Gen Surg Cases · trauma
Stable soft-sign neck with negative CTA but persistent dysphagia — the gullet workup and the carotid blush plan
Fellowship clinical-management station on stable soft-sign penetrating neck injury with negative CTA but persistent dysphagia: gullet second-test doctrine, CTA performance fences, carotid contingency, observation disposition.
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Target exams
FRACSFRCS(Gen Surg)ABSFRCSC
Prompt
A 41-year-old woman 90 minutes after a zone II stab: systolic 124, alert, small stable haematoma, dysphagia, no active bleeding, no expanding haematoma, no shock. CTA shows no extravasation, dissection, or flap but deep surgical emphysema tracks near the oesophagus. The candidate must run no-zone selection, explain why the negative CTA does not close the gullet, order the swallow-or-scope sequence, state what a carotid blush would change, and set disposition with the published numbers.
Management
- Select: stable soft-sign platysma-violating wound earns CTA first — 121 of 156 soft-sign patients scanned with 12 positives (10%), against 40% therapeutic when explored without imaging — so scan by signs regardless of zone.[4]
- Trust vessels cautiously: CTA at 83 to 100% sensitive with 90 to 100% NPV supports observation of the vascular tree with re-examination — and CTA triage cut negatives from 48% to 0% in the selective series.[2][25]
- Never trust the gullet on CTA alone: 92% sensitive yet 19% of oesophageal injuries missed, so persistent dysphagia with deep emphysema earns swallow and/or endoscopy — 465 swallows with 9 injuries and none missed; flexible endoscopy 100% sensitive altering 69.1%.[3][21][20]
- Sequence the gullet: water-soluble swallow then rigid or flexible endoscopy per availability — contrast finds 62% against 100% for rigid scope historically — with admission, nil-by-mouth, antibiotics per local protocol, and theatre on any positive.[20][21]
- State the carotid contingency: a blush, dissection, or flap in a stable patient earns operative planning off the same CTA — open repair for accessible zone II, endovascular for I/III or inaccessible — since stable hard-sign CTA prevented 17 unnecessary explorations at one false-negative cost.[13][29]
References9ShowHide
- [2]Ibraheem K, Wong S, Smith A, et al. Computed tomography angiography in the "no-zone" approach era for penetrating neck trauma: A systematic review. J Trauma Acute Care Surg, 2020.PMID 32890346
- [3]Paladino L, Baron BJ, Shan G, et al. Computed tomography angiography for aerodigestive injuries in penetrating neck trauma: A systematic review. Acad Emerg Med, 2021.PMID 34021515
- [4]Ibraheem K, Khan M, Rhee P, et al. "No zone" approach in penetrating neck trauma reduces unnecessary computed tomography angiography and negative explorations. J Surg Res, 2018.PMID 29229116
- [13]Blair KJ, Hawley KL, Burlew CC Management of carotid artery injuries: What you need to know. J Trauma Acute Care Surg, 2026.PMID 42473982
- [19]Armstrong WB, Detar TR, Stanley RB Diagnosis and management of external penetrating cervical esophageal injuries. Ann Otol Rhinol Laryngol, 1994.PMID 7979000
- [20]Srinivasan R, Haywood T, Horwitz B, et al. Role of flexible endoscopy in the evaluation of possible esophageal trauma after penetrating injuries. Am J Gastroenterol, 2000.PMID 10925975
- [21]Nel L, Jones LW, Hardcastle TC Imaging the oesophagus after penetrating cervical trauma using water-soluble contrast alone: simple, cost-effective and accurate. Emerg Med J, 2009.PMID 19164619
- [25]Osborn TM, Bell RB, Qaisi W, et al. Computed tomographic angiography as an aid to clinical decision making in the selective management of penetrating injuries to the neck: a reduction in the need for operative exploration. J Trauma, 2008.PMID 18545110
- [29]Schroll R, Fontenot T, Lipcsey M, et al. Role of computed tomography angiography in the management of Zone II penetrating neck trauma in patients with clinical hard signs. J Trauma Acute Care Surg, 2015.PMID 26317813