Approach to Penetrating Neck Trauma 
Lillian Hsu, Pako Motlaleselelo, Mike M. Mallah 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Background:  
Civilian penetrating neck trauma results in a 
mortality rate that ranges from 3-6% and constitutes 
approximately 5-10 % all trauma worldwide. Vessels 
are the most injured structures in the neck and 
vascular involvement increases the mortality rate to 
as high as 50%. Higher energy  mechanisms (such as 
gunshot wounds) are more likely to be associated 
with significant vascular injury. Aerodigestive tract 
involvement must also be quickly assessed and 
treated promptly if present. 
Neck trauma is often high acuity, complex, 
and challenging to treat. Management of these 
injuries is dependent on the location of the injury 
meaning which zone—described below—of the neck 
is wounded.  In general, patients exhibiting any “hard  
signs” of injury will require operative management. 
The “hard signs are:  
● Pulsatile bleeding from a wound 
● Expanding hematoma 
● Decreased pulses or evidence of distal ischemia 
(including mental status changes or altered 
neurologic examination 
● Audible bruit or palpable thrill 
● Respiratory distress or inspiratory stridor 
● Hoarseness 
● Bubbling in wound 
● Subcutaneous emphysema 
● Difficult or painful swallowing 
● Shock 
 
The treatment of penetrating neck injury for 
symptomatic or mildly symptomatic patients is less 
certain and constantly evolving, with sufficient 
evidence for both operative and nonoperative 
management strategies. In areas with limited 
resources, it is critical to have a thorough and 
accurate physical exam, as this will most likely 
determine the need for operative exploration. If 
available, in a hemodynamically stable patient, it is 
always helpful to have imaging adjuncts to determine 
precise location and extent of injury. The most 
helpful imaging modality to assess for vessel 
involvement is CT angiography of the neck. In a 
resource-limited environment, other options include 
duplex ultrasound, flexible or rigid esophagoscopy, 
or contrast x-rays, as described further below.  
 
In areas where adjunctive imaging is not 
accessible and in patients who are not in immediate 
distress, surgeons should use serial physical exams 
to determine the need for operative intervention, as 
initially asymptomatic patients can quickly worsen.  
 
Anatomy:  
The neck is divided into 3 main zones:  
● Zone I: From clavicle and suprasternal notch to 
the cricoid cartilage  
● Zone II: From the cricoid cartilage to the angle of 
the mandible  
● Zone III: From the angle of the mandible to the 
base of the skull  
 
 
Zone I is the least commonly injured zone due to 
some protection by the thoracic skeleton. For this 
same reason, it is also the most difficult zone of the 
neck to obtain adequate exposure. It contains:  
● Common carotid arteries 
● Vertebral arteries  
● Subclavian arteries 
● Trachea 
● Esophagus 
● Thoracic duct 
● Thymus gland 
● Apex of pleura and lung 
 
Zone II is the largest, and thus most frequently 
injured zone in the neck. It is also the easiest to 
access surgically. It contains:  
● Internal and external carotid arteries 
● Jugular veins 
● Pharynx 
● Larynx 
Approach to Penetrating Neck Trauma 
Lillian Hsu, Pako Motlaleselelo, Mike M. Mallah 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
● Esophagus 
● Thyroid gland 
● Parathyroid gland 
● Recurrent laryngeal nerves 
● Vagus nerves 
 
Zone III is closest to the skull base, making it 
difficult to perform an adequate physical exam and 
obtain adequate surgical exposure. This area is also 
partly behind the ascending ramus of the mandible 
making exposure extremely difficult. It contains:  
● Distal extracranial internal carotid artery 
● Vertebral arteries 
● Most proximal segments of the jugular veins 
● Parotid gland and facial nerve branches 
 
Structures in the neck are contained in tight 
fascial compartments that may limit external signs of 
hemorrhage, contributing to the ambiguity of 
physical examination. For this reason, serial physical 
examination by the same team is useful to determine 
treatment course. 
 
The fascial planes of the neck, in Blue, seen in cross section at 
the level of the 6th vertebra. A penetrating injury to the carotid 
artery inside the carotid sheath (Red circle) may exert 
significant pressure on the adjacent trachea or larynx without 
much externally visible swelling.  
 
 
Surgeons operating within the neck should be 
intimately familiar with its fascial planes and their 
effect on the spread of blood under pressure. The 
most superficial fascial plane is the one that contains 
the platysma. This is known as the superficial layer 
of the deep cervical fascia, or the investing fascia. 
Penetrating injuries that have failed to pass this layer 
do not require further exploration, although this 
situation does not rule out blunt injury to the trachea 
or arterial structures. 
 
The platysma is contained by the Investing fascia. Like the deep 
layers of cervical fascia, this layer can contain an expanding 
hematoma, transmitting pressure to the blood vessels or the 
airway 
.  
Principles:  
As with any trauma evaluation, ABCs 
(airway, breathing, circulation) should first be 
evaluated in the usual order for penetrating neck 
trauma. Up to 10% of patients with penetrating neck 
trauma can present with respiratory distress and 
require immediate airway control, which can be a 
significant challenge. See Airway Management in 
Trauma. 
 
Selection 
of 
Operative 
Versus 
Nonoperative 
Management  
There are very few strict guidelines regarding 
operative management of penetrating neck trauma. 
Foremost, if the patient exhibits any hard sign of 
injury as mentioned above, he or she should be taken 
for immediate operative exploration.  
Conversely, 
if 
the 
patient 
is 
hemodynamically stable and imaging is available, 
the patient should undergo CT imaging (with or 
without angiography.)  
If the wound does not penetrate the platysma, 
it is highly unlikely that the patient suffered a 
significant injury, and operative exploration is not 
necessary. Especially if advanced imaging is not 
available, it is reasonable to explore a small stab 
wound in a hemodynamically stable patient to 
confirm that the platysma was not violated.  
Approach to Penetrating Neck Trauma 
Lillian Hsu, Pako Motlaleselelo, Mike M. Mallah 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Zone II is readily accessible to the surgeon, 
and symptomatic patients should undergo operative 
exploration immediately with any hard sign of 
injury.  
It is important to highlight the utility of Foley 
catheter balloon tamponade in patients with life 
threatening or bleeding penetrating neck wounds, 
particularly in low resource settings. It has a 97% 
success rate at hemorrhage control, as minor arterial 
and venous injuries are definitively managed this 
way. A Foley catheter balloon can be inflated in the 
tract of the injury in casualty while the patient is 
being prepared for surgery.  
 
A Zone II injury to the left neck, patient’s head is rotated to his 
right. A single foley catheter was applied to arrest bleeding in 
a secondary hospital, and the patient was transferred. CT 
angiogram showed injury to an unnamed branch of the left 
dorsal scapular artery. The catheter was removed in theater 
and no further bleeding was noticed. In a setting without a CT 
scanner, an appropriate strategy would be neck exploration 
with proximal and distal exposure of the carotid arteries and 
jugular vein, followed by exploration of the tract and removal 
of the catheter. 
 
If possible, all patients managed with Foley 
balloon tamponade require CT angiography prior to 
removal of the catheter to determine whether the 
injury is amenable to observation or surgical 
intervention. If imaging is not available and a Foley 
balloon has been placed for tamponade, perform 
surgical exploration. Obtain proximal and distal 
control of vessels near the tract before opening the 
tract and exploring it.  
A chest x-ray is important to obtain with 
suspected injuries in this area due to its proximity to 
the mediastinum and potential to cause breathing 
issues from damage to the lungs. A lateral view 
should be obtained if the injury is in close proximity 
to the aerodigestive tract with particular attention 
paid to the prevertebral space. 
 
Lateral neck x-ray in a patient with esophageal perforation, 
showing significant air in the subcutaneous (Red arrow) and 
mediastinal 
(Black 
arrow) 
spaces, 
tracking 
upwards 
underneath the prevertebral fascia (Purple arrow.) 
 
 
Anteroposterior chest x-ray in the same patient, showing 
subcutaneous air (Red arrows) and mediastinal air (Black 
circle.) Both photos courtesy of Frank Gaillard, from the case 
https://radiopaedia.org/cases/8282?lang=us  
 
Diagnosing Vascular Versus Other Major Structure 
Injury  
If there are no hard signs of injury, the 
physical exam in the immediate post-injury period is 
Approach to Penetrating Neck Trauma 
Lillian Hsu, Pako Motlaleselelo, Mike M. Mallah 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
not dependable for diagnosing vascular injury. 
Initially asymptomatic patients can develop delayed 
pseudoaneurysms and neurologic events. Serial 
physical exams, however, can be useful, especially 
in diagnosing vascular injury. Auscultating the 
carotid arteries for a bruit in the hours following 
injury can be diagnostic in the absence of additional 
imaging. CT angiography has been shown to have 
100% sensitivity in diagnosing vascular injury. If 
unavailable, duplex ultrasound imaging (shown to 
have up to 92% sensitivity) can be performed.  
Damage to other major neck structures, such 
as the esophagus, can be difficult to diagnose as there 
are often not immediate physical signs. If the patient 
presents with odynophagia, this should absolutely be 
explored further with esophagography followed by 
rigid esophagoscopy, which has a higher sensitivity 
and less risk of increasing pneumomediastinum if an 
injury is present than flexible esophagoscopy. Using 
both imaging modalities greatly decreases the false 
negative rate of injury detection.  
 
Lateral view Barium swallow study shows extravasation of 
contrast from the posterior hypopharynx area after a gunshot 
wound to the neck. The Red Arrow shows the point of 
extravasation, and the Blue Arrow shows passage of the 
contrast inferiorly into the mediastinum. This patient will 
require surgical exploration, debridement, and repair of the 
perforation. Case courtesy of RMH Core Conditions, from the 
case https://radiopaedia.org/cases/26313?lang=us 
 
Carotid Artery Repair 
There are three options regarding carotid 
artery repair – reconstruction, ligation, and non-
operative management. Operative decision making is 
based mainly on patient presentation as well as injury 
location (Zone I, II, or III.) Non-occlusive injuries 
to the carotid that are limited to the intimal layer 
can be safely observed. Zone I injuries are often the 
most subtle and often require imaging for accurate 
diagnosis. Operative repair for zone II injuries 
(usually accompanied by at least one hard sign of 
vascular injury) are performed via oblique cervical 
incision. Patients presenting with neurologic deficits 
should have repair as opposed to ligation. Injury to 
the carotid artery in zone III should be focused on 
controlling hemorrhage and preserving cerebral 
perfusion. If available, angiographic imaging should 
be obtained first in a stable patient. 
 
Patient with right Zone 2 stab wound. Five Foley catheters were 
used to arrest arterial hemorrhage before surgery. Common 
carotid artery laceration at the bifurcation was repaired with a 
bovine pericardium patch. The right internal jugular vein was 
ligated. Note that in a resource-limited setting, the ligated vein 
could have been used to patch the arterial repair. 
 
Venous Injury Management 
The focus in penetrating neck trauma is often 
airway management and arterial injury. Venous 
injuries can often be overlooked, especially if other 
existing injuries are managed nonoperatively. 
Approach to Penetrating Neck Trauma 
Lillian Hsu, Pako Motlaleselelo, Mike M. Mallah 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Approximately 18% of penetrating neck trauma 
involving vasculature will result in an arteriovenous 
fistula. Where possible, angiography should be used 
to assess vascular injury. When a venous injury is 
diagnosed, ligation of great veins of the neck or 
thorax is a safe option with fairly limited long term 
effects, provided the internal jugular veins are not 
both ligated simultaneously.  
  
Esophageal Injury 
Esophageal injury can be difficult to 
diagnose without imaging, especially immediately 
following neck trauma. Unfortunately, delayed 
diagnosis contributes significantly to morbidity and 
mortality. Some signs suggestive of esophageal 
injury 
include 
hemoptysis, 
odynophagia, 
hematemesis, and respiratory distress. If available, 
esophageal injury is best assessed by barium 
swallow. Barium has a higher sensitivity for small 
esophageal injuries than a water-soluble contrast, but 
also has the potential to cause more mediastinal 
damage in the setting of a perforation. 
 
Tracheal Injury 
Priority should always be given to stabilizing the 
airway in trauma situations. Signs of tracheal injury 
include 
bubbling 
from 
the 
wound, 
stridor, 
hemoptysis, and subcutaneous air, though several of 
these signs can also be seen with GI tract injury. If 
there is concern for airway compromise, and general 
anatomic relationships are preserved, rapid sequence 
intubation is appropriate. In situations with massive 
trauma and distortion of landmarks, the exposed 
trachea can be directly intubated or a provider can 
use a flexible endoscopic guided oral intubation if it 
is available. When possible, techniques without 
direct visualization should be avoided to prevent 
further injury. If tracheal intubation is unsuccessful, 
invasive airway management is the next step, most 
commonly via cricothyroidotomy as a last resort. 
Needle cricothyroidotomy with bag valve mask 
oxygenation is also an option, Blind nasotracheal 
intubation is not appropriate in this scenario. 
 
The Role of Cervical Spine Collars 
Studies have shown that survivors of 
penetrating neck trauma are unlikely to have unstable 
cervical spines. The application of a cervical collar 
may conceal serious injuries and further delay 
treatment. 
For 
these 
reasons, 
patients 
with 
penetrating neck trauma should not routinely be 
placed in cervical collars unless the patient exhibits 
focal neurologic deficits. 
Outside of these guiding principles, the 
physical exam and clinical suspicion for major injury 
must be heavily relied upon. Given kinetic and 
thermal energy transfer, gunshot wounds are more 
likely than stab wounds to cause vascular injury.  
 
Decision Making: 
Airway management in these patients can be 
very difficult due to distortion or ongoing bleeding. 
Often patients with airway swelling will prefer to sit 
upright: there is no reason to “force” them to lie 
down in such circumstances. Expert assistance and 
video-assisted techniques are often necessary. Do not 
hesitate to perform a cricothyroidotomy or other 
surgical airway if necessary. This issue is discussed 
further in Airway Management in Trauma. 
Left neck hematoma after stab wound. A hematoma like this has 
the potential to deviate the airway significantly and make safe 
orotracheal intubation difficult or impossible. Photo courtesy 
of Dr. Demetrios Demetriades.  
 
We present one algorithm below, modified 
for 
low-resource 
settings, 
summarizing 
the 
considerations outlined in this chapter.  
Approach to Penetrating Neck Trauma 
Lillian Hsu, Pako Motlaleselelo, Mike M. Mallah 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
An algorithm for management of penetrating neck injury, with 
different pathways on the right side depending on availability 
of CT scan in the same facility. Note that these patients should 
not be transported to another facility for CT scanning as they 
could deteriorate suddenly.  
 
The stable patient 
Preoperatively, it is the most helpful to obtain 
vascular 
imaging 
in 
the 
form 
of 
duplex 
ultrasonography or angiography if the patient is not 
exhibiting immediate signs of distress. As mentioned 
above, physical examination in the immediate 
aftermath of the injury is not always dependable, but 
surgeons can perform serial physical exams if initial 
presentation 
does 
not 
demand 
immediate 
exploration. 
Current 
data 
supports 
selective 
management based on physical exam and additional 
imaging, which is not always available. Patients may 
need to be observed for up to 48 hours, which can be 
resource consuming. Ultimately, when in doubt, the 
patient should undergo surgery, as a carefully 
performed negative neck exploration has less 
morbidity than a missed injury. 
 
The unstable patient 
Patients exhibiting one or more hard signs of 
vascular injury should be taken for immediate 
exploration. Neck exploration for trauma is 
performed through an oblique incision along the 
anterior border of the sternocleidomastoid, curving 
posteriorly near the angle of the mandible to avoid 
injury to the mandibular branch of the facial nerve. 
More details on neck exploration and repair of 
specific injuries are provided in another chapter in 
this Manual.  
 
 
Lillian Hsu, MD 
Medical University of South Carolina 
USA  
 
Pako Motlaleselelo, MBBS 
University of Cape Town  
South Africa 
 
Mike M. Mallah, MD 
Medical University of South Carolina 
USA 
 
Acknowledgment: Doug Norcross MD FACS 
 
April 2023 
