Stable zone II stab with hoarseness and crepitus — signs-first triage, CTA selection, and the gullet second test

Model answer

• Triage frame: platysma violated means the pathway starts; the neck is evaluated as a unit rather than by external zones, and the no-zone approach safely spares negatives — with zones matching internally in only 59.1% and 23.5% discordant, so manage by signs regardless of zone.^[1]
• Hard-sign accuracy: hard signs are specific but insensitive for major injury (sensitivity 55.4%, specificity 88.1%) across 310 patients with 29.7% major injury — presence selects, absence never excludes; the any-sign-or-instability composite reaches 96.7% sensitivity at 34.4% specificity.^[9]
• Asymptomatic boundary: 99 asymptomatic patients with 79 scanned and 3 positives (4%) needed no therapeutic exploration, and 24 of 24 observed needed none — observation in hospital, never discharge, with re-examination.^[4]
• CTA vascular plan: stable soft-sign disease goes to CTA — sensitivity 89.5 to 100%, specificity 61 to 100% in soft signs; 83 to 100% sensitive with 90 to 100% NPV overall — positive means extravasation, dissection, or flap.^[2]
• Gullet limit with numbers: CTA for aerodigestive injury is 92% sensitive and 88% specific, yet 5 of 26 oesophageal injuries (19%) were initially missed — CTA alone is not sufficient, so add swallow and/or endoscopy whenever concern remains.^[3]
• Swallow: 465 water-soluble contrast studies with 11 positives (9 injuries), no missed injuries and no significant adverse events.^[21]
• Endoscopy: flexible endoscopy across 55 suspected injuries gave sensitivity 100%, specificity 92.4%, NPV 100%, altering management in 38 patients (69.1%).^[20]
• Contrast-versus-scope: contrast diagnosed 62% of cervical oesophageal injuries against 100% for rigid oesophagoscopy; large penetrations still take limited debridement, primary repair when possible, muscle flap, and external drainage.^[19]
• Carotid flap decision: repair or revascularize except the devastated comatose, with open repair for accessible zone II and endovascular for I/III or inaccessible lesions; ligation carried 100% poor outcomes (5 deficits, 4 deaths in 9) against 30% with restoration.^[11][13][15]
• Bleeding bridge: active bleeding earns Foley balloon tamponade first — delayed failure 7% against 26% with pressure, mortality 5% against 23% — then theatre.^[30]