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Chapter 32 FOREIGN BODIES of the HEAD, NECK, and SKULL BASE

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Chapter 32 FOREIGN BODIES of the HEAD, NECK, and SKULL BASE Foreign Bodies of the Head, Neck, and Skull Base Chapter 32 FOREIGN BODIES OF THE HEAD, NECK, AND SKULL BASE RICHARD J. BARNETT, MD* INTRODUCTION PENETRATING NECK TRAUMA Anatomy Emergency Management Clinical Examination Investigations OPERATIVE VERSUS NONOPERATIVE MANAGEMENT Factors in the Deployed Setting Operative Management Postoperative Care PEDIATRIC INJURIES ORBITAL FOREIGN BODIES SUMMARY CASE PRESENTATIONS Case Study 32-1 Case Study 32-2 Case Study 32-3 Case Study 32-4 Case Study 32-5 Case Study 32-6 *Lieutenant Colonel, Medical Corps, US Air Force; Chief of Facial Plastic Surgery/Otolaryngology, Eglin Air Force Base Department of ENT, 307 Boatner Road, Suite 114, Eglin Air Force Base, Florida 32542-9998 423 Otolaryngology/Head and Neck Combat Casualty Care INTRODUCTION The mechanism and extent of war injuries are sig- other military conflicts. In a study done in Croatia with nificantly different from civilian trauma. Many of the 117 patients who sustained penetrating neck injuries, wounds encountered are unique and not experienced about a quarter of the wounds were from gunshots even at Role 1 trauma centers throughout the United while the rest were from shell or bomb shrapnel.1 The States. Deployed head and neck surgeons must be injury patterns resulting from these mechanisms can skilled at performing an array of evaluations and op- vary widely, and treating each injury requires thought- erations that in many cases they have not performed in ful planning to achieve a successful outcome. a prior setting. During a 6-month tour in Afghanistan, This chapter will address penetrating neck injuries all subspecialties of otolaryngology were encountered: in general, followed specifically by foreign body inju- head and neck (15%), facial plastic/reconstructive ries of the head, face, neck, and skull base. Multiple (32%), pediatric (10%), laryngology (8%), rhinology case studies will be presented to illustrate the types of (8%), oral surgery (13%), otology (7%), and general ear, foreign body injuries encountered in a war zone and nose, and throat (7%). This is somewhat consistent with their treatment. PENETRATING NECK TRAUMA The significant areas most commonly injured with the distal carotid artery and jugular vein along with penetrating neck trauma are the great vessels, fol- the vertebral arteries and pharynx. lowed by the spinal cord, the aerodigestive tract, and In a study looking at the overall injury rates ac- various nerves.2 cording to zone, zone II was most commonly injured (47%), followed by zone III (19%) and zone I (18%). Anatomy About one in six cases involved injury to more than one zone.3 In patients with stab wounds, zone I was The neck’s anatomy is unique in that many vital again most commonly injured (44%), followed by zone structures are arranged in tight fascial compartments, II (29%) and zone III (27%). Three out of every four stab making it particularly vulnerable to penetrating neck wounds involved the left side of the neck, probably trauma. In many cases this trauma can be lethal. A because the attackers were right-handed.3 good foundation in the anatomy of the neck is es- sential when managing a penetrating neck injury. Emergency Management Understanding the fascial planes and compartments of the neck in particular is vital in understanding the When dealing with a penetrating trauma of the clinical presentation of various penetrating injuries. head and neck, the initial evaluation should follow The neck is generally divided into three anatomical advanced trauma life support guidelines. Particular zones for purposes of clinical evaluation and com- attention should be paid in the initial survey to airway munication among physicians (Figure 32-1). Zone I is obstruction (due to laryngotracheal trauma or external located between the body of the clavicle and the up- compression by a hematoma), tension pneumothorax, per border of the cricoid cartilage. This area contains the great vessels, including the origin of the common carotid artery, the subclavian vessels, and the vertebral III artery. The brachial plexus, trachea, esophagus, the Mandible upper aspect of the lung, and the thoracic duct can also be found in this region. The clavicle can make this II zone difficult to expose surgically. Zone II lies in the Cricoid area between the upper border of the cricoid cartilage and the angle of the mandible. The great vessels are also in this zone, but the subclavian vessels are not. I The trachea and esophagus are vulnerable in this zone, as they are in zone 1. Zone II is more readily ac- cessible from an examination and surgical standpoint Figure 32-1. Surgical zones of the neck: zone I is between the compared to the other two zones. Zone III extends clavicle and cricoid, zone II is between the cricoid and angle from the angle of mandible to the base of skull and is of mandible, and zone III is between the angle of mandible difficult to access clinically and surgically. It includes and the base of the skull. 424 Foreign Bodies of the Head, Neck, and Skull Base significant active bleeding both externally and in the gestive tract can usually be watched conservatively thorax, and spinal cord injury or brain ischemia from unless the clinical condition changes.5 In one study, a carotid artery occlusion. 68% of penetrating neck injuries trajectories on CT After finishing the primary survey, the secondary scan were noted to be distant from vital structures and survey should be completed with particular attention no further intervention was performed.6 CT scanning paid to subtle vascular or laryngotracheal injuries, can also provide insight into the status of the spinal pharyngoesophageal injuries, cranial or peripheral cord, presence of bone or foreign body fragments in nerve injuries, and occult pneumothoraces. the spine, and hematomas near the spinal cord.5 Helical CT angiography has recently been used to Clinical Examination evaluate large neck vessels after a penetrating neck injury. Results appear to be helpful in the evaluation An extensive head and neck exam should be process; in some cases, the method is used as the completed for any penetrating neck injury or foreign initial investigational tool when a vascular injury is body presence. This is usually performed as part of suspected.7–9 Munera prospectively compared con- the primary and secondary survey (specifics can be ventional angiography to helical CT angiography found in Chapter 11, Primary and Secondary Trauma in a study of 60 patients. CT angiography showed Assessment). When dealing specifically with foreign a sensitivity of 90%, specificity of 100%, positive body injury to the head and neck, physical exam is the predictive value of 100%, and negative predictive most reliable diagnostic tool. If possible, a systematic, value of 98%.7 In a larger study with 175 patients, written protocol should be used. The protocol should Munera found similar results, suggesting again that be specifically directed to reveal injuries to the laryn- CT angiography can be very helpful in evaluating gotracheal/pharyngoesophageal region, the vessels arterial injuries in the head and neck. He did men- pertinent to the zone involved, the lungs, and the tion, however, that CT angiography may have some spine. “Hard” signs are usually considered definitive limitations with metallic artifacts or large amounts indications of a specific injury, while “soft” signs are of air in the soft tissues, in which case conventional suspicious but not necessarily diagnostic. 2,4 The way angiography may be more helpful.8 in which the injury occurred strongly influences signs Patients who have sustained penetrating neck injury and symptoms; for example, casualties with gunshot with unexplained central neurological signs should wounds (GSWs) usually present with a hematoma undergo a brain CT scan. The brain CT is particularly (20.6%), and those who sustained stab wounds with useful in these scenarios for locating ischemic infarc- odynophagia (14.3%) and hemothorax or pneumo- tion secondary to a carotid injury or a direct injury from thorax (13.5%).2 shrapnel.5 Also, a chest radiograph should be obtained in zone I injuries because 16% of GSWs to this region Investigations are associated with a hemothorax or pneumothorax.2 It can be difficult to detect some foreign bodies, While plain chest and neck films, ultrasound, color even when there is high suspicion of their presence. flow Doppler, angiography, and esophageal studies This difficulty can be of significant consequence in can all play a role in penetrating neck injury, computed the vicinity of critical structures such as major ves- tomography (CT) has become perhaps the most useful sels, airway passages, gastrointestinal organs, and tool in evaluating GSWs and foreign bodies. neurological structures. Foreign body localization is dependent on the composition of the object. Various Computed Tomography factors can make a foreign object more or less detect- able, such as the density of the object, the number of In Afghanistan, CT was used as a study of first Hounsfield units it displays on CT, the proportion of choice in all stable patients who sustained GSWs and the object that is air versus water, its ferromagnetic other foreign body wounds to the head and neck. When makeup, and its size. Some foreign objects, such as performing the CT, entry and exit wounds should metal, bone, and windshield glass, can be readily be marked, and fine-cut (3 mm) CT slices should be detectable on radiograph. However, other types of performed between the two points. If there is no exit glass and most plastics (including those used in most wound, then the slices should be performed between IEDs) may not be detectable on radiograph, CT, or the entry wound and the remaining fragment. Trajec- MRI. Some foreign bodies can be hidden by bleed- tory can prove vital in determining the need for further ing and inflammation regardless of their composi- studies or surgical intervention.
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