The Oesophagus and Stick Injuries Flashcards
Why are stick injuries challenging? (3)
- Every case is different
- Limitations to assess patient with in house
- Challenges with surgical tx.
Pros (2) and cons (2) of xrays for stick injury?
Pro:
Recognise air entry
See large FB
Con
Difficult to see wood
Limited anatomy detail
Ideal imaging for stick injury?
CT
How can oesophagoscopy be utilized for stick injury?
Look for tears
Why is stick injury surgery challenging? all aspects (9)
- Lack of advanced diagnostic facilities = uncertain about injury;
- The oesophagus = unfamiliar area
- Vital structures in the surgical area
- Normal anatomy may be disrupted
- Careful monitoring and extensive post op care
- Failure to remove all FB = recurrent abscessation;
- Traumatic foreign bodies we only know that we have removed all foreign material when the wound has healed uneventfully and the patient has suffered no recurrent abscessation within the area over a period of 6-12 months or more postoperatively;
- Owner guilt if they have thrown the stick;
- Available finances
Which aspect is normally affected due to the trajectory of the foreign body?
Dorsal +/- caudal
“Small proximal oesophageal tears may heal spontaneously.”
Is my statement true or false?
True
What is the treatment option for large oesophageal tears?
Surgery
What is the worst case pathophysiology of large esophageal tears?
Larger oesophageal tears will result in saliva, fluid and food entering the local tissues of the neck where they will cause a local cellulitis and infection. This can extend down the tissue planes of the neck to cause a mediastinitis. If the mediastinum is breached the infection will then spread to the pleural cavity (pyothorax) which can be fatal.
What are the other possible causes of subcutaneous emphysema in the neck region?
Penetrating skin wound
Tracheal laceration
Penetrating oropharyngeal/oesophageal lesion
Investigation of Patients with a (Suspected) Stick Injury Without Advanced Imaging…?
- History
- CE
- Biochem + haem
- Examine mouth under GA
- Images
- Probe
Where are the possible injury locations of stick? (5)
Tongue or tongue base
Hard or soft palate
Tonsils or tonsillar crypts
Laryngopharynx;
Dorsal pharyngeal wall
How to assess the hard/soft palate?
Retroflex the soft palate rostrally and look for injuries in the caudodorsal nasopharynx and foreign material dorsal to the soft palate;
How to assess tonsils/tonsillar crypts?
Protrude the tonsils from the tonsillar crypts and examine both carefully;
How to examine dorsal pharyngeal wall?
Examine by retroflexion of the soft palate.
If there is air within the tissue planes of the neck , what are the D/Dx? (3)
Oral/oesophageal FB
Penetrating skin wound
Tracheal laceration
How common is it for a pneumomediastinum to become a pneumothorax?
Extremely unusual
How can endoscopy be used for stick injuries? (2)
- Of the penetrating tract: to assess the depth of the injury and the presence/removal of foreign material.
- Oesophagoscopy: This is ideal to allow direct assessment of the oesophagus.
Which area of oesophagus is difficult to examine to endoscope why?
Proximal - To examine the oesophagus it must be inflated with air however it is difficult to keep the proximal oesophagus inflated during proximal oesophagoscopy as air leaks through the proximal oesophageal sphincter.
What are the two ways to see radiographically tracts?
- Probe and xray
- Iodine based contrast
If a FB isnt obvious - what is likely to be seen if there is an oesophgeal tear?
Air in fascial plane
What is seen on xray to identify a pneumomediastinum?
see the outside wall of the thoracic trachea and individual vessels in the cranial thorax because these are now surrounded by air.
Once a under tongue laceration has been explored/flushed. How should this wound heal?
Leave the wound to granulate or suture the wound closed using 3/0 or 4/0 monofilament absorbable suture material placed in a simple interrupted or simple continuous pattern if the wound has been thoroughly explored and debrided.
In deep large under tongue laceration, what should be used to probe?
10FG urinary catheter
How to approach a deep penetrating wound if you can palpate the probe?
Base your surgical exploration on the distal extent of the tract where you can feel the probe.
Make your skin incision over where you can palpate the probe, extend the incision deeper until you reach the probe/tract and follow this along the entire length of the tract back towards the site of penetration.
Identify and remove any foreign material.
Debride devitalised tissues.
Lavage with saline.
Debride the wound edges and suture.
3/0 or 4/0 monofilament absorbable suture material.
simple interrupted or simple continuous suture pattern.
Consider placing a surgical drain.
If a probe in a deep peneration cannot be palpated, what should be performed and how?
Perform a radiographic contrast study.
Inject 1-3 ml of iodine-based contrast through a catheter placed into the tract.
Take a lateral radiograph of the region.
Look for filling defect which would suggest foreign material in the tissues.
Following deep penetration iodine x rays, what happens next if there is a filling defect?
Surgically explore the tract by incising the soft tissues over the proposed location of the probe (judged from radiographs).
Following deep penetration iodine x rays, what happens next if there isnt a filling defect?
Be managed conservatively (flush with saline) or the tract could be surgically explored as described above.
How to approach a partial soft palate tear?
Leave to granulate
How to approach a full thickness tear of the soft palate?
Debride + suture
3/0 or 4/0 monofilament absorbable suture material;
simple interrupted or simple continuous suture pattern.
How to manage a shallow pharyngeal tear?
Granulate
How to manage a deep pharyngeal tear?
Work up - probe/iodine and approach
When is surgical exploration/repair NOT recommended for oesophagus wound? (2)
Puncture
<5mm
If from your investigations, you have concluded that the dog has an oesophageal tear but you cannot confirm the size of the tear by oesophagoscopy then you should…?
Perform surgical exploration and repair of the oesophageal injury.
Where are most oesophageal injuries?
Proximal and involve the dorsal/caudal oesophageal wall
What approach is made to access the proximal oesophagus?
Lateral approach to the oesophagus as for cricopharyngeal myectomy
How is a patient positioned for proximal oesophagus approach?
Lateral - injury uppermost
Where is the skin incision on the approach to the proximal oeosphagus?
The skin incision is made just below the jugular vein and is centred over the larynx and continued a few centimetres further in a distal direction.
To approach the proximal oesophagus; how would you position the neck?
The patient’s head and neck are extended with a sandbag placed under the laryngeal region.
Which muscle is incised on the approach to the proximal oeosphagus?
Platysma
Which cartilages are identified on the approach to the proximal oeosphagus? (2)
Thyroid
Cricoid
Approach to proximal oesophagus:
The injury is usually apparent at this stage because which muscles are also usually damaged in very proximal oesophageal injuries? (2)
- Cricopharyngeus
Thyropharyngeus
On surgical approach to proximal oesophagus::
What happens to to tear?
he oesophageal tear and local tissues are debrided, the area is flushed with sterile saline and the oesophageal tear is closed using 2 or 3 metric monofilament slowly absorbable suture material placed in a simple interrupted pattern with sutures placed 3-4 mm from the wound edges and 2-3 mm apart.
Which type of drain following the explore of proximal oesophagus?
Closed suction
Ventral approach to oesophagus:
Make a midline skin incision, extend through the subcutaneous tissues and separate which msucles (2)
sternohyoideus and sternothyroideus
IfIf the stick has been removed prior to surgery - why examine it?
Assess its potential to splinter,
If the stick is still in place ideally try not to remove it before surgery - why?
It will aid intraoperative identification of the location of any oesophageal injury.
Place what immediately prior to surgery if the stick has already been removed because this will aid identification of the oesophagus intraoperatively?
Orogastric tube
Which aspect of postoperative care do you think is really important following repair of an oesophageal tear or laceration to reduce the risk of oesophageal wound dehiscence? (2)
- Placement of a gastrostomy or percutaneous endoscopic gastrostomy tube to allow the oesophagus to “rest” whilst maintaining nutrition.
- Following surgical correction of an oesophageal tear or laceration nil per os and feeding via a gastrostomy tube is recommended for 5-10 days postoperatively.
Post op meds after stick injury?
Analgesia !!!
ABx (broad spectrum for 5-10days)
Why is there a reason NOT to C+S a stick injury wound straight away?
value in swabbing the wound as the bacteria are likely to be environmental contaminants and oral bacteria
The clinical signs of residual foreign material within the local tissues includes… (3)
- Recurrent cervical swell (tend to reduce with ABx and then recur)
- Abscess
- Discharging sinus
Preferred imaging for residual foreign material? (2)
Ultrasound
CT
When should ABx be given for surgery for chronic stick injury?
STOP before surgery - to identify
When to perform surgery for chronic stick injury?
Perform surgery when there is an obvious swelling, abscess or discharging tract.
Which approach for a chronic stick injury?
Unless the lesion has been confidently localised and lateralised by imaging place the patient in dorsal recumbency for surgery and perform a ventral midline approach.
How can pus be used in surgery for chronic stick injury?
Follow tract to identify area
True or false
It is essential to remove all fibrous tissue and draining tracts to obtain a successful outcome
False - removal of the foreign body will result in resolution of the clinical signs because it is the foreign body that is the underlying cause of the problem and not the fibrosis or draining tracts.
