With the neck protected by the spine posteriorly, the head superiorly, and the chest inferiorly, the anterior (larynx and trachea) and lateral regions are most exposed to trauma.
Few emergencies pose as great a challenge as neck trauma. Because a multitude of organ systems (eg, airway, vascular, neurological, gastrointestinal) are compressed into a compact conduit, a single penetrating wound is capable of considerable harm. Furthermore, seemingly innocuous wounds may not manifest clear signs or symptoms, and potentially lethal injuries could be easily overlooked or discounted.
Neck injury may result in the laceration of major vessels, potentially leading to hemorrhagic shock. Extracranial arterial injuries to the brachiocephalic, common carotid, and vertebral arteries can result in major neurologic deficits.
Airway occlusion and exsanguinating hemorrhage pose the most immediate risks to life. From the time when Ambroise Pare successfully treated a neck injury in 1552, debate has continued about the best approach for particular neck wounds. Awareness of the various presentations of neck injuries and the establishment of a well-conceived multidisciplinary plan prior to the traumatic event is critical for improving patient outcome.
The neck is divided into anatomic zones or regions to assist in the evaluation of neck injuries. The image below illustrates the zones of the neck.
Neck trauma. Zones of the neck.
Signs and symptoms
Signs of laryngeal or tracheal injury
Sucking, hissing, or air frothing or bubbling through the neck wound
Subcutaneous emphysema and/or crepitus
Distortion of the normal anatomic appearance
Pain on palpation or with coughing or swallowing
Pain with tongue movement
Crepitus: Noteworthy in only one third of cases
Signs of esophageal and pharyngeal injury
Sucking neck wound
Bloody nasogastric aspirate
Pain and tenderness in the neck
Resistance of neck with passive motion testing
Bleeding from the mouth or nasogastric tube
Signs of carotid artery injury
Decreased level of consciousness
Dyspnea secondary to compression of the trachea
Signs of jugular vein injury
These include hematoma, external hemorrhage, and hypotension.
Signs of spinal cord or brachial plexus injury
Diminished upper arm capacity
Priapism and loss of the bulbocavernous reflex
Poor rectal tone
Urinary retention, fecal incontinence, and paralytic ileus
Hypoxia and hypoventilation
Signs of cranial nerve injury
Facial nerve (cranial nerve VII): Drooping of the corner of the mouth
Glossopharyngeal nerve (cranial nerve IX): Dysphagia (altered gag reflex)
Vagus nerve (cranial nerve X, recurrent laryngeal): Hoarseness (weak voice)
Spinal accessory nerve (cranial nerve XI): Inability to shrug a shoulder and to laterally rotate the chin to the opposite shoulder
Hypoglossal nerve (cranial nerve XII): Deviation of the tongue with protrusion
See Clinical Presentation for more detail.
In addition to cervical and chest radiography, the following supplementary tests may be useful:
Computed tomography (CT) scanning
Magnetic resonance imaging (MRI)
Color flow Doppler ultrasonography
Contrast studies of the esophagus
Laryngoscopy, bronchoscopy, pharyngoscopy, and esophagoscopy may be useful in the assessment of the aerodigestive tract. Rigid endoscopes are superior to flexible scopes.
See Workup for more detail.
In neck trauma, emergency department care commences with assessment and stabilization of the patient’s airway, breathing, and circulation (ABCs):
Airway: Perform emergent orotracheal intubation in patients displaying signs of acute or impending respiratory distress
Breathing: Ventilatory distress that persists beyond competent intubation indicates a possible tension pneumothorax, which requires needle decompression and chest tube placement
Circulation: Bleeding that originates from neck trauma is controlled with direct pressure; in selected cases, bleeding that cannot be controlled or reached with direct pressure may benefit from balloon tamponade
In rare instances, when applying direct pressure to wounds is impractical, a cricothyroidotomy may be required, with subsequent packing of the pharynx as a temporary strategy.