SURG 32 30 January 2019

THYROID 3.6 Natakneng 2020

Rommel Rasos, MD Mariano Marcos State University

Outline:
A. Penetration and Blunt Trauma to the Neck
B. Differential Diagnosis of Neck Masses
a. Inflammatory Neck Masses
b. Congenital Neck Masses
c. Primary Neoplasms of the Neck
d. Thyroid Neck Masses
i. Papillary
ii. Follicular
iii. Medullary
iv. Anaplastic

STAB INJURIES
VITAL STRUCTURES  Single-entry vs multiple stab wounds
 Air passages – trachea, larynx, pharynx, lungs  Higher incidence of subclavian vessel laceration due to
 Vascular – carotid, jugular, subclavian, innominate, aortic downward direction
arch  Lower incidence of spinal injuries
 Gastrointestinal - pharynx, esophagus
 Neurologic – spinal cord, brachial plexus, peripheral nerves, IMMEDIATE SURGICAL EXPLORATION
cranial nerves  Massive bleeding
 Expanding hematoma
KINETIC ENERGY
 Nonexpanding hematoma with hemodynamic instability
 Kinetic energy affects magnitude of injury:  Hemomediastinum
o KE = ½ M (V1 – V2)
 Hemothorax
 Hypovolemic shock
HANDGUNS
 Projectile type
MANAGEMENT
 Speed
 “For the stable patient, the choice of management remains
o Handguns/pistols are low velocity (90-600 m/s)
controversial: either mandatory exploration for all penetrating
 Caliber neck wounds or selective exploration with observation [and
o .44-caliber magnum is comparable to a rifle
monitoring]”
 Yaw
o Tumbling bullet causes injury in a wider path NECK ZONES
RIFLE
 Military bullets
o Jacket creates smoother flight, clean hole, through-
and-through wound
o High velocity (760 m/s) transmits energy waves
surrounding tissue
 Hunting rifles with expanding bullets
o Soft-tips expand, create large wound cavity, may
not exit, may fragment
 High mortality

SHOTGUNS  ZONE I
 Velocity ~ 300 m/s o Vascular structures are in close proximity to thorax
 Distance o Protection by bony thorax and clavicle
o Pellets scatter at longer distances o Difficult to explore
 Type of weapon o Median sternotomy for R injuries
o Sawed-off shotgun sprays the shot earlier o Left anterior thoracotomy for L injuries
 Size of projectile (shot) o High mortality rate: 12%
o Birdshots (< 3.5 mm, 12m range) o Management:
o Buckshots (> 3.5 mm, 150m range). Comparable to  Angiography if stable
handgun bullet wounds  Mandatory exploration usually not
 Wadding recommended
 May consider barium swallow
 ZONE III
o Protected by skeletal structures
o Difficult to explore; may need craniotomy for high
carotid injury
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SURG 32: THYROID 3.6
o CN injuries may indicate great vessel injury preoperative arteriography on stable patients because their
o Management surgical approach is more difficult than zone II injuries.
 Angiography if abnormal neurologic  In addition, when wounds involve both sides of the neck with zone
exam in stable patient I and zone III injuries, four-vessel angiography (bilateral carotid
 Frequent intraoral examination for and vertebral arteries) should be considered in stable but
edema/hematoma symptomatic patients.
 ZONE II  Approximately 30% of patients with carotid artery injury present
o Most common region injured (60-75%) with a neurologic deficit. Arterial injury or propagation of a
o Isolated venous and pharyngoesophageal injuries thrombus into the skull can lead to cerebral ischemia. One third of
are most commonly missed the population cannot tolerate complete unilateral carotid
o Management occlusion.
 Admit for observation
 Radiology and endoscopy if stable and MANAGEMENT OF PENETRATING ZONE II INJURY
no signs of major injury

INITIAL MANAGEMENT
 Airway establishment
o Intubation
o Cricothyroidotomy
o Tracheostomy
 Blood perfusion maintenance
o Large-bore IV
 Clarification and classification of wound severity
 Do not probe wound
 Routine AP/lat neck and chest films
 In the emergency department, satisfactory control of the
airway is established by intubation, cricothyroidotomy, or
tracheostomy. Direct transcervical tracheal intubation is safer  Certain indications for an angiogram in zone II injuries
than oral or nasal intubation when the oral cavity, pharynx, or include a stable patient who has persistent hemorrhage or
larynx are traumatized and filled with blood. neurologic deficits compatible with adjacent vascular
 In the setting of a gunshot wound, it may be difficult to fully structure damage. An example of this is a Horner’s syndrome
evaluate the cervical spine until the airway is controlled. indicative of sympathetic nerve plexus injury or hoarseness
 Similarly, a tracheal tear may be exacerbated by extending indicating a recurrent laryngeal nerve injury. This neurologic
the neck, which distracts the proximal and distal segments. picture suggests that the carotid sheath has been violated,
and vascular integrity needs confirmation by angiography, as
MANAGEMENT OF PENETRATING INJURY well as frequent close observation to detect for a lacerated
*this part is lifted from Cumming’s Otolaryngology Head and Neck carotid artery, intimal tear, or pseudoaneurysm.
surgery which was Doc’s source for this part, I think, or so I believe
hehe. 

 In the conscious patient a full neurologic examination should be

done and a chest radiograph taken. The radiograph should be
examined to rule out hemothorax, pneumothorax, or
pneumomediastinum. The latter would suggest a punctured viscus
and demands further evaluation. Subclavian vessel injury may be
first recognized by an abnormal chest radiograph. All patients
should be managed assuming potential cervical spine fractures BLUNT NECK INJURY
until they undergo radiographic evaluation. On radiographs, all  Occult cervical spine injury
cutaneous wounds can be marked with radiopaque objects to aid  Delayed onset of signs and symptoms
in evaluating the site of the injury.  Careful observation
 A positive angiogram may mandate an immediate trip to the  Thrombosis, intimal tears, dissection, pseudoaneurysm
operating room, but evaluation of the upper digestive tract in the
radiology suite may be useful if time and the patient’s condition
permit. Zone I and zone III injuries usually require routine

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