Airway Injury & Carotid Dissection
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As we leave the topic of facial and neck trauma,
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it's important for me to mention a few other entities
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that can occur lower down in the neck rather
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than the facial bones. Here's one of them.
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Here's a patient who has an air leak that occurred
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due to traumatic injury to the larynx.
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So the patient shows widening of the thyroid
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thyroid cartilage from side to side with an air
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collection which is communicating with the
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paraglottic space. And then from the paraglottic space,
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it goes out into the anterior strap muscles.
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So this is an airway injury.
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And whenever you see unexplained
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emphysema in the neck,
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you want to make sure that there isn't a communication
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with either the breathing tube or the swallowing tube,
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as the case may be.
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Here you can see that in point of fact,
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that small air leak at the thyroid notch led
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to gross air in the subcutaneous tissue,
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outlining the carotid artery in the jugular vein and
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separating the visceral space
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from the carotid space.
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So communication even into the epidural space of the
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spinal canal, airway injury. And this may occur usually,
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with regard to the larynx, rarely with the trachea.
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The second neck injury that I'd like to
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mention is the carotid dissection.
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Patients with carotid dissection will
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present with neck pain. Rarely,
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but most importantly they may present with a stroke
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and that is because of a thrombus which forms
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along the dissected internal carotid artery.
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The third common presentation besides neck
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pain and stroke is the presence of a Horner
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syndrome because of involvement of the
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sympathetic nervous system plexus which
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abides within the carotid sheath.
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Here we have the normal right internal carotid
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artery with fat around the blood vessels
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into the parapharyngeal space.
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Here we have a narrowed internal carotid
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artery and if we do fat suppression,
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we'd see that this is bright signal intensity that's not
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due to fat but is due to hemorrhage in the wall
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accounting for the narrowing of the internal
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carotid artery with carotid artery dissection.
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This up here is the parapharyngeal space.
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This is the post-styloid parapharyngeal space or the
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carotid sheath structures with a carotid dissection.
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When you look at carotid dissection,
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you just should be aware of the so called Biffl
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scale for carotid dissection. Grade one,
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irregularity or dissection with less than 25% stenosis.
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Grade two, greater than 25% luminal narrowing.
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Grade three, pseudo aneurysm. Grade four,
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complete occlusion of the dissected carotid artery.
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And grade five, transection with active contrast extravasation
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extravasation. A word on carotid dissection and
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the seatbelt sign. So the seatbelt sign,
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as I mentioned previously,
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is the discoloration across the shoulder and neck
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secondary to the trauma of the seatbelt
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as you are forced forward or back,
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depending upon on which side the car is hit.
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The seatbelt sign, in and of itself, is not a
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good predictor of carotid dissection.
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In fact,
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we looked at a multi institutional
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study with over 500 cases,
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and carotid dissection from the seatbelt sign
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alone occurred in only three out of 500 cases.
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So, very uncommon.
David M Yousem, MD, MBA
Professor of Radiology, Vice Chairman and Associate Dean
Johns Hopkins University
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