Detection and evaluation of aerodigestive tract injuries caused by cervical and transmediastinal gunshot wounds.

BACKGROUND

Aerodigestive tract penetrations occurring with gunshot wounds to the neck and thorax are uncommon but are frequently associated with multiple organ injury and contribute to significant morbidity.

METHODS

The selective management strategy used at our institution for suspected aerodigestive tract involvement with cervical, thoracic inlet, and transmediastinal gunshot wounds is reviewed with reference to eight clinical cases from 1989 to 1995.

RESULTS

Seven pharyngoesophageal and four laryngotracheal injuries are described with three patients sustaining combined aerodigestive organ wounds. Associated injuries occurred in seven of the eight cases. Diagnosis of aerodigestive tract penetrations were made by triple endoscopy in five patients, by contrast esophagography in one case, and at operation for associated injuries in two patients. No injuries were missed during endoscopy or contrast studies. Two patients suffered complications including delayed recognition of an esophageal injury and pneumonia in one case and dehiscence of a distal esophageal repair in another. An associated vascular injury resulted in a single death in the series.

CONCLUSIONS

A high index of suspicion must be maintained for aerodigestive tract involvement with cervicothoracic gunshot wounds. We advocate operative endoscopic inspection during emergent exploration in unstable patients or arteriography with endoscopy in stable patients. Adjunctive contrast pharyngoesophagography is performed to confirm equivocal endoscopic findings, evaluate the extent of leak, or completely exclude injury.