Which of the following statement(s) is/are true concerning the definitive management of neck injuries?

c. The combination of esophography and endoscopy improves the accuracy of detecting esophageal injury with penetrating trauma

d. External drainage is an important aspect of the surgical management of an esophageal injury

Blood vessels are the most commonly injured structures in the neck. Major arterial injuries occur in 18% of penetrating neck wounds and major venous injuries in 26%. Blunt vascular injures account for a very small percentage of carotid injuries, however their management is somewhat controversial with treatment highly variable dependent upon the vascular lesion as well as concomitant injuries. When anatomically feasible, pseudoaneurysms are probably best managed by resection. The best treatment for arterial dissection, however, although not completely resolved, would appear to be systemic anticoagulation if possible to prevent propagation, embolization or thrombosis. Resection may not be required in the majority of patients. Penetrating carotid injury most commonly presents with exsanguinating hemorrhage. The indication for repair versus ligation of a carotid injury depends, in part, on the neurologic presentation. Patients without a neurologic deficit and a carotid injury should have restoration of vascular continuity with good neurologic outcome anticipated. Also, patients with all grades of neurological deficits short of coma should have primary vascular repair. Although experience with revascularization of patients suffering acute stroke from arteriosclerotic occlusive disease suggests that hemorrhagic infarction and death may result from revascularization, several reviews of acute revascularization in the trauma patient note that combined morbidity and mortality are significantly less in those patients repaired primarily compared to those managed with arterial ligation. Traumatic injury to the vertebral arteries are now more commonly identified due to the more liberal application of neck angiography. Unilateral vertebral artery occlusion seldom results in a neurologic deficit. Treatment of blunt vertebral artery injury with thrombosis generally is nonoperative: systemic anticoagulation is recommended to avoid further propagation of existing thrombus.

The diagnosis of esophageal injury can be difficult. The sensitivity of esophography in detecting esophageal injuries varies from 50% to 90%; the sensitivity of endoscopy ranges from 29% to 100%. These modalities should be considered complimentary, and when combined have an accuracy of nearly 100%. Since virtually all reported deaths from cervical esophageal injuries are the result of delayed or misdiagnosis, a particularly high index of suspicion is warranted. When injured, the esophagus should be meticulously debrided and repaired primarily in one or two layers. It is important to drain all such wounds, because infection or salivary fistula is not an infrequent complication.