18-yrs-old male who sustained a right-sided cervical

Discussion in 'MRCS Forum' started by Lona., Dec 17, 2007.

  1. Lona.

    Lona. Guest

    You evaluate an 18-yrs-old male who sustained a right-sided cervical laceration during a gang fight. Your intern suggests nonoperative management and observation. Which of the following is a relative rather than an absolute indication for neck exploration?
    a- Expanding hematoma
    b- Dysphagia
    c- Dysphonia
    d- Pneumothorax
    e- Hemoptysis
  2. Lona.

    Lona. Guest

    Answer: d. (Schwartz, 7/e, pp 163-166) Reports of a more than 50% incidence of negative explorations of the neck. Iatrogenic complications, and serious injuries overlooked at operation have caused a reassessment of the dictum that all penetrating neck wounds that violate the platysma must be explored. Stable patients with zone III (between the angle of the mandible and the skull) or zone I (inferior to the cricoid cartilage) injuries, or multiple neck wounds, should undergo initial angiography irrespective of the ultimate treatment plan. Algorithms exist for nonoperative management of asymptomatic patients that employ observation alone or combinations of vascular and aerodigestive contrast studies and Endoscopy. Nevertheless, recognition of acute signs of airway distress (stridor, hoarseness, dysphonia), visceral injury (subcutaneous air, hemoptysis, dysphagia), hemorrhage (expanding hematoma, unchecked external bleeding), or neurologic symptoms referable to carotid injury (stroke or altered mental status) or lower cranial nerve or branchial plexus injury requires formal neck exploration. Pneumothorax would mandate a chest tube; the necessity for exploration would depend on clinical judgment and institutional policy.

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