A 51 yo M presents to the ED with 2 self inflicted stab wounds to the neck 3 days ago. On exam, you notice two wounds to his anterior neck located near the laryngeal prominence.  He is in no distress, however his voice is high pitched and he has extensive subcutaneous crepitus on examination of his face, chest and back.  A CT neck and chest is obtained and shown below. What's the diagnosis?   (scroll down for answer)

Answer: Subcutaneous emphysems and extensive pneumomediastinum due to penetrating neck trauma

• Zones of the neck
• Zone I-  clavicles to the cricoid cartilage
• Zone II- cricoid cartilage to the angle of the mandible
• Zone III- above the angle of the mandible
• Classically, Zone II injuries --> OR for surgical exploration: Zone II contains major vascular structures (carotid arteries, vertebral arteries, jugular veins) and the esophagus, trachea, larynx and spinal cord
• Zone I and III injuries require further evaluation
• Initial management:
• ABC's (assume a difficult airway!!), full neuro exam, expose patient to look for further injury
• Hard signs of injury include those that require immediate surgery consult/repair
• Vascular injury (hemorrhagic shock, arterial bleeding, expanding hematoma, thrill/bruit)
• Laryngotracheal injury (stridor, hemoptysis, dysphonia, bubbling wound, signs of airway obstruction) 

References: 

 Bean AS. Trauma to the Neck. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill; 2020.