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Penetrating Neck Injury (PNI) pose a challenging decision making in term of either to treat conservatively or operatively.
A 66 years old man presented to us after being assaulted with a utility knife. He sustained laceration wounds which violates the platysma muscle over his right neck Zone 1 and right submandibular Zone 2. Airway assessment shows evidence of soft signs of vascular and laryngotracheal injury which are hoarseness of voice, subcutaneous emphysema contralateral side to the stab wound of his neck with nonexpanding and nonpulsatile hematoma over the ipsilateral side. Other primary survey does not show any other life threatening injury. Soft tissue Neck Xray shows the presence of subcutenous emphysema over the left side of neck and prevertebral air. ORL and Anasthesiology team was consulted. Trial of bedsite flexible scope for airway assessment was suboptimal as patient was uncooperative. Decision was made to proceed with CTA neck and shows extensive subcutaneous emphysema involving the neck extending to deep neck spaces with pneumomediastinum, right submandibular subcutaneous hematoma without the evidence of vascular injury and preserved trachea and esophageal structure. 5 hour after the injury, patient start to develop dysphonia and hemoptysis which are the hard signs of laryngotracheal injury. Patient was given IV Dexamethasone 8mg and was then brought to Operating Room for elective intubation with neck exploration, direct laryngoscope and esophagoscopy. Intraoperative finding shows there was hematoma at the right vallecular extending to lateral pharyngeal wall and right pyriform sinus which was the possible exit wound from the stab injury. The supraglottic structure was edematous with slit like opening. Airway was secured with video laryngoscopy assisted endotracheal intubation in single attempt. Patient was extubated after day 3 post trauma.
Discussion & Conclusion
PNI victim may initially present with soft signs of vascular or aerodigestive injury. It is crucial to monitor the progression of the injury and identify the hard signs as shown in this case. A delay in decision may results in a failed airway and subsequent life threatening condition. Early referral to the primary team and Anasthesiology team to derive with collective decision is also fundamental in this case.
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