How should I evaluate and manage a patient with a suspected neck injury?

Evaluation and Management of Suspected Neck Injury

CT angiography (CTA) of the neck is the first-line imaging modality for evaluating patients with suspected neck injury who do not require immediate surgical intervention. 1

Initial Assessment

Clinical Evaluation

1. Assess for "hard signs" of vascular or aerodigestive injury:

   • Active hemorrhage
   • Pulsatile or expanding hematoma
   • Bruit or thrill in wound region
   • Hemodynamic instability
   • Unilateral upper-extremity pulse deficit
   • Massive hemoptysis or hematemesis
   • Air bubbling in the wound
   • Airway compromise
   • Cerebral ischemia symptoms

2. Assess for "soft signs" of injury:

   • Nonpulsatile/nonexpanding hematoma
   • Venous oozing
   • Dysphagia
   • Dysphonia
   • Subcutaneous emphysema

Management Algorithm

For patients with hard signs:

• If hemodynamically unstable or with airway compromise: Immediate surgical exploration without preoperative imaging 1
• If hemodynamically stable with intact airway: CTA of the neck (74% of these patients may avoid surgical exploration) 1

For patients with soft signs:

• CTA of the neck as first-line imaging evaluation 1

Imaging Protocol

Primary Imaging

• CTA of the neck: High sensitivity (90-100%) and specificity (98.6-100%) for vascular injuries 1
  • Simultaneously identifies extravascular soft-tissue and aerodigestive injuries with sensitivity of 100% and specificity of 93.5-97.5% 1
  • Consider CT esophagography in conjunction with CTA if aerodigestive injury is suspected 1

Secondary Imaging (if CTA is normal/equivocal but clinical suspicion remains)

• For suspected vascular injury: Catheter angiography 1
• For suspected aerodigestive injury: Barium swallow with water-soluble contrast 1
• For suspected spinal injury: MRI of the neck 1

Special Considerations

Penetrating Neck Injuries

• Traditionally classified by anatomic zones:
  • Zone I: Clavicles/sternal notch to cricoid cartilage
  • Zone II: Cricoid cartilage to mandibular angle
  • Zone III: Mandibular angle to skull base
• Current literature supports a "no-zone" approach with imaging-based evaluation 1
• Vascular injury occurs in up to 25% of penetrating neck injuries 1

Contrast Considerations

• If risk of allergic reaction to iodinated contrast is high:
  • Consider premedication per ACR recommendations
  • If contrast cannot be given, unenhanced CT may be performed with understanding that vasculature will be underevaluated 1

Suspected Malignancy

• For patients with neck mass at increased risk for malignancy:
  • CT or MRI with contrast is strongly recommended 1
  • Fine-needle aspiration instead of open biopsy 1

Pitfalls and Caveats

1. Don't miss associated injuries: Fractures at one level of the spine are associated with injury at other noncontiguous levels in approximately 20% of trauma patients 1

2. Avoid premature antibiotic therapy: Do not routinely prescribe antibiotics for patients with a neck mass unless there are signs of bacterial infection 1

3. Beware of elderly patients: The sensitivity of clinical criteria (like NEXUS) for detecting cervical spine injury declines significantly in patients ≥65 years of age 1

4. Don't assume cystic masses are benign: Continue evaluation of cystic neck masses in patients at increased risk for malignancy until a diagnosis is obtained 1

5. Consider mortality factors: In open neck injuries, mortality is associated with initial systolic blood pressure and Glasgow Coma Scale 2

By following this evidence-based approach to neck injury evaluation, you can ensure appropriate diagnosis and management while minimizing unnecessary procedures and optimizing patient outcomes.