What is a relative indication for neck exploration in a patient with a neck laceration?

Relative vs. Absolute Indications for Neck Exploration in Penetrating Neck Trauma

Dysphagia is a relative indication for neck exploration in a patient with a neck laceration, while expanding hematoma, dysphonia, pneumothorax, and hemoptysis are absolute indications requiring immediate surgical intervention. 1, 2

Absolute Indications for Neck Exploration

Absolute indications (hard signs) requiring immediate surgical exploration without preoperative imaging include:

• Expanding hematoma: Indicates active bleeding that could rapidly compromise the airway or lead to exsanguination 1
• Dysphonia: Suggests laryngeal or recurrent laryngeal nerve injury requiring immediate intervention 2
• Pneumothorax: Indicates significant aerodigestive tract injury with air entering the pleural space 2
• Hemoptysis: Suggests tracheal or major vascular injury with blood entering the airway 2
• Other hard signs include active hemorrhage, pulsatile hematoma, bruit/thrill, hemodynamic instability, unilateral upper-extremity pulse deficit, massive hematemesis, air bubbling in the wound, and airway compromise 3

Relative Indications for Neck Exploration

Relative indications (soft signs) that may warrant further evaluation before deciding on surgical exploration:

• Dysphagia: While concerning for esophageal or pharyngeal injury, this is considered a soft sign that allows time for imaging studies before determining the need for surgery 2
• Other soft signs include nonpulsatile/nonexpanding hematoma, venous oozing, subcutaneous emphysema 3

Management Algorithm

1. Initial assessment: Determine presence of hard vs. soft signs 2

2. For hard signs (absolute indications):

   • Proceed directly to surgical exploration without imaging 1
   • Mortality increases significantly with delays in surgical intervention 1

3. For soft signs only (relative indications):

   • Obtain CT angiography (CTA) as first-line imaging 3
   • Consider additional studies based on specific concerns:
     • For suspected esophageal injury: CT esophagography or barium swallow 3
     • For equivocal CTA with vascular concerns: Conventional arteriography 3

Evidence Quality and Evolution of Management

• Historical approaches advocated mandatory exploration of all penetrating neck injuries, but contemporary evidence supports a more selective approach based on clinical signs 3, 4
• The American College of Radiology now recommends a "no-zone" approach focusing on clinical signs rather than anatomic zones alone 3
• CTA has high sensitivity (90-100%) and specificity (98.6-100%) for detecting vascular injuries, allowing safe selective management 5

Common Pitfalls to Avoid

• Delaying surgical exploration in patients with hard signs (expanding hematoma, dysphonia, pneumothorax, hemoptysis) significantly increases mortality 1
• Relying solely on physical examination without appropriate imaging in stable patients with soft signs only 2
• Failing to recognize that dysphagia, while concerning, allows time for imaging evaluation before deciding on surgical intervention 2
• Underestimating the significance of dysphonia as a hard sign requiring immediate intervention 2