Chapter 8 Operative Exposure in Neck Trauma: Exposure of the Trachea and Esophagus in the Neck

This chapter will discuss exposure of actual or suspected injuries to the trachea and esophagus in the neck. Though the major emphasis of this lab experience is operative exposure, general review of the principles of diagnosis and management will also be presented.

Learning Objectives

By the end of the ASSET course, participants should be able to do the following:

1. Describe signs and symptoms of tracheal and esophageal injuries.
2. Describe diagnostic modalities to identify injuries to these structures.
3. Describe and demonstrate recommended position and prep for surgical exploration.
4. Demonstrate the incision options to expose the trachea and esophagus.
5. Demonstrate steps in surgical exposure of the trachea and esophagus in the neck.

Considerations

• Injuries to the trachea can occur from either blunt or penetrating mechanisms. Penetrating injuries to the neck are more common and require operative intervention.
• Hematomas can cause extrinsic compression of the airway.
• The most common cause of esophageal injury is iatrogenic (e.g., from endoscopy); otherwise, penetrating mechanisms are much more common than blunt.
• Physical signs suggesting tracheal and laryngeal injury include stridor, hoarseness, hemoptysis, and subcutaneous emphysema.
• Physical signs suggesting esophageal injury include dysphagia, odynophagia, blood in the oropharynx, and subcutaneous emphysema.
• Finding air in the mediastinum or deep neck on CT or plain film is also suggestive of injury to the trachea or esophagus.
• Initial priority is control of the airway and further diagnostic evaluation by bronchoscopy, endoscopy, or CT imaging, based on stability and suspected injury.
• Broad-spectrum antibiotics should be initiated early.
• Position and preparation are the same as for vascular exposure (see chapter 7).

Surgical Exposure

Tracheal Injuries (Cervical)

• Cervical tracheal (upper third) injuries are best exposed through a collar incision made 1–2 cm above the sternal notch and extended laterally beyond the medial border of the sternocleidomastoid muscles. If the injury extends into or involves the thoracic trachea, the incision can be extended into the chest via a sternotomy (Figure 1).
• The platysma is divided in the same orientation to expose the strap muscles, taking care to avoid or control the anterior jugular veins.
• The subplatysmal flaps are raised superiorly and inferiorly, and the strap muscles are separated or divided at the midline. This allows for exposure of the anterior portion of the thyroid gland, portions of the cervical trachea, and the bilateral carotids (Figure 2).
• Exposure of the remainder of the trachea requires division of the thyroid isthmus and extension into the chest via a partial or full median sternotomy (Figure 3).
• When exposing the trachea, it is important not to devascularize it circumferentially, as successful repair is dependent on good blood supply.
• The principles of surgical treatment of tracheal injuries are debridement of devitalized tissue (including cartilage), end-to-end anastomosis with absorbable suture, and flexion of the neck to avoid tension on the anastomosis.
• Simple, clean injuries without devascularization can be repaired primarily with simple absorbable sutures.

Esophageal Injuries (Cervical)

• The esophagus is optimally exposed through an incision anterior to the sternocleidomastoid muscle.
• Though the esophagus can be accessed through either side of the neck, an incision on the left is preferable, as the upper esophagus resides predominantly in the left neck.
• The esophagus is formed at the inferior portion of the cone-shaped cricopharyngeal muscles, and encircling the esophagus can only be accomplished below these muscles. As such, the esophagus is generally found lower in the neck than one might expect and is often most easily encircled at the level of the clavicle.
• Dissection of the esophagus is facilitated by passage of either a nasogastic or orogastric tube.
• The carotid sheath should be mobilized laterally and the trachea medially, allowing for visualization of the upper esophagus from the cricopharyngeus to its entry into the posterior mediastinum (Figures 4 and 5).

• Mobilization of the thyroid medially may require division of the middle thyroid vein and inferior thyroid artery. Care should be taken to avoid injury to the recurrent laryngeal nerve, which runs in the tracheoesophageal groove (Figure 6). If the nerve is not readily visible, do not make an effort to visualize it, as this risks unnecessary injury.
• To prevent stretch injury to the recurrent laryngeal nerve, the thyroid retraction should be anterior and medial. Superior retraction of the thyroid gland must be specifically avoided.
• Once the subfascial plane has been entered, dissection with a right angle clamp is undertaken. The tip of the right angle should hug the muscular layer of the esophagus to develop a circumferential plane around it, working first behind and then anterior to this structure.
• The esophageal dissection should be done well below the cricoid cartilage and cricopharyngeal muscles with gentle medial traction of the trachea to avoid injury to the recurrent laryngeal nerve.
• Using a right angle clamp, a Penrose drain is passed around the esophagus. Using the drain, the esophagus is gently retracted laterally and superiorly (Figures 6–9), and a combination of sharp and blunt dissection is used to further dissect the esophagus.
• Care must be taken to avoid injury to the posterior tracheal wall while performing this dissection.
• The entire cervical esophagus can also be approached through a collar incision, as described previously for tracheal injuries.
• Injuries to the esophagus can be primarily repaired.
• If either the trachea or esophagus has required repair, vascularized muscle (strap muscles) should be used to cover the repair. This is especially important with combined injuries to prevent breakdown and fistulation between the two structures.