Neck crepitance: evaluation and management of suspected upper aerodigestive tract injury.

OBJECTIVE: To determine safe criteria for the management of patients with crepitance of the neck.

HYPOTHESIS: Upper aerodigestive tract injury may lead to significant morbidity and mortality. Historically, this kind of injury has been managed by immediate surgical exploration, repair, and drainage. More recently, a nonoperative approach has been advocated.

STUDY DESIGN: Retrospective chart review of patients admitted to the University of Louisville Trauma Center with suspected upper aerodigestive tract injury.

METHODS: We reviewed the charts of 236 patients admitted to the trauma service from 1995 to 1999 with the diagnosis of aerodigestive tract injury or subcutaneous emphysema.

RESULTS: Nineteen patients were identified with cervical emphysema or cervical crepitance, or both, thought to be caused by an upper aerodigestive tract injury. The average patient age was 38.5 years; 68% of patients were men. The mechanisms of injury were motor vehicle accident (43%), gunshot wound (37%), assault (10%), blunt neck trauma (5%), and stabbing (5%). Each patient presented with cervical emphysema shown by radiograph or crepitance, or both; 21% had dysphagia and 63% were hoarse or had stridor. Location of the injury was tracheal or laryngeal in 37%, hypopharyngeal in 27%, oral pharynx in 16%, esophageal in 5%, and unidentified in 15% of patients. Because of suspected aerodigestive tract injury, 79% of patients were taken to the operating room for direct laryngoscopy and esophagoscopy, and abnormalities were found in 80%. The diameter of the average laceration of the upper aerodigestive tract was 1.6 cm. Associated injuries included mandible fractures in 37% of patients. Broad-spectrum antibiotics were given to 95% of the patients. The initial management involved immediate surgical exploration in 55% of the total number of patients, with 83% of the surgically explored patients undergoing tracheotomy. The remaining 45% of patients were managed without surgery. Complications occurred only in operative patients, with aspiration occurring in 10%, bilateral hypoglossal nerve paralysis in 5%, and vocal cord paralysis in 5%. None of the patients developed postinjury or operative abscess.

CONCLUSION: The findings show that suspected upper aerodigestive tract injury can be managed without surgery but that a high index of suspicion for airway compromise and associated facial injuries must be considered.