Unusual clinical course, Challenging differential diagnosis, Management of emergency care
Sebastian D. Sgardello, Michel Christodoulou, Ziad Abbassi
(Department of General Surgery, Hospital Center Valais Romand – Hospital Sion, Sion, Switzerland)
Am J Case Rep 2019; 20:1801-1804
Penetrating neck injuries (PNI) have a relatively low incidence constituting just 1.6% to 3.0% of overall suicide attempts. Nonetheless, the anatomical challenges as well as the likelihood of vascular and airway lesions make it one of the most lethal injury types of all Abbreviated Injury Scale regions.
Traditional PNI management which divides PNI into anatomical zones is being reconsidered in light of high numbers of negative surgical explorations, weak correlation between the area of wounds and organ injury and significantly longer hospitalizations.
CASE REPORT: A 52-year-old female was admitted after a self-inflicted, right para tracheal stab wound. A cervico-thoracic computed tomography (CT) scan excluded vascular and other organ lesions. A right pneumothorax was treated with a chest drain and a right exploratory cervicotomy was performed. A pharyngoscopy and an esophagoscopy showed no lesions.
CONCLUSIONS: Advanced Trauma Life Support (ATLS) principles determine the initial assessment of PNI. Invasive airway management was required if orotracheal intubation is unfeasible. Hemodynamically unstable patients with platysma, vascular or aerodigestive lesions require surgery. Laryngotracheal injuries require panendoscopy and bronchoscopy prior to surgical exploration. Pharyngo-esophageal injuries may be treated conservatively. Esophageal lesions require timing dependent surgery. Recently, a “no zone” approach irrespective of anatomical classification shows improved results in stable PNI. Multidetector helical CT with angiography (MDCT-A) significantly reduces negative exploratory surgery. Consensus regarding the best management of PNI is shifting, as increasing evidence suggests a “no-zone” approach is more beneficial and cost effective.
Keywords: Neck Injuries, Pneumothorax, Schizotypal Personality Disorder, Suicide, Attempted