Neck exploration is performed in a systematic fashion to evaluate and repair all structures deep to the platysma that have been injured by penetrating trauma. The neck is divided into three zones for the purposes of decision making in trauma surgery.

Zone I lies below the clavicles and comprises the thoracic inlet. Injuries in this region may require sternotomy or thoracotomy (see Fig. 13.4) for adequate vascular control. Hemodynamically unstable patients are taken directly to the operating room, whereas stable patients are best evaluated first by arteriography or computed tomography angiography (CTA). Chest radiography is done to look for associated hemopneumothorax and injury to the superior aspect of the lung. Significant vascular injury is unlikely, however, if physical examination and chest radiographic findings are negative. Esophageal contrast studies with or without endoscopy, as well as bronchoscopy, are necessary to complete the nonoperative evaluation. These studies may be selectively omitted if the CTA reveals the path of penetration to be remote from the aerodigestive tract. Positive findings direct operative repair.

Zone II (between the clavicle and angle of the mandible) includes most of the neck. Injuries to this zone that penetrate the platysma generally warrant exploration, and prompt surgery is required in unstable patients. Massive hemorrhage is likely as a result of an injured common carotid artery or its branches, vertebral artery, jugular vein, or a combination of these. Manual pressure is maintained to control bleeding; blind clamp application for hemorrhage control is to be condemned. Stable patients may be evaluated instead by angiography (or CTA, depending on local scanning capabilities and radiology expertise), followed by radiographic or endoscopic hypopharyngeal and esophageal evaluation. The larynx and trachea must be examined by fiberoptic or rigid endoscopy if appropriate signs or symptoms are present, such as cervical subcutaneous emphysema (by examination or radiography), stridor, respiratory difficulties, hemoptysis, or hoarseness. A selective approach to exploration may be appropriate if diagnostic studies yield negative results.

Zone III extends from the angle of the mandible to the skull base. Patients unstable because of bleeding must be taken expeditiously to the operating room. Meanwhile, manual pressure is applied to the wound to prevent exsanguination. Alternatively, a Foley catheter may be gently inserted into the wound and its balloon inflated to the point of hemorrhage control. If followed by hemodynamic improvement, preoperative diagnostic and therapeutic arteriography may be possible because attaining distal control near the skull base may be exceedingly difficult if not impossible. When nonoperative evaluation is pursued, fiberoptic endoscopic evaluation of the pharyngeal area should be conducted as well.