What is the recommended surgical approach for a Zone 2 neck stab wound with signs of airway injury, including bubbling from the wound and surgical emphysema?

Surgical Approach for Zone 2 Neck Stab Wound with Airway Injury

For a Zone 2 neck stab wound with bubbling from the wound and surgical emphysema indicating tracheal injury, perform an incision along the anterior border of the sternocleidomastoid muscle (Option B). 1

Immediate Management Priorities

This patient presents with "hard signs" of aerodigestive tract injury requiring immediate surgical exploration without imaging:

• Air bubbling through the wound is an absolute indication for immediate neck exploration 2, 3
• Surgical emphysema (subcutaneous emphysema) indicates significant tracheal or laryngeal injury with air dissecting into soft tissues 1, 2
• These findings mandate direct surgical intervention to prevent airway compromise and mortality 2, 4

Correct Surgical Approach

The standard approach for cervical esophageal and tracheal injuries is through a left neck incision along the anterior border of the sternocleidomastoid muscle 1. This provides:

• Excellent exposure of the cervical esophagus and trachea 1
• Direct access to Zone 2 structures including the carotid sheath 1
• Ability to perform circumferential mobilization for repair 1

A collar incision may be used if bilateral cervical exploration is required, but the anterolateral approach along the sternocleidomastoid is the primary recommendation 1

Why Other Options Are Incorrect

• Extending the wound after probing (Option A): Probing neck wounds is contraindicated as it can disrupt clot formation, cause further bleeding, and does not provide adequate exposure for definitive repair 2, 5

• Pfannenstiel incision (Option C): This is a suprapubic transverse incision used for pelvic surgery and has no role in neck trauma 1

• Midline sternotomy (Option D): Reserved for injuries to the heart, great vessels, and hilar structures, not for Zone 2 neck injuries 1. While it can be extended to the neck via a "roof window," it is not the primary approach for Zone 2 tracheal injuries 1

• Horizontal incision (Option E): Not a standard approach for penetrating neck trauma requiring exploration of deep structures 1

Critical Surgical Steps

Once the anterolateral incision is made:

1. Achieve circumferential esophageal/tracheal mobilization to facilitate repair 1
2. Debride the perforation site to healthy tissue 1
3. Perform tension-free closure using single- or double-layer technique 1
4. Buttress the repair with vascularized tissue such as sternocleidomastoid muscle 1
5. Provide adequate drainage of the surgical field 1
6. Consider tracheotomy if there is concern for ongoing airway compromise, as 83% of surgically explored patients with aerodigestive injury require tracheotomy 6

Airway Management Considerations

Avoid positive pressure bag-mask ventilation and blind tube passage in patients with open airway injuries, as this can worsen subcutaneous emphysema and create false passages 5. If intubation is required before surgical exploration, consider awake techniques or videolaryngoscopy with direct visualization 5.

Common Pitfalls

• Delaying surgical exploration for imaging: Patients with hard signs (air bubbling, massive emphysema) should proceed directly to the operating room without CT imaging, as delays significantly increase mortality 2, 7
• Inadequate exposure: The anterolateral approach provides superior exposure compared to simply extending the stab wound 1
• Missing associated injuries: 37% of patients with aerodigestive tract injuries have associated mandible fractures requiring evaluation 6