Neck injuries from trauma can be life-threatening due to the important structures in the neck. A systematic approach is needed to evaluate and manage neck injuries. It is important to understand the neck anatomy, which can be divided into zones. Zone 1 injuries carry the highest risk and mortality. Common injuries include fractures to laryngeal cartilage and soft tissue injuries. Injuries are evaluated with imaging and laryngoscopy. Management depends on injury severity and may involve airway support, antibiotics, steroids, or surgery to repair damaged structures.

2.  Neck injuries can be very deceiving.
 Seemingly minor injuries can quickly become
life threatening.
 The insidious nature of injury to this area often
leads to a delay in diagnosis.
 Cervical spine fractures are commonly
associated.
 Neck must be manipulated carefully until
cervical spine X-rays have been obtained.
 Cricoid is most important part of laryngeal
skeleton.

3.  Acute injuries to cricoid cartilage pose the
most immediate threat to airway.
 Injuries to thyroid present with delayed
airway compromise from expanding
haematoma.
 Hyoid injury may even be overlooked
altogether.
 The subglottic space in children is very
much more susceptible to internal soft
tissue injury than it is in adult.

4.  Given the critical nature of the
contents of the neck, there is a need
for a systematic approach to
evaluation and management.
 This approach is based on a good
understanding of the underlying
anatomy.

5.  Neck contents are contained by two
discrete fascial layers:
 The superficial fascia:
 Which envelops the platysma muscle.
 The deep cervical fascia:
 Contains the sternocleidomastoid and
trapezius muscles.
 It is also used to mark the pretracheal
region which includes the trachea,
larynx, thyroid gland.

6.  It also invests the prevertebral area
Containing the prevertebral muscles,
phrenic nerve, brachial plexus, and
axillary sheath.
The carotid sheath encloses the carotid
artery, internal jugular vein, and vagus
nerve.

7.  Anterior Triangle: Bounded by:
 Mandible above
 Anterior border of the
sternocleidomastoid muscle posteriorly
 Midline of the neck anteriorly
 Posterior Triangle:
 sternocleidomastoid muscle anteriorly
 Trapezius posteriorly
 Middle third of the clavicle inferiorly

8.  Important structural contents include:
1. Carotid Artery
2. Internal jugular vein
3. Vagus nerve
4. Thyroid gland
5. Larynx
6. Trachea
7. Esophagus

10.  Has fewer vital structural contents:
1. Subclavian artery
2. Brachial plexus
 Injury to this area can have catastrophic
outcomes

12.  Anatomy classification is excellent for
describing the static location of structures
 Injury is not static, and an injury to the
neck may enter the anterior triangle and
then pass through the posterior triangle.
 A more useful classification of neck
anatomy for trauma is the Zone
classification developed by Roon and
Christensen

13.  This classification system can guide the
clinician in the diagnostic and therapeutic
management
 Based on level of injury to the neck in a
caudal to cranial orientation
 Zone 1:
 Lower Border = Clavicles
 Upper Border = Cricoid Cartilage

14.  Zone I Structures
 Vertebral arteries
 Proximal carotid arteries
 Major thoracic vessels
 Superior Mediastinum
 Lungs, trachea
 Esophagus
 Spinal cord
 Cervical nerve roots

15. Zone 1

16.  Begins at the inferior portion of the cricoid
cartilage and extends upwards to the angle
of the mandible
 Structures within this area include:
 Carotid and vertebral arteries
 Jugular veins
 Pharynx, larynx, trachea, and esophagus
 Cervical spine and spinal cord

17. Zone 2

18.  This zone is located in between the angle of
the mandible and the base of the skull
 Vital structures include:
 Distal carotid arteries
 Vertebral arteries
 Pharynx
 Spinal cord

19. Zone 3

21.  Neck trauma accounts for 5-10% of all serious
traumatic injuries.
 More common in adolescents and young male
adults.
 Zone I injuries are associated with the highest
morbidity and mortality rates.
 Initially missed cervical injuries secondary to
neck trauma result in a mortality rate of greater
than 15%.
 Overall mortality rate is 2-6%.

22. 22
 High velocity.
 Low velocity.

23. HIGH VELOCITY
INJURIES
 Velocity may be so
high that the
wound becomes
compound.
 Road traffic
accidents.
 Injuries at work.
LOW VELOCITY
INJURIES
 Rarely become
compound.
 Blows with fists.
 Sports injuries.

24. 24

25. 25
 Snowmobile racing.
 Motor cycle racing.
 Basketball.
 Karate.
 Sometimes with golf & cricket ball.
 Ice hockey.

26.  If the driver or front passenger is not belted, he is
in danger of thrusting forward with the head
extended, forcing the anterior neck against the
steering column or dashboard also known as
padded dash syndrome. This leads to crushing of
the trachea usually at the cricoid ring as well as
possible compression of the esophagus against the
vertebrae.
 Shoulder harnesses appear to offer some, though
incomplete, protection against blunt neck trauma;
cerebral vessel and laryngeal injuries secondary to
shoulder strap compression have occurred.

27.  Form of BNT that occurs typically in young
adolescent patients who ride motorcycles, all-terrain
vehicles, or snow mobiles when they strike a
stationary object such as a wire fence or tree limb.
Clothesline injuries can also occur in high contact
sports.
 A large amount of energy is transferred to a small
neck and this leads to crushed laryngeal cartilage
and frequently cricotracheal separation. With
cricotracheal separation, the injured airway is
held together by intervening mucous membranes.

29.  Occurs in 10% of all trauma cases.
 Victims tend to die at the scene.
 Form of BNT that consists of
◦ Homicidal strangulation: ligature suffocation or
manual choking
◦ Suicidal strangulation:
◦ Postural asphyxiation: seen in children; occurs
when the neck is placed over an object and the
body weight produces compression.

30.  Significant cervical spine and spinal cord
damage happens in only those hangings that
involve a fall from a distance greater than the
body height.
◦ General strangulation can be associated with
delayed laryngeal edema.
◦ Homicidal strangulation: injures via carotid
artery occlusion or carotid sinus reflex death;
CSRD is a disputed mechanism of death in
which manual stimulation of the carotid sinus is
believed to cause strong glossopharyngeal nerve
impulses leading to terminal cardiac arrest.

31.  Suicidal strangulation: Injury associated with
larynotracheal separation and neurovascular
injuries. The mechanism of action for suicidal
strangulation is the following: pressure is
applied to jugular veins leading to obstruction of
venous return from the brain. This results in
venous congestion in the brain and loss of
consciousness ensues. The patient falls with his
or her full weight against the ligature and the
trachea is compressed, restricting airflow to the
lungs. This results in irreversible asphyxiation
or death.

32.  Incidence: It is infrequently associated with BNT &
is present 3%-14% of the time with laryngeal
fractures.
 MOA: Compression of the cornu of the thyroid
cartilage or other parts of the laryngeal cartilage
against the cervical spine.
 Clinical features: Subcutaneous emphysema,
dysphagia, odynophagia, hematemesis, hemoptysis,
tachycardia, fever.

33.  Evaluation: Gastrografin study
recommended as first line, if negative,
consider barium swallow (greater sensitivity
of about 90%); endoscopy – rigid &/or
flexible endoscopy.
 Management: observe - if clinical exam is
benign; if surgical - then debridement with
two-layered primary closure +/- muscle flap
over suture line to prevent TE fistula.

34.  Incidence: reported as highly associated with BNT
but no exact statistics
 MOA: Can be caused by severe hyperextension
during acceleration/deceleration motor injuries.
Significant cervical spine and spinal cord damage
can occur in hangings that involve a fall from a
distance greater than the body height. Cervical
spinal disruption subsequent to strangulation is
almost uniformly fatal.

35.  Clinical features: Hemiplegia, quadriplegia, CN deficits,
change of sensorium, Horner’s syndrome, neurogenic
shock.
 Evaluation: Concern for cervical spine injuries arises
based on clinical exam and imaging – AP and lateral
cervical radiography plain films and CT scan.
 Management: NS should be consulted for any surgical
intervention. From the ENT standpoint, cervical
stability is important to establish especially in the event
of tracheostomy placement or endoscopy. Cervical spine
precautions including cervical spine immobilization and
supine placement of the patient on a backboard are
necessary.

36.  Incidence: 1-3% of all BNT, 20-30% mortality
 Mode of action:
 Direct forces can shear the vasculature.
 Excessive rotation and/or hyperextension of
the cervical spine causes distention and
stretching of the arteries and veins producing
shearing damage and resultant thrombosis.
 Basilar skull fractures may disrupt the
intrapetrous portion of the carotid artery.

37.  “Hard signs” – bruit/thrill, expanding or
pulsatile hematoma, pulsatile or severe
hemorrhage, pulse deficit.
 “Soft signs” – hypotension, shock, stable
hematoma, CNS/PNS ischemia.
 Note: often blunt vascular injury in the form of
acute ischemic stroke is the initial manifestation
of BNT in patients with a delay in presentation of
symptoms.
 Classic presentation: A neurologically intact
patient who develops hemiparesis after a high-
speed MVC.

38.  Evaluation: Four-vessel angiography remains gold
standard – sensitivity of 99%. CTA 68%
sensitivity, 67% specificity. MRA 75%, 67% for
specificity and sensitivity, resp. Duplex US
sensitivity 90-95% with a skilled technician.
 Management: Depending on extent of injury.
Surgical repair preferred over ligation; primary
repair preferred over grafting.

40. 40
 Sites.
 Tissues.

41. 41
 Supraglottis.
 Glottis.
 Subglottis.
 Mixed.

42. 42
 Laryngeal Framework:
 Hyoid.
 Thyroid.
 Cricoid.
 Tracheal rings.
 Internal Soft Tissues.

43. 43
 Fracture of hyoid bone.
 Odynophagia, dysphagia.
 Swelling of base of tongue.
 Bleeding into soft tissues of
paraglottic space.

44. 44
 Fracture the skeleton of larynx.
 Fate of thyroid cartilage depends on
its degree of calcification and thus on
age of patient.

45. 45
 Minimal injury results in no fracture.
 If there is any rigidity or force is great
enough, cartilage will split down front &
down thyroid prominence.
 Inherent elasticity allow it to spring back.
 Disruption of anterior commissure.
 Epiglottis falls backwards.

46. 46
 Vocal cords literally roll up on
themselves towards arytenoids.
 As thyroid becomes compressed
against cervical spine, arytenoids are
sandwiched.
 Bleeding into interarytenoid space &
subsequent swelling.

47. 47
 Shatter rather like an egg.
 Loss of thyroid prominence.
 Arytenoids are sandwiched.

48. 48
 Only complete ring in respiratory
tract.
 If disrupted then it will stenose.
 Very difficult defect to repair.
 Soft tissue injury from high velocity
blunt injuries separates the trachea
from cricoid.

49. 49

50. 50
 Oedema.
 Haematoma: Supraglottis, paraglottic
space, Reinke’s space.
 Web: Abrasions at anterior
commissure.
 Glottic Incompetence.

51. 51
 Arytenoid fixation.
 Resorption of thyroarytenoid muscle.
 Atrophy of the vocal cord.
 Recurrent laryngeal nerve paralysis
(subglottic injuries).

52. 52
 May heal without any affect.
 Rarely fractured ends form bursa
which results in continual movement
of fractured edges & requires
excision.

53. 53
 If fractured, heal by fibrous union.
 If compressed then it has to be
reconstituted and held outwards with
a stent.

54. 54
 Tracheomalacia.
 Intubation granuloma.

55. 55

56. 56
 History.
 Clinical examination.
 Radiology.
 Laryngoscopy.

57. 57
 Awareness of possibility in every upper
body trauma victim.
 Dyspnoea.
 Dysphonia.
 Dysphagia.
 Pain.
 Cough.
 Hemoptysis.

58. 58
 Stridor.
 Cervical bruising.
 Surgical emphysema confined to neck.
 Loss of thyroid prominence.

59. 59
 Great vessels.
 Cervical spine.
 Chest: Haemothorax/ Pneumothorax,
emphysema, distant oesophageal
tears.
 Abdomen: Gastric dilatation.

60. 60
 Plain Radiographs of the neck.
 X-ray Chest.
 CT Scan.

61. 61
 Flexible laryngoscopy: performed in
all patients.
 Rigid laryngoscopy: may exacerbate
the effects of injury

62. 62
 Protection of the airway.
 Protection of the laryngeal function.

63. 63

64.  Group 1:
◦ Minor endolaryngeal hematomas or lacerations, no
detectable fracture
◦ Treatment: humidified O2 and observation
 Group 2:
◦ Edema, hematoma, minor mucosal disruption
without exposed cartilage, non-displaced fracture,
varying degrees of airway compromise
◦ Treatment: tracheostomy to secure the airway along
with panendoscopy

65.  Group 3:
◦ Massive edema, large mucosal lacerations, exposed
cartilage, displaced fracture(s), vocal cord immobility
◦ Treatment: tracheostomy along with exploration and
repair
 Group 4:
◦ Same as group 3 but more severe with severe mucosal
disruption, disruption of the anterior commissure, and
unstable fracture, 2 or more fracture lines
◦ Treatment tracheostomy along with exploration and repair
with stent placement
 Group 5:
◦ Complete laryngotracheal separation
◦ Treatment: urgent tracheostomy along with exploration
and repair

66. 66
 Admission to the ICU for strict monitoring.
 Serial flexible nasolaryngoscopy
examinations.
 High humidity atmosphere.
 Oxygen may be given.
 Antibiotic therapy.
 Maximal dose parental steroid therapy.
 Antireflux therapy.

67. ◦ Lacerations involving free margin of the
vocal fold
◦ Large mucosal lacerations
◦ Exposed cartilage
◦ Multiple & displaced, or unstable, or
comminuted cartilage fractures
◦ Avulsed or dislocated arytenoids cartilages

68. ◦ Vocal fold immobility or detachment of the
anterior commissure
◦ Cricotracheal separation.
◦ Fractures of the median or paramedian parts
of the thyroid alae.
◦ Cricoid fracture.
◦ Airway compromise.
◦ It is recommended that all surgical patients
receive panendoscopy intraoperatively for a
detailed examination of the injury before
surgical repair.

69. 69
 Majority do not require open exploration.
 Most will require observation in hospital at
least overnight for laryngeal oedema &
airway obstruction.
 If either of these is disturbed, larynx
should be intubated and later explored and
reconstructed.

70. 70
 Many of these patients will end up with a
poor voice if glottis has been damaged.
 Unusual for these patients to require a
permanent tracheostomy.

71. 71
 Half the patients will require laryngeal
exploration and reconstruction.
 Skeletal damage is repaired by
reconstitution using stents.
 Soft tissue injuries are dealt with by
reducing bleeding, evacuating spaces, &
using quilting sutures.
 If cricoid is injured, primary repair should
be attempted.

72. 72
 If failed then one of the many
techniques applied to chronic cricoid
stenosis be used.
 Seperation of cricotracheal membrane
is dealt with fairly reasonably by
drooping the larynx in neck and
pulling the trachea upwards for an
end-to-end anastomosis, excising any
damaged tracheal rings.

73. 73
 If only the glottis is involved then
results with regards to breathing
should be good.
 If subglottis is involved the patient
faces certain future surgery for
chronic subglottic stenosis.

74.  BNT is not common in children; however,
LT injury is most commonly related to in
BNT in children.
 Bicycle accidents and falls are common
causes in younger children
 The larynx is situated higher in neck and
protected by mandible
 Lies at C3 level in the neonate and
descends during first 3 years of life to
its adult position at C6.

75.  Less laryngeal fractures because of
elasticity of cartilages
 Submucosal tissues are loosely attached to
the underlying perichondrium, increasing
the likelihood of soft tissue damage like
edema or hematoma and subsequent airway
obstruction.
 Controversy in intubation vs tracheostomy.
It is usually not possible to perform an
awake tracheostomy; It is recommended to
manage with intubation followed by prompt
tracheostomy.