Penetrating Wounds of the Neck

Abstract

The management of penetrating wounds of the neck provides several decision-making steps that remain controversial. The two basic concepts of management include the idea that all wounds deep to the platysma should be explored and (the more conservative concept) that selective neck exploration should be based on a battery of tests to identify traumatic injuries. The areas of agreement within these two schools of thought include exploration of wounds with obvious injury, exploration of wounds in which patients cannot be stabilized satisfactorily for further testing, and the idea that all patients with wounds deep to the platysma should be admitted to the hospital. The remaining issues, including the need for angiography, barium swallow, or endoscopy, still are contested. Mandatory exploration of neck wounds became popular during World War II. The weapons used, the lack of accurate testing, and delays in treatment caused by transport problems played significant roles in the development of this policy. Proponents of mandatory exploration of neck wounds contend that delays in treatment result in increased mortality rates. Also delays caused by lengthy diagnostic testing have resulted in rapid exsanguination of patients who might otherwise have been surgically salvageable. These factors, along with the potential for undetected injuries and the associated complications (including false aneurysms and mediastinitis) favor mandatory exploration. Advocates of routine neck explorations also note the low morbidity rates associated with a neck exploration. Reported rates of negative exploration are high, however, approaching 45%, and mortality rates vary from 2% to 9%. Selective neck exploration has gained popularity in some centers because of the lower negative exploration rates associated with this treatment, while comparable mortality rates are achieved. May found a negative exploration rate of 12% in his series of selective neck explorations and a mortality rate of approximately 3%. Furthermore, Noyes found that the hospital stay for patients with selective observation management not requiring a neck exploration was 2.8 days, compared with 4.2 days for patients with mandatory but negative neck explorations. A summary of diagnostic techniques and their indications in selecting patients with penetrating neck wounds for surgery is presented in Table 5. It has become apparent that both selective and mandatory explorations of neck wounds play important roles in treatment.(ABSTRACT TRUNCATED AT 400 WORDS)