Neck Wounds Research Articles

Damage control sternotomy for penetrating mediastinal vascular injury

Whilst temporary vacuum-assisted wound management has become a mainstay in the treatment of patients with severe abdominal trauma in extremis, the use of this technique in the management of exsanguinating injuries and resultant physiologic decompensation in other body cavities is ill defined. Concerns over potential cardiac and pulmonary compromise secondary to packing along with the lethal nature of penetrating injuries to the thorax has limited extension of these practices to the management of this body region. Many patients with central vascular injuries secondary to penetrating trauma either expire prior to hospital arrival or arrive haemodynamically unstable and require emergency department thoracotomy. To our knowledge, there are no reports of the use of damage control sternotomy with temporary substernal and intrathoracic packing for traumatic thoracic injuries. We report our experience treating an adolescent patient who sustained a central venous injury and bilateral lung lacerations with a damage control sternotomy approach. A 15-year-old girl presented to the emergency department after sustaining multiple stab wounds to the neck, chest and back. On arrival to the emergency department, she was tachycardic (HR = 120) and hypothermic (T = 34.5 8C) but normotensive (SBP = 113) and neurologically intact (GCS = 15). Exam findings included a 3 cm laceration extending from zone 2 to zone 1 of her right neck, a 2 cm infraclavicular sucking wound to the left chest with associated crepitus and a 5 cm laceration to the posterior left shoulder. Standard ATLS resuscitation was performed and a left tube thoracostomy was placed with resultant rush of air and 500 ml of bloody drainage. A subsequent chest X-ray demonstrated a large right haemothorax. After placement of a right tube thoracostomy and immediate drainage of over 1000 ml of blood, the patient began to cough, resulting in massive bleeding from her neck wound and haemodynamic instability. Direct pressure was applied to the neck to temporarily control bleeding. Subsequent Accepted 1 March 2010

Melioidosis and the vacuum-assisted closure device: a rare cause of a discharging neck wound, and a new approach to management

We report a case of melioidosis presenting as a discharging neck abscess, and we describe the use of a vacuum-assisted closure device in its management. We report the case of a 44-year-old, Afro-Caribbean woman with melioidosis. We also present the results of a literature search using the search terms 'melioidosis', 'Burkholderia pseudomallei' and 'vacuum-assisted closure device'. Microbiological analysis identified the causative organism as being the bacterium Burkholderia pseudomallei, and its antimicrobial sensitivities to imipenem and ciprofloxacin. A vacuum-assisted closure device was used to manage the patient's melioidosis of the neck; we believe this is the first report of such treatment. Melioidosis is rare in the UK and western world; however, exposure can occur during travel to endemic areas. We therefore draw attention to this infection as part of the differential diagnosis of a neck abscess. We propose the use of vacuum-assisted closure devices as useful adjuncts to the management of discharging neck wounds.

Safety Evaluation of New Hemostatic Agents, Smectite Granules, and Kaolin-Coated Gauze in a Vascular Injury Wound Model in Swine

In 2007, a potent procoagulant mineral called WoundStat (WS), consisting of smectite granules, received clearance from the Food and Drug Administration for marketing in the United States for temporary treatment of external hemorrhage. Previously, we found that microscopic WS particles remained in the injured vessels that were treated, despite seemingly adequate wound debridement. Thus, we investigated the thromboembolic risk of using WS when compared with kaolin-coated gauze, Combat Gauze (CG); or regular gauze, Kerlix (KX) to treat an external wound with vascular injuries in pigs. The right common carotid artery and external jugular vein of pigs were isolated and sharply transected (50%). After 30 seconds of free bleeding, the neck wounds were packed with WS, CG, or KX and compressed until hemostasis was achieved (n = 8 per group). Wounds were debrided after 2 hours, and vascular injuries were primarily repaired with suture. Blood flow was restored after infusing 1 L of crystalloid (no heparin or aspirin) and the wounds were closed. Two hours later, computed tomographic angiography was performed, and the wounds were reopened to harvest the vessels. The brains and lungs were recovered for gross and microscopic examination after euthanasia. No differences were found in baseline measurements. Thrombelastography showed similar hypercoagulability of the final blood samples when compared with baselines in all groups. All vessels treated with KX or CG were patent and had no thrombus or blood clot in their lumen. In contrast, seven of eight carotid arteries and six of eight jugular veins treated with WS developed large occlusive red thrombi and had no flow. Small clots and WS residues were also found in the lungs of two pigs. Histologically, significant endothelial and transmural damage was seen in WS-treated vessels with luminal thrombi and embedded WS residues. WS granules caused endothelial injury and significant transmural damage to the vessels that render them nonviable for primary surgical repair. The granules can enter systemic circulation and cause distal thrombosis in vital organs. More relevant in vitro and in vivo safety tests should be required for clearance of new hemostatic agents.

Product Update

Improvised explosive devices are the weapons of choice for the insurgent enemy in Iraq and Afghanistan. More soldiers are surviving these blast injuries due to improved torso protection yet are sustaining head and neck wounds in numbers that exceed those from previous wars. Although moderate and severe traumatic head injuries are easily identified and aggressively treated, mild traumatic brain injuries (m-TBIs), or concussions, had previously been deemed inconsequential and often overlooked. Recently, however, the U.S. Department of Defense and Veterans Health Administration have placed emphasis on identifying service members at risk for m-TBI because a select number continue to have disabling symptoms that can negatively affect quality of life. Research regarding the effects and treatment of blasts injury are gaining momentum, but further work needs to be accomplished. This article provides a three-question screening tool that can be used to identify these at-risk veterans.

A Signature Wound of War: Mild Traumatic Brain Injury

Improvised explosive devices are the weapons of choice for the insurgent enemy in Iraq and Afghanistan. More soldiers are surviving these blast injuries due to improved torso protection yet are sustaining head and neck wounds in numbers that exceed those from previous wars. Although moderate and severe traumatic head injuries are easily identified and aggressively treated, mild traumatic brain injuries (m-TBIs), or concussions, had previously been deemed inconsequential and often overlooked. Recently, however, the U.S. Department of Defense and Veterans Health Administration have placed emphasis on identifying service members at risk for m-TBI because a select number continue to have disabling symptoms that can negatively affect quality of life. Research regarding the effects and treatment of blasts injury are gaining momentum, but further work needs to be accomplished. This article provides a three-question screening tool that can be used to identify these at-risk veterans.

Pedicle transfer in oral cavity reconstruction

In head and neck reconstructions when a free flap is used intra orally to provide the lining its vascular pedicle has to be transferred to the neck for anastomosis. This has to be performed in such a way that the pedicle does not get kinked or twisted. The pedicle is enrolled in a split open glove from its point of entry into the flap till its proximal most part. In order to prevent twisting of the vessels and to maintain orientation, the glove is wrapped in such a way that the imprint on the glove is on the visualized surface. The glove wrapped pedicle is passed from inside the oral cavity while an artery clamp passed from the neck wound through the submandibular or subcutaneous tunnel holds the tip of the glove component and guides it safely to the neck without exerting any traction on the flap or the pedicle vessels.

Undesired reaction following intramuscular application of medicine: Case history

The paper describes the therapy of a neck wound in a horse that occurred as a consequence of an inflammatory reaction to an administered medicine. During the clinical examination, we established that it was a neck wound that had occurred as a consequence of an inflammatory reaction on the spot where the medicine had been administered. There was an expressed fist-size tissue defect, with necrosis covering the skin, the subcutaneous tissue, the cutaneous muscle, and the neck musculature. The ventral part of the wound contained a pocket with exudate and hypergranulation. Therapy was based on asceptic treatment of the area around the wound, trimming the edges of the wound, washing the wound, removing hypergranulation, draining, protecting the area from drying, applying treatment with antibiotics. The wound healed per secundam intentionem.

Pedicle transfer in oral cavity reconstruction

ABSTRACTIn head and neck reconstructions when a free flap is used intra orally to provide the lining its vascular pedicle has to be transferred to the neck for anastomosis. This has to be performed in such a way that the pedicle does not get kinked or twisted. The pedicle is enrolled in a split open glove from its point of entry into the flap till its proximal most part. In order to prevent twisting of the vessels and to maintain orientation, the glove is wrapped in such a way that the imprint on the glove is on the visualized surface. The glove wrapped pedicle is passed from inside the oral cavity while an artery clamp passed from the neck wound through the submandibular or subcutaneous tunnel holds the tip of the glove component and guides it safely to the neck without exerting any traction on the flap or the pedicle vessels.

Application of a Fibrin Sealant (Tissucol) in Head and Neck Cancer Reconstruction

Background: Obliteration of dead space to prevent postoperative hematoma and the prevention of neck wound infections are critical for successful head and neck reconstruction. This report describes a strategy that involves the use of a fibrin sealant (Tissucol, Baxter Corp.) to minimize postoperative complications following head and neck cancer ablation. Patients and Methods: This study included 64 patients who underwent ablative oral cancer surgery and radical neck lymph node dissection. Of these, 27 were treated with Tissucol after cancer ablation, whereas 37 were not; these 37 patients formed the control group. After flap inset and pedicle reperfusion, Tissucol was sprayed onto the dead space present in the deep neck lesions, and gentle manual pressure was immediately applied. Postoperatively, the drainage amount and the wound condition were assessed routinely. Results: Following Tissucol application, all the flaps survived without any pedicle compromise. The occurrence of postoperative neck hematoma was found to be significantly lower in the study group than in the control group (7% versus 27%, p＜0.01). Further, the neck wound drainage amount was also found to be lower in the patients of the study group than in the control group (142.1±19.0 ml versus 239.4±48.9 ml; p=0.07). No statistical differences were noted in the occurrence of oral wound infection between the groups (14.8% versus 16.2%, p=1.00). However, although oral wound infection and subsequently orocutaneous fistula was observed in the study group, it did not invade the deep neck areas. Satisfactory results were achieved in all patients, without any major complications. Conclusion: Tissucol could apparently minimize the occurrence of postoperative hematoma and decrease the neck wound drainage amount, thereby reducing the incidence of postoperative complications.

Current Concepts in the Epidemiology and Management of Battlefield Head, Face and Neck trauma

There has been a significant increase in the incidence of head, face and neck (HFN) injuries in the 21st century in comparison to that experienced in the previous century. In...

Two cases of penetrating injury of the neck

Penetrating neck trauma has been a significant cause of morbidity and death. More than 4,000 cases of neck wounds were reported during American civil war with mortality rate of 15%. The risk of death was reduced to 11% in World War I and 7% in World War II [1]. We present two cases of penetrating neck injury (Grenade splinter-1, Stab-1) reporting to a mid zonal hospital in counter insurgency situation.

The effect of smoking, drinking and smoking cessation on morbidity and mortality in oral cancer

Methods: We look at recent neck dissections performed n our unit, using the same type of skin incision. Patients ere photographed by our medical illustration department nd questionnaires were posted out to both, patients and a roup of randomly selected individuals to rate the scars from he neck wounds. Results and discussion: Since Criles’s description of the adical neck dissection, numerous alternative incisions for eck dissections have been described. Most surgeons develop preference for a particular incision, their choice being influnced by access, morbidity, complications and aesthetics. We eview an incision routinely used in our unit, which fulfills ll the above criteria and demonstrates that aesthetics does ot compromise the nodal harvest.

Unanticipated complication of a malpositioned central venous catheter

We report an unusual complication that occurred late in the postoperative period, due to a damaged and malpositioned peripherally inserted central catheter (PICC) used for central venous pressure monitoring during esophagocoloplasty and for postoperative parenteral nutrition. On the seventh postoperative day, the development of a leak from the neck wound coincided with the administration of intravenous fluids via the PICC. The leak had occurred as a result of slow erosion of the left internal jugular vein (IJV) by the damaged edges of the catheter.

Cut throat zone II neck injury and advantage of a feeding jejunostomy

Penetrating neck injuries account for 5-10% of trauma cases and are potentially life threatening. We report a case of cut- throat zone II neck injury in a 45-year-old male extending up to posterior pharyngeal wall and exposing the underlying cervical vertebra. Tracheostomy was done and wound repair was started from the posterior aspect in layers using 3-0 Vicryl. Intraoperatively, a conscious decision was taken for a feeding jejunostomy for postoperative feeding, which was likely to be prolonged, in view of sensory-nerve damage along the transected pharynx. Prolonged use of Nasogastric tube for postoperative feeding was thus avoided and the discomfort, risk of aspiration and foreign body at injury site eliminated. One week postoperative, the patient experienced severe bouts of coughing and restlessness on oral intake; during this period enteral nutrition was maintained through feeding jejunostomy. At the time of discharge at 1 month, the patient was accepting normal diet orally and was detubated and vocalizing normally. We conclude that postoperative nutrition is an important area to be considered for deep neck wound with nerve injuries due to delayed tolerance to oral feeding till the regeneration of sensory nerves. A feeding jejunostomy or feeding gastrostomy performed simultaneously in such patients with nerve injuries is far superior over nasogastric-tube feeding when prolonged postoperative feeding is expected.

Vacuum‐assisted closure therapy in the management of head and neck wounds

The wound vacuum-assisted closure (VAC) has been used in many areas of surgery to promote healing and facilitate secondary reconstruction. Until recently, this treatment modality was overlooked in the otolaryngology literature, and the authors propose that its use should be routine in the treatment of complex head and neck wounds. An unbiased cohort study without conflict of interest at two tertiary care centers. All patients treated by the authors presented with complex head and neck wounds from 2005 to 2007 and were subjected to wound VAC therapy. The wound VAC dressing was changed every 72 hours, and the wound etiology, wound site, history of chemotherapy and radiation, hospital duration, gender, outcome, and ancillary procedures were recorded. Nineteen patients with 33 wounds were treated using VAC therapy. Eighty-four percent of these patients healed completely without the need for further surgical intervention. The mean age of this cohort was 63.2 years, with a range of 48-75 years. Males far outnumbered females in this study (17:2). Outpatient therapy commenced at discharge after an average of 11.4 days following a hospital stay ranging between 5 and 28 days. Adjunctive procedures performed during and after VAC therapy included hyperbaric oxygen treatment, dermal grafts, salivary diversion, and regional flap reconstruction. This study shows the applicability and versatility of vacuum-assisted wound closure in the head and neck. Based on our results the authors feel that this mode of therapy should be a routine part of the Otolaryngologist's armamentarium for the treatment of complex and refractory head and neck wounds.

Contamination of postoperative head and neck wounds with urogenital microbes

Objectives. To investigate the impact of mixing surgical subspecialty patients on postoperative wound infections. Method. A retrospective analysis of postoperative wound infections in head and neck surgery patients before and after mixing them with urology patients. We selected two periods that are identical in duration and seasonal spread. The first was from March 2005 to November 2005 and the second was from March 2006 to November 2006. Results. 1381 patients underwent head and neck surgery at our institute in the two periods; 705 in the first and 676 in the second. The number of patients with positive swabs was 19 (2.7%) in the first group and 28 (4.1%) in the second group. Positive swabs (infective episodes) increased from 93 (13.2%) to 135 (20%) and the monthly breakdown of the two periods showed a statistically significant increase (P = 0.047). Urogenital microorganisms were the main factor contributing to the increase in wound infection rates in the second period (P = 0.008). Other organisms like MRSA, remained statistically unchanged (P = 0.464). Conclusions. We recommend that head and neck surgery patients are better managed on separate wards. If this is not possible, extra attention should be paid to prevent cross infection. Clinicians must have a low threshold of suspecting relevant microorganisms when other specialty patients are on the same ward.

Role of collagen cross-linking on equine wound contraction and healing

The present study was carried out to evaluate the effect of collagen cross-linking inhibition on equine wound contraction and healing. In five male adult donkeys, two full-thickness skin wounds (20 × 20 mm in diameter) were created on the lateral aspect of forelimbs, at the mid-point between the carpal and fetlock joints under general anesthesia. Two other wounds were created on the neck of each donkey symmetrically. Left-side wounds (test group) and right-side wounds (control group) were treated topically with beta-aminopropionitrile fumarate, 5 mg/ml, added to methyl cellulose gel and only methyl cellulose gel, respectively. Treatment of wounds were started at 24 h after wounding and continued every other day for ten successive days. The wounds were evaluated over a 3-week period. On days 0, 1, 3, 5, 7, 9, 12, 15, 18, and 21, digital photographs were taken of all wounds after careful shaving to visualize the wound margin. Rulers were held vertically and horizontally close to the wound as a reference. Epithelialization and granulation tissue formation were measured for each wound using Scion Image software. Percentage of the wound contraction, epithelialization, and healing were calculated for each wounds. At the end of the study, biopsy was taken from the center of each wound for hydroxyproline measurement and the same corner of each wound for histopathological examination. Macroscopic evaluation revealed significant differences in wound contraction and healing process between test and control groups in wounds located in neck (P 0.05). Significant differences were observed in the percent of wound contraction and healing between the test and control groups in wounds located in the forelimb (P 0.05). There were no significant differences between median of hydroxyproline levels of left and right wounds in forelimb and neck (P > 0.05). Histopathological examination revealed no significant differences between median of epithelialization, inflammatory infiltration, presence of dermal granulation tissue, fibroblast proliferation, arrangement of fibroblasts, collagen deposition, and collagen bundle formation scores in the specimens prepared from left and right wounds in forelimb and neck (P > 0.05). Our data demonstrated that collagen cross-linking could play a key role in equine wound contraction and healing at the limb and neck area.

A simplified technique of free flap pedicle transfer for reconstruction of defects following head and neck cancer ablation

Free flaps are being widely used for reconstruction of defects following head and neck cancer ablation. The pedicle of the flap is usually tunneled into the neck wound for anastomosis to the neck vessels. This transfer of the pedicle can be technically difficult to execute and associated with difficulties of torsion and kinking. No effective method has been so far reported to make this procedure easy and safe. A very easy and effective method for the pedicle transfer is described in this report, which has been practiced successfully in our head and neck service in more than 175 free flaps.

Passive versus active drainage following neck dissection: a non-randomised prospective study

Drainage is used following neck dissection to prevent the collection of fluid and aid healing. Active drains are thought to be more effective due to their ability to assist adherence of skin flaps and the minimisation of bacterial migration. There is controversy regarding the type of drain (active or passive) which should be used due to concerns about the potential for compromise of free flap pedicles with active drains. A prospective non-randomised study was undertaken to determine if there were any differences in neck healing following neck dissection between active and passive drains. A consecutive series of patients (the majority of whom had free flap reconstruction) were included over an 8 month period and were examined for delayed healing of the neck wound, flap loss, infection, haematoma and fistula. A total of 60 patients underwent 72 neck dissections during the study period (passive: 13, active: 47). The delayed healing rate in patients with passive drains was 54% compared with 6% for active drains (P < 0.001). This difference remained significant irrespective of surgeon grade, nodal status and whether or not a free flap was performed. There was no patient in whom the drain was thought to contribute to free flap loss. This non-randomised study has shown a significant difference in neck healing depending on the type of drain used following neck dissection. Despite the numerical differences between the groups the patients were relatively well matched for the parameters described. This difference in neck healing, combined with the lack of evidence for a contribution to flap loss, suggests active drains should be used following neck dissection in both free flap and non-free flap cases.

TREATMENT OPTIONS FOR HEAD AND NECK WOUNDS

TREATMENT OPTIONS FOR HEAD AND NECK WOUNDS