neck trauma with a “no-zone” approach

Answer 15

1. Presence of hard signs = Operative exploration/repair
2. If no hard signs = CT angiography

CT Angio positive: Operative exploration/repair

CT Angio negative:
- If low risk trajectory: observe
- If high risk trajectory: directed angiography or panendoscopy
- Trajectory risk is vaguely defined but relates to the surroudning structures to the tract and what is around

Main difference between this and zone-based approach is the routine use of neck exploration in Zone II injury

Kevan Trauma Pg 29

Question 16

What is the proportion of vascular injuries in neck trauma? What is the management approach to vascular injuries?

Answer 16

INJURIES:
- Internal jugular vein - 9%
- Internal carotid or common carotid - 7%

APPROACH:
- Ligate vs. primary repair
- Vascular patch or graft
- Involve vascular surgery

Question 17

Describe the Schaefer-Fuhrman classification for laryngeal trauma

Answer 17

1. Class I:
   - Minor endolaryngeal hematoma
   - No mucosal disruption or laceration
   - No exposed cartilage
   - No detectable fracture
2. Class II:
   - Mild edema, hematoma
   - Mild mucosal laceration and disruption but no exposed cartilage
   - Undisplaced fracture
3. Class III: VCD
   - Significant edema and mucosal disruption
   - Vocal fold immobility
   - Cartilage exposure
   - Displaced fracture
4. Class IV: USA
   - Undisplaced fracture, 2+ fracture lines
   - Severe mucosal disruption
   - Anterior commissure involvement
5. Class V: Complete laryngotracheal separation

Question 18

Which classes of laryngeal injury require surgical management?

Answer 18

1. Class III-V: Tracheostomy
2. Class III: May be candidate for endoscopic repair
3. Class IV: Open repair, endolaryngeal stent
4. Class V: Open repair, tracheal reanastomosis

Kevan Trauma Pg 30 for algorithm

Question 19

What are the signs and symptoms suggestive of laryngeal trauma?

Answer 19

SIGNS:
1. Dysphonia
2. Dyspnea
3. Dysphagia
4. Odynophagia
5. Stridor / airway obstruction
6. Hemoptysis
7. Loss of laryngeal crepitus or thyroid cartilage eminence

SYMPTOMS:
1. Subcutaneous emphysema (crepitus)
2. Neck swelling
3. Anterior neck ecchymoses or tenderness
4. Mucosal swelling, edema, lac, hematoma
5. Cartilage exposure
6. VC or arytenoid asymmetry/dysfunction
7. Palpable deformity

Question 20

Discuss the initial management of suspected laryngeal fracture

Answer 20

1. ABCDE: Airway, breathing, circulation, disability, exposure (follow trauma protocol)

Airway: Unstable or stable?
- Impending airway obstruction: tracheostomy, then CT/DL/Esophagoscopy
- Airway stable: FNL first

FNL: Findings normal or abnormal?
- Normal: medical management, serial examination
- Abnormal: CT scan

CT findings: Airway encroached or not?
- Airway encroached: Tracheostomy, surgery
- No airway encroachment (Schaefer I/II): Medical management, serial examination
- Management on CT depends on Scaefer staging below

Surgical Management: Direct laryngoscopy, esophagoscopy, ± stenting (midline thyrotomy or anterior cricoid split), ± tracheostomy (unstable airway, Schaefer III+)
- III: ORIF, thyrotomy OR endoscopic repair
- IV: ORIF, thyrotomy, repair with endolaryngeal stent
- V: Debridement and primary anastomosis

Question 21

Discuss the measures for conservative management of laryngeal trauma

Answer 21

1. Admit for observation (minimum 24 hours)
2. Humidificatiion
3. PPI, reflux management
4. Serial endoscopic examinations
5. Steroids
6. Heliox at bedside
7. Voice rest
8. Racemic epinephrine PRN
9. Antibiotics, especially if mucosal tear
10. Head of bed elevation
11. Possible NG if significant mucosal damage

Same as post-operative care for repaired laryngeal trauma

Question 22

What are the criteria for medical management of traumatic laryngeal injuries?

Answer 22

1. Edema
2. Small hematoma
3. Non-displaced single stable fracture
4. Lacerations with no cartilage exposure
5. Normal vocal fold movement
6. No injury to anterior commissure

Question 23

What are the indications for open repair of traumatic laryngeal injuries?

Answer 23

1. Mucosal lacerations that are large or involve the anterior commissure/free edge of the vocal fold
2. Exposed cartilage
3. Multiple or displaced fracture of cricoid and/or thyroid
4. Vocal fold immobility of disruption of the cricoarytenoid joint
5. Airway compromise requiring intubation/tracheotomy
6. Active bleeding or hemoptysis
7. Concordant injury to neck requiring surgical exploration
8. Air escaping through the neck wound

Question 24

What are the indications for stenting in laryngeal trauma?

Answer 24

1. Schaefer IV
   - Unstable fracture
   - 2+ fracture lines or multiple displaced laryngeal fractures
   - Severe mucosal disruption / endolaryngeal lacerations
   - Anterior commissural involvement
   - Architecture or larynx not maintained by open fracture fixation (loss of cartilaginous framework)

Stent left in place for 2 weeks and then removed in OR as an endoscopic procedure

Question 25

What are the potential complications of laryngeal trauma?

Answer 25

1. Vocal fold paralysis
2. Posterior glottic stenosis
3. Anterior glottic web
4. Subglottic stenosis
5. Airway obstruction
6. Aspiration
7. Dysphonia
8. Dysphagia

Question 26

What is the typical management of pharyngeal injuries (e.g. from traumatic intubation)?

Answer 26

1. Minor pharyngeal lacerations:
   - Short course of antibiotics
2. Severe injuries (eg. perforation of pyriform sinus or esophagus)
   - Repair surgically and drain
   - Feeding via NG tube x 5-7 days
3. Injury above arytenoids
   - NPO x 7 days, NG fed
4. Injury below arytenoids
   - Repair transcervically + place drain
5. If C-spine violated via pharynx –> high osteomyelitis risk
   - Consult neurosurgery and spine
   - Broad spectrum antibiotics
   - High risk of DISH syndrome (Diffuse idiopathic skeletal hyperostosis)

Question 27

Regarding parotid duct injury, discuss:
1. Landmarks of the parotid duct
2. Types of injury that pur parotid duct at risk
3. Course of Stenson’s duct
4. Signs of parotid duct injury

Answer 27

Landmarks:
1. Parotid Duct Line: Course of the parotid duct follows a line demarcated between the tragus and the middle of the upper lip

Risks:
- Vertical lacerations anterior to posterior border of masseter muscle likely to injure parotid duct

Course of Stenson’s Duct:
1. Exists anterior aspect of the parotid gland
2. Travels superficial to masseter muscle and courses around anterior border
3. Pierces the buccinator at the anterior border of the masseter
4. Runs with the buccal branch of the facial nerve
5. Opens at the buccal mucosa around the 2nd upper molar

Signs:
1. Decreased upper lip elevation (suggests buccal branch injury)
2. Pooling of secretions in the wound

Kevan Trauma 31

Question 28

What is the classification of parotid duct injuries?

Answer 28

Van Sickels Classification of Parotid Duct Injury:
1. Site A: Intraglandular injury or posterior to masseter
2. Site B: Injury over the masseter
3. Site C: Injury distal to anterior border of the masseter

Question 29

Discuss the management of parotid duct injuries

Answer 29

3 Possible Methods:
1. Primary microsurgical anastomosis (preferred if feasible)
2. Diversion of salivary flow (Creation of oral fistula) - technically difficult
3. Suppression of salivary gland function (E.g. duct ligation) - gland atrophies after a period of swelling, pain, possibly infection

TECHNICAL POINTERS:
- Soft polymeric silicone or polyethylene 22G catheter threaded through Stensen’s duct to identify duct
- Repair of duct with 6-0 or 7-0 monofilament suture under microscope
- Suture the stent to the buccal mucosa for 10-14d

A. SITE A INJURY (Intraglandular injury)
1. Closure of capsule ± ligation of duct
- Pressure dressing and antisialogogues are provided post-procedurally to help facilitate glandular atrophy

B. SITE B INJURY (Over Masseter)
1. Primary Anastomosis is ideal
- Anastomosis is performed over an angiocath which is sutured to the buccal mucosal opening and left in place for 10-14 days

C. SITE C INJURY (Anterior to masseter)
1. Primary anastomosis if possible (usually not feasible as usually there is insufficient distal length)
2. Salivary diversion if anastomosis not feasible
- Proximal stump is brought through the buccinator and oral mucosa and sutured in place

Kevan Trauma Pg 32

Question 30

Discuss the management of sialoceles secondary to parotid parenchymal injury

Answer 30

Most will resolve conservatively:
1. Needle aspiration (fluid may be sent for amylase)
2. Compression dressing (difficult, controversial)
3. Broad spectrum antibiotics
4. Anticholinergics: Scopolamine, glycopyrrolate, TCA
5. Botox injection
6. NPO and TPN

If chronic:
1. Parotidectomy
2. Tympanic neurectomy
3. Low dose RT (very old school)

Question 31

Describe the degrees of burn injury

Answer 31

1. Superficial burns (first degree)
   - Deepest Skin structure involved: Epidermis only
   - Appearance clinical: Dry burn, blanching, erythematous
   - Pain: Painful to palpation
   - Prognosis: Heals without scarring, 5-10 days
2. Superficial partial thickness (second degree)
   - Deepest Skin structure involved: Papillary dermis involved
   - Appearance clinical: Moist burn, but blanches
   - Pain: Painful to palpation
   - Prognosis: Heals without scarring (< 3 weeks)
3. Deep partial thickness (second degree)
   - Deepest Skin structure involved: Reticular dermis involved
   - Appearance clinical: Dry, not blanching, yellow or white
   - Pain: Decreased pain sensation
   - Prognosis: Will heal with scarring 3-6 weeks, requires debridement with skin grafting
4. Full thickness burn (third degree)
   - Deepest Skin structure involved: Into subcutaneous tissue/hypodermis
   - Appearance clinical: White or black/brown, non-blanching
   - Pain: Decreased pain sensation
   - Prognosis: Heals by contracture > 8 weeks, requires debridement and skin grafting optimally

Question 32

How do you calculate Total body surface area of burns in adults vs children?

Answer 32

ADULTS
1. Rule of 9s:
- 9% for each upper limb (18%)
- 9% for head/neck
- 18% for front of torso
- 18% for back of torso
- 18% for entire front of leg (9% upper lower)
- 18% for entire back of leg
- 1% for groin area

2. Approximate with hand (hand ~1% TBSA)

CHILDREN:
1. Same Rule of 9s, EXCEPT:
- 18% for head and neck (9% more than adults)
- Leg surface is 14%

Kevan Trauma Pg 33

Question 33

How do you determine fluid resuscitation needs in the context of a burn?

Answer 33

Parkland Formula = 4 x mass in kg x TBSA (of second/third/fourth degree burns only) = volume (in mL) needed over 24 hours
- First 1/2 given in first 8 hours
- Second 1/2 given in the remaining 16 hours

Example: 70kg, 30% TBSA
- 4 x 70 x 30 = 8400 mL
- 4200 given in first 8 hours (525mL/hr)
- 4200mL given in next 16 hours (260mL/hr)

Question 34

How do you calculate fluid resuscitation and maintenance fluids in pediatrics/children?

Answer 34

Pediatric fluid resuscitation = maintenance + replacement

MAINTENANCE PER HOUR:
4-2-1 rule:
1. 4mL/kg for the first 10kg in weight
2. 2mL/kg for the next 10kg in weight
3. 1mL/kg for the remaining kg in weight
Easy trick: Starting at 20kg, just add 40 to weight to get the mL

REPLACEMENT:
- Severe hypovolemia: 20mL/kg bolus of isotonic saline
- Moderate hypovolemia: 10mL/kg over 30-60 minutes, then reasseess for another bolus needed

Maintenance Solution in kids: D5-1/2NS with 30 KCl
Maximum of 60mL/kg in 3 boluses before considering pressors (for low BP)

Question 35

What are the clinical signs of a tension pneumothorax?

Answer 35

1. Dyspnea
2. Hypotension
3. Tracheal deviation to contralateral side
4. Decreased breath sounds on ipsilateral side
5. Increased resonance on percussion on ipsilateral side

Question 36

Describe the Glasgow Coma Scale (GCS)

Answer 36

EYES /4, VERBAL /5, MOTOR /6

EYES:
1. Not opening at all
2. Open to painful stimuli
3. Open to voice
4. Open spontaneously

VERBAL:
1. No verbal response
2. Mumbled words/incomprehensible sounds
3. Inappropriate words/random
4. Confused
5. Oriented

MOTOR:
1. No motor response
2. Decerebrate posturing (extension in response to pain)
3. Decorticate posturing (flexion in response to pain)
4. Withdraws from pain
5. Localizes to pain
6. Obeys commands

Question 37

Describe the general work-up and management of a patient presenting with facial trauma

Answer 37

HISTORY: (AMPLE)
1. Allergies
2. Medications
3. Past medical history
4. Last meal
5. Events leading up to injury

PHYSICAL EXAM:
1. ABCDE
2. Inspection:
- SEADS: Swelling, erythema, atrophy, deformity, scars
- Midface projection
- Occlusion
- Raccoon eyes, battle sign, hemotympanum

3. Palpation
   - Palpable step deformities
   - Palpate maxilla and ensure not mobile
4. Cranial nerve examination, especially:
   - CNII: RAPD
   - CNIII, IV, VI: Intact EOMs
   - CNV: Preserved sensation in V1/2/3
   - CNVII: Intact facial nerve function
   - CNVIII: Preserved hearing, rinne/weber

IMAGING: If stable, directed

TREATMENT:
1. Consult other services as appropriate
2. Tetanus prophylaxis for EVERYONE
3. Antibiotics if open injury
4. Conservative vs. operative management
5. Immediate vs. delayed repair

Question 38

Describe the Tetanus Prophylaxis Protocol

Answer 38

1. Td = Tetanus Diptheria Vaccine (has tetanus toxoid)
   - Provides long term protection against tetanus
   - Any tetanus toxoid containing vaccine can be given
2. TIg = Tetanus Immunoglobulin (immunoglobulin only)
   - Provides immediate, short term protection against tetanus

TREATMENT PROTOCOL
1. Unknown or incomplete (< 3 doses) in series
- Everyone gets vaccine (Td)
- Contaminated wounds also get TIg

2. Complete series (3+ doses) and < 5 years since last booster
   - No vaccine
   - No immunoglobulin
3. Complete series (3+ doses) and 5-10 years since last booster dose
   - Contaminated wounds get vaccine ONLY
   - No immunoglobulin
4. Complete series (3+ doses), >10 years since last dose
   - Everyone gets vaccine booster
   - No immunoglobulin

Question 39

Describe the approach to anesthetizing the ear

Answer 39

The following approach completely anesthetizes the auricle except for the CONCHA and MEDIAL SURFACE OF THE TRAGUS, which require direct injection.

STEPS:
1. Cotton ball placed in EAC to catch blood
2. Start from inferior, aim antero-superior towards auriculotemporal distribution
3. Then aim post-auricular via same injection site
4. Then continue up post-auricular area with new injection point toward top of helix
5. Inject towards root of helix starting from the top of the helix, from a posterior to anterior approach

Kevan Trauma Pg 35 (slightly inaccurate #4 diagram)

Question 40

Regarding injury to the facial nerve, discuss:
1. Proximal to what line do you repair the facial nerve?
2. What are some strategies for repairing a traumatized facial nerve?
3. What are 3 types of facial nerve repair?

Answer 40

LOCATION:
- Proximal to the vertical line running through lateral canthus and through mental foramen is where you would repair the facial nerve

STRATEGIES FOR REPAIR:
- Distal excitability lost after ~72 hours - ideal to fix before then
- If primary repair not possible, clip/tag ends for future repair
- Re-approximation done with 8-0 to 10-0 monofilament suture under microsocpy

TYPES OF FACIAL NERVE REPAIR:
1. Epineural
2. Perineural
3. Interfascicular

Question 41

Where are airway burns most common and least common?

Answer 41

• Supraglottis most commonly affected in airway burn
• Tracheal/subglottis is very rare - usually the result of supra-heated gas or steam

Question 42

Discuss the management of burns of the oral cavity. What are the potential complications and how can these be managed?

Answer 42

• Prolonged wait to allow demarcation of the burn (usually 10-14 days)
• Excision of burn areas after demarcation

Complications:
- Contracture is a long term complication - leads to microstomia. Prevented by fitting oral appliance, possible repair with estlander flap depending on tissue loss