Management of Penetrating Zone 2 Neck Injuries
The management of penetrating zone 2 neck injuries depends critically on hemodynamic stability and presence of "hard signs"—patients with hard signs require immediate surgical exploration without imaging, while stable patients with soft signs should undergo CT angiography followed by selective management. 1
Initial Assessment and Risk Stratification
The key to managing zone 2 penetrating neck trauma is distinguishing between patients requiring immediate operative intervention versus those who can safely undergo imaging-guided selective management 1.
Hard Signs Requiring Immediate Surgical Exploration
Proceed directly to the operating room without preoperative imaging if any of the following are present 1:
- Active hemorrhage or pulsatile/expanding hematoma
- Hemodynamic instability
- Airway compromise or air bubbling from the wound
- Hemoptysis (suggests tracheal or major vascular injury)
- Dysphonia (indicates laryngeal or recurrent laryngeal nerve injury)
- Pneumothorax (indicates significant aerodigestive tract injury)
- Bruit or thrill over the wound
- Unilateral upper-extremity pulse deficit
- Massive hematemesis
Delaying surgical exploration in patients with hard signs significantly increases mortality 1. The mortality rate for penetrating neck injuries can reach 10%, making prompt recognition and intervention critical 2.
Soft Signs Allowing Selective Management
Stable patients with the following findings can safely undergo imaging before deciding on surgical intervention 1:
- Dysphagia (may indicate esophageal or pharyngeal injury)
- Nonpulsatile, nonexpanding hematoma
- Subcutaneous emphysema
- Venous oozing
The "No-Zone" Approach
Current evidence supports abandoning the traditional zone-based mandatory exploration approach in favor of a selective, clinical signs-based strategy regardless of injury zone 1, 3. Historically, all zone 2 injuries underwent mandatory exploration 4, but this resulted in 52-53% negative explorations with no significant injuries found 5, 4.
The American College of Radiology now recommends focusing on clinical presentation rather than anatomic zones alone 1. This selective approach has demonstrated superior patient outcomes compared to traditional mandatory exploration 3.
Imaging Algorithm for Stable Patients
First-Line Imaging: CT Angiography
For stable patients with soft signs, CT angiography (CTA) with IV contrast is the imaging study of choice (rated 9/9 - "usually appropriate") 2. CTA has excellent diagnostic performance with:
- Sensitivity: 90-100% for detecting vascular injuries 1, 6
- Specificity: 98.6-100% for vascular injuries 1, 6
Obtain plain X-ray of the neck first (rated 7/9) if there is a gunshot wound or any question about retained foreign bodies, as metallic fragments can interfere with MRI 2.
Follow-Up Imaging Based on CTA Results
If CTA is normal or equivocal but vascular injury remains a concern:
- Conventional arteriography is the next step (rated 8/9) 2
- MRA with and without IV contrast may be appropriate (rated 5/9) 2
- Ultrasound may be appropriate (rated 4/9) 2
If CTA is normal or equivocal but aerodigestive injury is suspected:
- Barium swallow (single contrast) is the preferred study (rated 8/9) 2
- MRI neck with and without IV contrast may be appropriate (rated 5/9) 2
Common Pitfalls and Caveats
Missed Injuries with Selective Management
Isolated venous injuries and pharyngoesophageal injuries are most likely to be missed on clinical examination alone 4. In one series, 23% of patients with injuries had no preoperative clinical suspicion of injury 4. This underscores the importance of liberal use of CTA in stable patients with any concerning mechanism or soft signs.
Arteriography Limitations
Arteriography can yield false-negative results—two arterial injuries were missed by arteriography in one series 4. However, in another study of 110 zone 2 injuries, only one patient had a significant arterial injury requiring surgery that was not predicted by physical findings 7.
Vertebral Artery Injuries
Vertebral artery injuries are particularly prone to delayed diagnosis 5. One patient died 4 months after injury from a missed vertebral artery pseudoaneurysm 5. Six of nine arterial injuries treated nonoperatively in one series were vertebral artery injuries 7, highlighting that not all vascular injuries require surgical repair.
Airway Management Considerations
If airway control is needed, rapid sequence intubation using succinylcholine has a 100% success rate and should be the initial technique 8. In a series of 58 patients requiring emergency airway management for penetrating neck injury, rapid sequence intubation was successful in all 39 cases attempted and even salvaged three failed fiberoptic intubation attempts 8.
Emergency tracheostomy should be reserved for situations where orotracheal intubation is impossible 8.
Outcomes with Selective Management
Selective management based on clinical signs and imaging results in acceptable mortality (6%) and complication rates (1-5%) while avoiding unnecessary exploration in approximately 52% of cases 5. This approach is safe across all neck zones when applied appropriately 5.