The Management of Penetrating Neck Injury With Retained Knife: 15-Year Experience From a Major Trauma Center in South Africa

Background This study reviews our cumulative experience with the management of patients presenting with a retained knife following a penetrating neck injury (PNI). Methods A retrospective cohort study was conducted at a major trauma center in South Africa over a 15-year period from July 2006 to December 2020. All patients who presented with a retained knife in the neck following a stab wound (SW) were included. Results Twenty-two cases were included: 20 males (91%), mean age: 29 years. 77% (17/22) were retained knives and 23% (5/22) were retained blades. Eighteen (82%) were in the anterior neck, and the remaining 4 cases were in the posterior neck. Plain radiography was performed in 95% (21/22) of cases, and computed tomography (CT) was performed in 91% (20/22). Ninety-five percent (21/22) had the knife or blade extracted in the operating room (OR). Formal neck exploration (FNE) was undertaken in 45% (10/22) of cases, and the remaining 55% (12/22) underwent simple extraction (SE) only. Formal neck exploration was more commonly performed for anterior neck retained knives than the posterior neck, although not statistically significant [56% (10/18) vs 0% (0/18), P = .096]. There were no significant differences in the need for intensive care admission, length of hospital stay, morbidities, or mortalities between anterior and posterior neck retained knives. Discussion Uncontrolled extraction of a retained knife in the neck outside of the operating room may be dangerous. Retained knives in the anterior neck commonly required formal neck exploration but not for posterior neck retained knives.

Bedside Neck Exploration for Venous Flow Coupler Signal Loss in Postoperative Free Tissue Transfer Monitoring

Objective To describe the role and efficacy of bedside neck exploration following free tissue transfer. Study Design Retrospective case series. Setting Single tertiary care institution. Methods A retrospective chart review was conducted of 353 patients who underwent free tissue transfer between January 2017 and April 2021. Bedside exploration was performed under mild sedation in patients who had loss of venous Doppler signal with equivocal clinical signs of venous insufficiency. Results A total of 11 patients underwent bedside assessment of the microvascular pedicle. In 6 cases, a return to the operating room was avoided. Five of these patients had coupler malfunction, and in 1 patient a venous kink was discovered and remedied at the bedside. Five patients required return to the operating room. Venous thrombosis requiring thrombectomy and revision of the venous anastomosis was discovered in 3 patients. One patient had a developing hematoma necessitating evacuation in the operating room, and 1 returned to the operating room due to sternocleidomastoid muscular compression of the venous pedicle. There were no flap failures within the study group. In all cases, broad-spectrum intravenous antibiotic coverage was prophylactically used, and no instances of wound infection were observed. Avoidance of returning to the operating room prevented an estimated $9222 of hospital charges per event. Conclusion Bedside neck exploration can be incorporated as a safe and cost-effective intermediary for definitive determination of need for return to the operating room.

Correlation of pre-operative imaging findings and parathyroidectomy outcomes support NICE 2019 guidance

Context Pre-operative localisation studies are standard practice in patients undergoing parathyroidectomy for primary hyperparathyroidism (pHPT). The most common modalities are neck ultrasound (US) and sestamibi scanning. However, the nature of pHPT is changing, with imaging increasingly yielding negative results. Numerous studies suggest unlocalised disease is associated with poor outcomes, calling into question whether such patients are best treated conservatively. Objective This study aims to correlate parathyroidectomy outcomes with pre-operative imaging in a single, high-volume institution. Methods Data from a prospectively maintained departmental database of operations performed from 2017-2019 was analysed. All patients undergoing first-time surgery for sporadic pHPT were included. Data collected included patient demographics, pre-operative imaging, surgical strategy, and post-operative outcomes. Results A total of 609 consecutive parathyroidectomies were included, with a median age of 59 years (range 20-87 years). The all-comer cure rate was 97.5%; this was 97.9% in dual localised patients (those with positive US and sestamibi), compared to 95.8% in the dual unlocalised group (those with negative US and sestamibi) (p=0.33). Unilateral neck exploration was the chosen approach in 59.9% of patients with double positive imaging and 5.7% of patients with double negative imaging (otherwise, bilateral parathyroid visualisation was performed). There was no significant difference in post-operative complications between patients undergoing unilateral or bilateral neck exploration. Conclusions Patients with negative pre-operative imaging who undergo parathyroidectomy are cured in almost 96% of cases, compared to 98% when the disease is localised. This difference does not reach statistical or clinical significance. These findings therefore support current recommendations that all patients with pHPT who are likely to benefit from operative intervention should be considered for parathyroidectomy, irrespective of pre-operative imaging findings.

Validity of no-zone approach for management of isolated penetrating neck injuries in hemodynamically stable patients

Background: Routine neck exploration for isolated penetrating neck injuries (PNIs) in hemodynamically stable patients increases the frequency of unnecessary interventions and complications. Current management protocol involves the no zone approach which uses physical examination and computerized tomographic angiography (CTA) to guide treatment. The aim was to assess the validity of the no-zone approach in the management of isolated PNIs in hemodynamically stable patients.Methods: This retrospective study included patients with isolated PNIs with soft signs who were hemodynamically stable. They were classified into patients with negative CTA findings and were managed conservatively and patients with positive CTA findings suspecting aerodigestive tract injuries (ADTIs) who were submitted to further selective investigations to confirm or rule out these injuries. Detected injuries were managed accordingly.Results: This study included 106 PNIs patients who had soft signs and were hemodynamic stable. 37 cases (34.9%) had negative CTA findings and were managed conservatively. Sixty nine patients (65.1%) had positive CTA findings and were subjected to subsequent selective investigations and revealed 3 patients with negative endoscopic findings who passed without need for any surgical intervention. Therefore, 40 (37.7%) patients were saved from surgery with no missed injuries. Patients with definitive injuries (66 patients) underwent neck exploration and managed accordingly. No missed injuries were recorded in this study. Complications were detected in 6 cases (5.7%) while death was recorded in 2 cases (1.9%).Conclusions: No-zone approach offers a safe management protocol for isolated PNIs in hemodynamically stable patients. It provides no missed injuries, negligible rates of negative exploration and minimal complications and mortality.

302 Migratory Foreign Body in The Neck- How A Fishbone Morphed into A Piece of Glass In 18 Months

Background Foreign body (FB) ingestion is a common presentation to ear, nose, and throat (ENT) surgeons. Usual culprits include fish or chicken bones, steak, or non-organic items. FBs can be categorised into batteries, hard objects, and soft boluses. Hard objects that have not passed beyond the post-cricoid region require removal to minimise perforation risk. In rare cases FBs are reported to migrate extra-luminally into surrounding tissues of the neck necessitating cross-sectional imaging ahead of neck exploration. Case Report A 70-year-old lady presented to A&E with a sensation of FBs in her throat. She was aphagic without dyspnoea. Home-cooked fish ingestion was the precursor. Panendoscopy was clear. The patient was discharged once tolerating fluids and soft diet. She presented 14 months later to the ENT clinic with a persistent FB sensation in her throat. A computed-tomography scan of neck showed a right sided, radio-opaque, 3 cm foreign body sitting just anterior to the carotid sheath, behind the right superior thyroid lobe. An elective external neck exploration revealed a 3 cm shard of glass which was successfully removed without complications. Conclusions Extra-luminal migration of FBs is extremely rare. They may present with life-threatening suppurative or vascular complications. A literature review revealed that migratory FBs tend to be sharp and long such as needles, wires, or fishbones. To allow prompt diagnosis and management, we propose a low threshold for CT imaging in instances with a clear history and persistent symptoms even when panendoscopy is negative.

Role of Tracheostomy in Dealing with Penetrating Neck Trauma: A Double Edged Sword

Background Penetrating neck trauma is an injury in which platysma muscle in neck is breached. It is a life threatening emergency and it requires urgent management by securing airway and neck exploration. Tracheostomy is one of the important procedures as it secures the airway though associated with complications and morbidity in the patients. Case Presentation We present 3 cases of penetrating neck trauma. Each patient is managed by different means of securing airway depending on the site of trauma and associated laryngeal injury. Conclusion Tracheostomy in penetrating neck trauma helps in securing the airway and paves way for safe neck exploration. Minor laryngeal injuries are managed conservatively in order to avoid complications associated with tracheostomy. Tracheostomy and other means of airway management in penetrating neck trauma depend mainly on individualised approach though tracheostomy at a lower site to that of wound should be preferred in major laryngeal injuries. Keywords: Penetrating Neck Trauma; Tracheostomy; Laryngeal Injuries; Airway Management.

Bilateral Neck Exploration May Not Reduce the Risk of Persistence but Shows a Perspective Advantage

There is still no consensus for an optimal surgical treatment of primary hyperpararthyroidism (PHPT). Virtually, most of the patients could be successfully treated with the selective parathyroidectomy (SPTE) based on preoperative visualization. However, this approach still has a “blind area” of undetected multiglandular disease (MGD). Bilateral neck exploration (BNE) may serve as a reasonable alternative but it meets the higher requirements for the surgical technique. A retrospective cohort study was conducted in order to reveal factors associated with the persistence of PHPT. 587 cases of PHPT patients who had received surgical treatment at SPSU Hospital in 2017–2018 were included. All the patients have at least one preoperative visualization study (neck ultrasound performed by a surgeon) before the operation. In 356 cases two studies were performed (additional 4D CT or MIBI scan) and 116 cases had all three. A surgeon was free to choose a type of the operation (selective or explorative) according to their strategic preferences. Bilateral neck exploration was performed in 160 cases. There was no difference in bilateral exploration rate (p = 0.3896) between the groups (with 1, 2 or 3 studies performed) indicating that the additional visualization does not allow to avoid bilateral exploration. MGD rate accounted for 7.4% (40 cases). It is important that any set of preoperative visualization modalities prove the absence of MGD reliably and select patients for SPTE precisely. Negative predictive value for different combinations of concordant studies (US+MIBI, US+CT and US+CT+MIBI) did not differ significantly and was 96.95%, 97.4% and 97.7% respectively. 26 cases of persistent disease were reported with no significant difference between BNE and SPTE groups. (6 vs 20 respectively, p = 0.792). A history of the thyroid or parathyroid operations was found to be the only factor predicting the higher risk of persistence (OR = 7.98; 95% CI [2.62 - 24.27]), while neither the number of parathyroid glands found during the surgery nor the number of preoperative visualization studies showed statistical significance. Only 47,5% cases of BNE was reported to have all four glands visualized. There rate of failure to found each gland was similar. Surprisingly, the superior parathyroid adenomas (P4) were more likely to be removed (chi-squared 10.378, p = 0.0006) but not in the cases with all four glands visualized intraoperatively (chi-squared 1.822, p = 0.0884). The true rate difference due to a hypothetical feature of parathyroid physiology seems to be not very likely. One may rather suggest than it is not an uncommon for a surgeon to identify a P3 gland as a P4 unless all for glands are visualized. This fact shows a perspective advanantage which may prevent some cases of persistence.

Original Preoperative Localization Technique of Parathyroid Adenomas by 3-Dimensional Virtual Neck Exploration

Objective. Preoperative imaging in primary hyperparathyroidism (PHPT) is essential for planning of parathyroidectomy—particularly for selection of a minimally invasive approach. The objective of this cohort study was to evaluate the diagnostic precision of 3D virtual neck exploration (3D-VNE), to evaluate its impact on choice of surgical approach, and to document the correlation with long-term outcomes. Methods. 235 consecutive patients with PHPT were studied (January 2014 to December 2018), with 6-month follow-up. 220 patients had a preoperative computed tomography (CT), 172 of these had a 3D-VNE based on the CT, and 226 patients had a Tc-99m sestamibi scan. Results. Sensitivity of exact, per gland, adenoma localization was 57.09% (95% CI: 50.85–63.10%) for nonspecialized radiologist interpretation of CT scan, 58.17% (95% CI: 51.99–64.10%) for Tc-99m sestamibi scan, and 90.21% (95% CI: 85.21–93.64%) for 3D-VNE, and thereby favoring 3D-VNE compared to CT scan alone (OR 34.5, 95% CI: 9.19–290.56%, P < 2.2 × 10−16) and to Tc-99m sestamibi scan (OR 16.25, 95% CI: 6.05–61.42%, P = 3.1 × 10−15). Specificity was 87.38% for CT scan, 86.36% for 3D-VNE, and 90% for Tc-99m sestamibi scan ( P > .05). The cure rate was 100%. The long-term recurrence rate (RR) was 2.978%. The RR was 1.324% in the video-assisted parathyroidectomy group of 151 patients and 5.952% in the group of 84 patients with cervicotomy ( P = .0459). Conclusion. CT-based 3D-VNE proved to be the most accurate localizing study in PHPT and aided in selecting patients for targeted minimally invasive parathyroidectomy, which was associated with the lower recurrence rate. 3D-VNE could be proposed as a first-line imaging study in patients with PHPT.

Long standing hypercalcemia in a 78-years old woman

A 78 years-old woman was found with worsening hypercalcemia, osteopenia and memory loss during the past 2 years. Multiple, repeated imaging studies failed to reveal the aetiology of the primary hyperparathyroidism. Bilateral neck exploration revealed a 4.5X2,3 cm right superior parathyroid adenoma in an ectopic position.