- Zone 1 = Thoracic Outlet - from sternal notch to level of cricoid cartilage
- Zone 2 = from cricoid cartilage to angle of the mandible - this is the part of the next where an injury to the Carotid artery can be controlled through a standard neck incision.
- Zone 3 = from angle of mandible to base of skull
In 1986 Meyer and Barrett showed that selective management of these wounds was safe. This consists of:
Immediate OR for active bleeding, expanding hematoma or clear evidence of aerodigestive injury.
If the patient is stable without an immediate indication for OR, they may undergo workup of the structures of the neck.
The structures of concern are:
- Vascular - Carotid arteries (common, internal, & external). Subclavians & aortic arch for zone 1 as well. These are worked up with angiography - good quality, well timed CT angio is probably equivalent.
- Esophagus - in zone 1 & 2 - Patient should have both EGD and Barium swallow - each has 80% sensitivity by itself, when combined, the sensitivity is 98%
- Trachea & Larynx - in zone 1 & 2 - Small injuries are usually asymptomatic and do not require treatment, therefore we do not work them up. If a patient is symptomatic (vocal changes, large amount of SQ air), bronchoscopy is performed
- Oropharynx & Hypopharynx - in zone 3 - thorough intraoral exam is performed.
If the work-up is negative, the patient may safely be discharged.
Recently, Jones demonstrated that plain CT is useful in further targeting the workup.
Note that the above work-up applies only to the anterior neck.
In the posterior neck, the structures of concern are:
- Vascular - vertebral arteries - angiography is performed - it can be therapeutic as well as diagnostic
- Bony - cervical spine - imaged with C-spine CT or plain films
- Neurologic - spinal cord - imaged with CT and possibly MRI
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