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Larynx, Hypopharynx and Mandible Injury Due to External Penetrating Neck Injury

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Larynx, Hypopharynx and Mandible Injury Due to External Penetrating Neck Injury Turkish Journal of Trauma & Emergency Surgery Ulus Travma Acil Cerrahi Derg 2013;19 (3):271-273 Case Report Olgu Sunumu doi: 10.5505/tjtes.2013.58259 Larynx, hypopharynx and mandible injury due to external penetrating neck injury Eksternal penetran boyun yaralanmasına bağlı gelişen larinks, hipofarinks ve mandibula yaralanması Gül ÖZBİLEN ACAR, Muhammet TEKİN, Osman H. ÇAM, Emre KAYTANCI Esophageal and laryngeal injuries due to ballistic injuries are Blastik travmalara bağlı özöfageal ve laringeal yaralanma- seldom encountered. Ballistic external neck traumas gener- lar nadir görülürler. Blastik travmalara bağlı gelişen dış ally result in death. Incidence of external penetrant neck boyun travmaları genellikle ölümle sonuçlanır. Penetran injuries may vary between 1/5000-137000 patients among dış boyun travmalarının acil servise başvuran hastalar ara- emergency service referrals. Vascular injuries, esophagus- sındaki insidansı 1/5000-137000 arasında değişmektedir. hypopharynx perforations, laryngotracheal injuries, bony Dış boyun travmalarında vasküler yaralanmalar, özofa- fractures, and segmentations may be encountered in exter- gus-hipofarenks perforasyonları, laringotrakeal yaralan- nal neck traumas. Here we report a 27-year-old male pa- malar, kemik yapılarda kırık ve parçalanmalar görülebilir. tient who was referred to our emergency department and Bu yazıda, eksternal blastik boyun travmasına bağlı ola- presented with hyoid bone fracture, multiple mandibular rak acil servise başvuran hiyoid kırığı, multipl mandibula fractures, and hypopharynx perforation due to a ballistic kırığı ve hipofarenks perforasyonu saptanan 27 yaşındaki external neck injury. erkek hasta sunuldu. Key Words: Ballistic injury; external neck trauma; hypopharynx Anahtar Sözcükler: Blastik travma; eksternal boyun travması; hi- perforation; hyoid fracture; mandible fracture. pofarenks perforasyonu; hiyoid kırığı; mandibula kırığı. Pharyngoesophageal perforations due to blunt ment with ballistic neck trauma resulting in hyoid, head and neck traumas are well described in the litera- hypopharynx, and mandibular injuries without major ture while laryngotracheal and pharyngoesophageal vascular injury. injuries due to ballistic traumas remain unclear due to the rarity of these cases. Traumas to the head and neck CASE REPORT regions have vital importance because of major vas- A 27-year-old male was referred to our emergency cular structures.[1] Deaths due to traumas of the head department because of ballistic neck trauma in July and neck regions are generally related with vascular 2009. In the first examination of the patient, soft tis- injuries. Neck injuries are classified in three zones.[2] sue injury in the right cheek and mouth floor was ob- served. Edema and hematoma in the uvula and soft In management of traumatic head and neck inju- palate were also present. In palpation, edema in the ries, it is still controversial to make immediate surgical left and right side of the mandible, malocclusion of exploration or to make serial physical examinations[3] the jaw, and stepping sign of the bony structure were (including angiography, with endoscopic examina- discovered. tions and selective surgical exploration). The patient had difficulty swallowing and had In this paper we report the approach and manage- blood mixed with saliva inside the mouth due to the ment of a patient admitted to the emergency depart- fracture of the mandible. There were a total of three Department of ENT, Istanbul Medeniyet University, Goztepe Training and İstanbul Medeniyet Üniversitesi, Göztepe Eğitim ve Araştırma Hastanesi, Research Hospital, Istanbul, Turkey. KBB Kliniği, İstanbul. Correspondence (İletişim): Osman H. Çam, M.D. Fahrettin Kerim Gökay Cad., Göztepe Eğitim ve Araştırma Hastanesi KBB Kliniği, İstanbul, Turkey. Tel: +90 - 216 - 566 40 00 / 9075 e-mail (e-posta): [email protected] 271 Ulus Travma Acil Cerrahi Derg bullet entry points: one in the left side of the neck on was excised. The left side of the esophageal injury was mandibular corpus, near the midline about 1 cm with repaired. There was also damage on the right side of irregular edges; a second about 1 cm in the left infe- the esophagus at the same level of the hypopharynx. rior lobule of auricle with irregular edges; and a third Esophageal injury was repaired on the right side. The in the left side about 2 cm inferior mandibular corpus muscles and subcutaneous tissues on right and left with irregular edges. In the left neck, air bubbles drew sides were transposed and sutured to the hypopharynx attention from one of the defects which was approxi- defect and reconstruction was performed. mately 2 cm inferior from mandibular corpus. There was a 1 cm laceration in the soft palate on In the neck on the right side of the mandibular the left side. There was a defect approximately 1.5 to corpus, there were two 1 cm length bullet exits: the 2 cm in size in the mouth floor on the right side. All first in the midline and the second more anteriorly. lacerations in the mouth were sutured. Two hemovac Due to the entrance of the bullet in the left shoulder, drains were inserted into the surgical field and trache- there were two wounds about 1 cm in diameter with otomy was performed between second and third tra- irregular edges, surrounded by ecchymosis, and one cheal rings. Neck was closed with subcutaneous and irregular wound on the right deltoideopectoral side 1 skin sutures. cm in diameter with ecchymosis around. All wounds had minimal hemorrhages. Oropharynx was examined with the help of mouth gag opener. On the right side at the level of second and The patient had mild respiratory distress, and had third molar teeth, there was a mandibular defect with a moderate subcutaneous emphysema. However, due 1.5 to 2 cm laceration of the buccal mucosa adjacent. to lack of cyanosis, major airway pathology was not One bullet stuck in the lacerations among the soft tis- thought. after airway application with intravenous ac- sues was removed. Other entry and exit holes in the cess, standard cranial and neck computed tomography neck were sutured, primarily after desepithelization. (CT) and a 3D cranium CT imaging were performed. Upper and lower jaws were stabilized and fixated with In the neck CT, hyoid bone corpus fracture was ob- the help of arch bars by the plastic surgeon. served using an aerial image between soft tissue at the A nasogastric tube was applied. The patient was level of tongue base and neck. Additionally, foreign transferred to the Intensive Care Unit with tracheoto- body artifact was seen inside the mouth. Multiple frac- my. On postoperative seventh day, the patient under- ture lines including the right and left side of the man- went a control Doppler ultrasonography. The vascular dibular corpus were seen. Doppler ultrasonography flow rates were within the normal limits. After 10 days of bilateral carotid arteries and flow rates were within postoperatively, all the sutures were removed and the normal limits. The patient’s carotid sheath remained patient was decannulated and fed orally. The patient intact, so angiography was not performed. was discharged to be followed by plastic surgery out- The patient was operated on by a team consisting patient clinic. of ear, nose, and throat (ENT), general, plastic, and cardiovascular surgeons. The patient was intubated na- DISCUSSION sotracheally under general anesthesia. Flexible endos- As always, the first step in penetrating neck trauma copy was performed by general surgeons. Esophagus patients is to ensure the safety of the airway. After was evaluated as normal. Then, direct laryngoscopy making sure that there is no interruption or obstruction was performed by the ENT team. Edema and hyper- in the airway, vascular injury and hemodynamics must emia were seen in the vocal cords and the band ven- be checked. Three quarters of patients with laryngo- tricles. Suspicious mucosal tears were observed in the tracheal injury need airway intervention.[4] Intubation mucosa of the left hypopharynx. Then, the neck was or emergent cricothyroidotomy must be performed in explored. Apron flap was elevated. The carotid sheath cases of airway interruption. In our patient, the exis- was investigated by vascular surgery consultant on the tence of mild respiratory distress and subcutaneous left side of the neck for possibility of a major vessel emphysema as well as possible laryngotracheal or hy- dissection. The carotid artery and the internal jugular popharyngeal injury was considered. vein were both intact. Vascular injury is one of the most important mark- On the left side of the neck approximately 2 cm ers in determining mortality and morbidity. Although inferior to mandibular corpus, the tract caused by a there was no evidence of vascular injury in carotid skin defect was followed and was seen entering the Doppler ultrasonography of our patient, carotid sheath hypopharynx. The left half portion of the hyoid bone was explored and followed during the vascular trace corpus was fractured and the left side of the esophagus for exclusion of the blast effect of the bullet resulting a was perforated by a bullet. The right side of the hy- possible aneurysm, pseudoaneurysm, or dissection. In oid bone was intact. The damaged portion of the hyoid ballistic, injuries occult bullet embolism, either arte- 272 Mayıs - May 2013 Larynx, hypopharynx and mandible injury due to external penetrating neck injury rial or venous, is also well described in the literature. In conclusion, ballistic neck traumas are crisis [5] Dyspnea, hemoptysis, and chest pain are the major management cases and multidisciplinary evaluation symptoms of venous bullet embolism while claudica- is needed during approach. Selective neck exploration tion, peripheral ischemia, and thrombophlebitis are the is still controversial. We need more studies with huge symptoms of arterial embolism. Our patient had only patient follow up to clarify this discussion. mild dyspnea, so bullet embolism was not mainly con- Conflict-of-interest issues regarding the authorship sidered. or article: None declared. Indications that immediate exploration for any REFERENCES penetrating neck injuries, regardless of zone, is neces- 1. Preston T, Fedok FG.
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