Mandatory exploration or observation for penetrating neck injuries?

In this issue (pages 33 to 38), Irish and colleagues present a 10-year review of blunt and penetrating cervical injuries. They attempt to address the potential role of selective, nonoperative management of visceral neck injuries. A number of important features of the Canadian experience with general and neck trauma are evident from their presentation and are worthy of discussion. The frequency of blunt and penetrating mechanisms (19 and 66 patients, respectively) illustrates 2 features: ( 1 ) neck viscera remain relatively resistant to injury from blunt forces, but the most commonly injured visceral structure in the neck is the laryngeal complex; (2) penetrating injuries, in Toronto and other Canadian cities, although not rare are also not frequent (average of 6.6/yr), and individual Canadian surgeons will infrequently be called upon to manage these injuries. Selective management as documented in this study was safe, with few complications ( 1 of 20 patients) and efficient: there were no negative explorations, no delayed diagnoses and a shorter hospital stay than for patients who underwent mandatory elective exploration. The disadvantage of selective management rests in its more complex algorithm than that associated with surgical exploration. Patients suitable for nonoperative treatment must be identified and separated from those requiring emergent neck exploration, the appropriate diagnostic evaluations and their limitations must be determined and patients must be carefully observed for evidence of injuries missed on initial evaluation. Potential diagnostic strategies range from physical examination alone to the exhaustive use of diagnostic studies, such as angiography, endoscopy and CT scanning. Much as a standard and explicit operative approach to neck exploration is employed, so too should be the approach to selective nonoperative management. Indications for mandatory exploration must be defined, indications for the use of individual diagnostic modalities should be defined and adhered to, and the indications for observation without investigations should be determined and applied. Most centres employing selective nonoperative management do so under explicit guidelines.