Learning objectivesBy reading this article you should be able to:Recall the key features that may indicate impending airway obstruction in a patient with acute neck trauma. Explain the principles of managing a patient with a threatened airway resulting from neck trauma. Distinguish the key features of the Advanced Trauma Life Support (ATLS) primary survey that are pertinent to patients with acute neck trauma. Outline the next steps in management of acute neck trauma after completing the primary survey and securing the airway.As a narrow conduit for the major blood vessels, aerodigestive tract, and neurological structures passing between the head and the torso, the neck is an especially hazardous area for traumatic injuries. Injuries in this area can be complex to manage, and airway management maybe particularly perilous.Common causes of neck trauma include road traffic collisions (RTCs), sporting injuries, and interpersonal violence. Sadly, interpersonal violence is a global problem. Whilst reported rates are highest in South Africa, Central and South America, the incidence of interpersonal violence rates is increasing in Europe. 1,2 In the year ending March 2019, there were approximately 47,000 offences involving a knife or sharp object in England and Wales; the highest number since comparable data have been recorded (March 2011). 3 It is becoming increasingly likely that anaesthetists, as part of James Shilston FRCA FFICM is a dual trainee in anaesthesia and intensive care medicine in the East Midlands, UK.David L Evans FRCA is an RAF consultant anaesthetist at Nottingham University Hospitals NHS Trust, which is a regional major trauma centre covering a population of around 4 million people. He also provides military medical support to multiple theatres of conflict including Afghanistan. Anthony Simons FRCS-ORL HNS is a consultant head and neck surgeon based at Nottingham University Hospitals NHS Trust who has an interest in airway and head and neck oncologyDavid A Evans FRCA is a consultant anaesthetist at Nottingham University Hospitals NHS Trust with interests in major trauma and head and neck anaesthesia Key pointsThe management of blunt and penetrating neck trauma can be complex and frequently requires close collaboration between anaesthesia and surgical teams. Adherence to Advanced Trauma Life Support (ATLS) principles is fundamental, with an emphasis on early assessment of the airway.The key principles of airway management are to identify any airway injuries and where possible ensure that the tip of the tracheal tube is positioned distal to the site of the injury without causing further airway trauma. If airway injury is suspected, the best ways to secure the airway in a cooperative patient are by awake fibreoptic intubation or awake surgical tracheostomy under local anaesthesia. Severe injuries require immediate surgical exploration. In less emergent situations CT scanning plays a valuable role in planning appropriate further management.
Objective Intrathoracic goiters are a heterogeneous group characterized by limited or extensive substernal extension. Whereas the former can be treated through cervicotomy, the latter sometimes requires a cervicosternotomy. Whether cervicosternotomy leads to more morbidity remains unclear. This study aimed to compare intra- and postoperative morbidity in patients treated by cervicotomy or cervicosternotomy for intrathoracic goiters and standard thyroidectomy. Methods In a prospectively gathered cohort undergoing thyroid surgery (2010–2019) intra- and postoperative morbidity of cervicotomy (N = 80) and cervicosternotomy (N = 15) for intrathoracic goiters was compared to each other and to a ‘standard’ thyroidectomy (N = 1500). Results An intrathoracic extension prior to surgery was found in 95 (6%) of all thyroidectomies. Eighty patients (84%) were operated by cervicotomy and 15 (16%) by cervicosternotomy. The risk of temporary recurrent laryngeal nerve palsy was much higher in the cervicosternotomy group (21%) compared to cervicotomy (4%) and standard thyroidectomy (3%). The risk of temporary hypocalcemia after cervicotomy (28%) was comparable to a standard thyroidectomy (32%) but higher after cervicosternotomy (20%). No cases of permanent hypocalcemia or laryngeal nerve palsy were observed in both groups with substernal extension. The need for surgical reintervention was significantly higher in the cervicotomy group (6%) compared to cervicosternotomy (0%) and standard thyroidectomy (3%). Conclusion In patients undergoing thyroid surgery for an intrathoracic goiter, cervicosternotomy was associated with more temporary laryngeal nerve palsy, but none of the interventions resulted in higher risks of permanent nerve damage, permanent hypocalcemia, or reintervention for bleeding. Reintervention was even more common after cervicotomy compared to cervicosternotomy. Level of evidence IV
We present the first case of upper airway obstruction secondary to a retropharyngeal Gardner-associated fibroma (GAF). A 16-month-old infant presented with a 3-month history of worsening dyspnoea and apnoeic episodes. Examination revealed stridor and left-sided retropharyngeal asymmetry. MRI demonstrated a mass in the retropharynx. Tracheostomy and pharyngeal biopsy under anaesthesia were performed, and histology confirmed a diagnosis of GAF. The mass was excised using a transcervical approach, and postoperative recovery was unremarkable. GAF is associated with Gardner’s syndrome (GS) and familial adenomatous polyposis (FAP), both of which are associated with multiple colonic polyps and increased risk of colorectal malignancy. Subsequent testing for an APC mutation seen in GS and FAP was negative in our patient. The details of this unusual presentation of a rare disease are given in addition to a review of the literature.
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