How should a penetrating Zone I neck injury be managed?

Management of Zone I Penetrating Neck Injury

For Zone I penetrating neck injuries, immediately assess for hard signs of vascular or aerodigestive injury—if present, proceed directly to surgical exploration without imaging; if absent and the patient is hemodynamically stable, obtain CT angiography (CTA) as the first-line diagnostic study. 1, 2

Initial Assessment and Triage

The management algorithm depends entirely on clinical presentation, not anatomic zone:

Hard Signs Requiring Immediate Surgical Exploration (No Imaging)

Proceed directly to the operating room if any of the following are present 2:

• Active hemorrhage or pulsatile hematoma
• Expanding hematoma (indicates active bleeding threatening airway or causing exsanguination)
• Hemodynamic instability (hypotension, tachycardia)
• Air bubbling from the wound
• Hemoptysis (suggests tracheal or major vascular injury)
• Massive hematemesis
• Airway compromise, stridor, or respiratory distress
• Dysphonia (laryngeal or recurrent laryngeal nerve injury)
• Bruit/thrill over the wound
• Unilateral upper-extremity pulse deficit
• Pneumothorax (indicates aerodigestive tract injury)

Delaying surgical exploration in patients with hard signs significantly increases mortality 2, 3.

Hemodynamically Stable Patients Without Hard Signs

Obtain CTA of the neck with IV contrast immediately 4, 1, 2. This is the imaging study of choice with 90-100% sensitivity and 98.6-100% specificity for detecting vascular injuries 1, 3.

Zone I-Specific Considerations

Zone I injuries (clavicles/sternal notch to cricoid cartilage) present unique challenges 1:

• Surgical access is most difficult due to bony constraints of the thoracic inlet 1
• Contains critical structures: great vessels (subclavian and carotid arteries, jugular veins), thyroid gland, trachea, esophagus, thoracic duct, and lung apices 1
• Higher risk of occult injuries, particularly hypopharyngeal/esophageal injuries that may be missed on initial imaging 5

Imaging Protocol for Stable Patients

Primary Imaging

CTA neck with IV contrast (rating 9/9 - "usually appropriate") 4:

• Evaluates vascular injuries with exceptional accuracy
• Simultaneously assesses extravascular soft tissue and aerodigestive structures with 100% sensitivity and 93.5-97.5% specificity 3

Adjunctive Studies Based on CTA Findings

If CTA is normal or equivocal but concern for vascular injury persists 4:

• Conventional arteriography (rating 8/9) for definitive evaluation and potential endovascular intervention 4

If concern for aerodigestive injury exists 4, 2:

• Barium swallow/esophagram (rating 8/9) for esophageal evaluation 4
• CT esophagography in conjunction with CTA (sensitivity 95-100%) 3
• Consider bronchoscopy and esophagoscopy if imaging equivocal

Plain X-ray neck (rating 7/9) 4:

• Useful for screening, particularly in gunshot wounds to identify retained fragments or trajectory
• Mandatory prior to MRI if metallic foreign bodies suspected

Surgical Management

Operative Approach for Zone I

When exploration is indicated 1, 3:

• Requires early subspecialty involvement: vascular surgery, thoracic surgery, otolaryngology, and potentially neurosurgery 3
• May require median sternotomy or thoracotomy for proximal vascular control of great vessels
• Systematic examination of thyroid gland, trachea, esophagus, and all vascular structures 2

Intraoperative Priorities

• Achieve proximal and distal vascular control before exploring hematomas
• Inspect the entire trajectory path
• Be vigilant for occult hypopharyngeal/esophageal injuries, as these are easily missed in Zone I 5

Resuscitation Principles

For patients in hemorrhagic shock 2, 3:

• Immediate transfer to operating room for surgical bleeding control
• Initiate massive transfusion protocol
• Target systolic BP 80-100 mmHg until bleeding controlled (permissive hypotension)
• Exception: Maintain systolic BP >110 mmHg if suspected spinal cord injury 3
• Maintain cervical spine precautions throughout

Postoperative Monitoring

Serial examinations are critical 2:

• Monitor for subcutaneous emphysema (suggests aerodigestive leak)
• Assess for dysphagia, dysphonia, respiratory distress
• Watch for delayed complications: anastomotic leak, abscess formation, recurrent laryngeal nerve injury
• Consider follow-up CT with contrast if clinical deterioration or new symptoms develop 2

Critical Pitfalls to Avoid

• Do not delay surgical exploration for imaging in unstable patients or those with hard signs 2, 3
• Do not rely solely on CTA for Zone I injuries—maintain high suspicion for occult esophageal injuries that may be missed on initial imaging 5
• Do not use zone-based algorithms—the "no-zone" approach focusing on clinical signs rather than anatomic location is now standard 1, 2, 6, 7
• Do not perform mandatory exploration of all Zone I injuries—selective management based on clinical signs and CTA is safe and reduces nontherapeutic explorations 6, 7, 8