Incisions on the neck with purulent inflammatory processes. Surgical treatment of abscesses and phlegmon of the neck

Abscesses and phlegmon of the neck are more often the result of purulent lymphadenitis, which develops as a result of infection with tonsillitis, inflammation of the periosteum of the jaws, oral cavity, middle ear mucosa, nasal cavity and its accessory cavities.

Abscesses and phlegmon of the neck are divided into superficial and deep. In addition to general complications, deep inflammatory foci of the neck are dangerous because they can spread through the tissue into the anterior and posterior mediastinum. This can cause compression of the trachea or swelling of the larynx, involve the walls of large arteries and veins in the process, which can lead to their melting and heavy bleeding, which often leads to death.

The main principle of the treatment of abscesses and phlegmon of the neck is a timely incision that provides a fairly complete opening and drainage of the pathological focus. The incision must be strictly layered. To open the affected spaces of the face and neck, the submandibular access is supplemented with a dissection of the anterior edge of the sternocleidomastoid muscle, separating the tissues in layers - subcutaneous adipose tissue, subcutaneous muscle, own fascia of the neck. Pushing back the sternocleidomastoid muscle, the tissues are opened in the circumference of the neurovascular bundle of the neck throughout, depending on the extent of the purulent process. After dissection skin if possible, blunt instruments (grooved probe, closed Kupffer scissors) should be used so as not to damage the blood vessels altered by the pathological process. Treatment of neck phlegmon depends on their location.

– Classification of abscesses and phlegmon of the neck

1. Subcutaneous phlegmon.

2. Phlegmon of the suprasternal interaponeurotic space (locked)

3. Bezold's phlegmon (bed of gr.-key-mastoid muscle) (closed)

4. Dupuytren's phlegmon (the main neurovascular bundle of the neck).

5. Phlegmon of the outer triangle of the neck (between 2 and 5 fascia)

6. Phlegmon of the previsceral space (between sheets of 4 fasciae).

7. Phlegmon of the peripharyngeal space.

8. Phlegmon of the retrovisceral space (4 and 5 fascias).

9. Phlegmon of the pharyngeal space.

10. Subtrapezoid phlegmon.

11. Prevertebral phlegmon.

8. Drainage of abscesses and phlegmon of the neck:

Opening of the submandibular phlegmon. The skin incision is made from the corner mandible anteriorly parallel to its lower edge and 2-3 cm below it. The length of the incision is 5-6 cm. The subcutaneous tissue is dissected, the subcutaneous muscle of the neck with superficial fascia. Special attention turn to passing above, at the edge of the lower jaw, r. marginalis mandibularis n. facialis. Dissect the capsule of the submandibular gland (2nd fascia of the neck) and evacuate the pus. With a purulent lesion of the gland itself, it is removed along with the surrounding tissue and lymph nodes (see Fig. 6.25).

Opening of the phlegmon of the fascial sheath of the cervical neurovascular bundle. Phlegmon vagina carotica are often the result of injury lymph nodes running along the neurovascular bundle. The purpose of the operation is to prevent the spread of the purulent process along the fiber up - into the cranial cavity, down - into the anterior mediastinum and into the previsceral space of the neck. Access is most often carried out through the fascial sheath of the sternocleidomastoid muscle.

An incision in the skin, subcutaneous tissue, subcutaneous muscle of the neck and superficial fascia is made along the anterior edge of the sternocleidomastoid muscle. The front sheet of its case is dissected, the muscle is pulled outward, and then the back sheet and immediately the front sheet are opened along the grooved probe. vagina carotica. With a blunt instrument, they penetrate to the vessels, remove pus, drain the fiber. In case of thrombosis of the internal jugular vein, it is ligated and crossed beyond the boundaries of the thrombus.

An autopsy of the posterior esophageal phlegmon is performed on the left side of the patient's neck. The position of the patient on the back with a roller under the shoulder blades, the head is turned to the right.

Incision of the skin, subcutaneous tissue, platysma and superficial fascia lead along the anterior edge of the left sternocleidomastoid muscle. The superficial sheet of the fascia of the neck (2nd fascia according to Shevkunenko) is opened along the grooved probe and enters the space between the sternocleidomastoid muscle and the neurovascular bundle from the outside and the larynx with the trachea and the thyroid gland inside. In the depth of the wound is the esophagus with the left recurrent laryngeal nerve. The posterior esophageal phlegmon is opened with a finger or a blunt instrument, the cellular space is drained.

Borders anterior section sublingual part of the neck (Fig. 84): from above - the hyoid bone (os hyoideum) and the hind belly m. digastricus, below - the edge of the jugular notch of the sternum (incisura jugularis), behind - the anterior edges of the sternocleidomastoid muscles (m. sternocleidomastoideus).

Rice. 84. Muscles of the neck: 1 - os hyoideum, 2 - m. thyreohyoideus, 3 - muscles of the pharynx, 4 - m. omohyoideus (venter superior), 5 - m. sternohyoideus, 6 - m. sternothyreoideus, 7 - m. sternocleidomastoideus (cms posterior), 8 - m. sternocleidomastoideus (crus anterior), 9 - m. digastricus (venter posterior), 10 - m. splenius capitis, 11 - m. levator scapulae, 12 - m. scalenus medius, 13 - m. scalenus anterior, 14 - m. omohyoideus (venter inferior)

The sublingual part of the neck is divided by the median line into two median triangles of the neck (trigonum colli mediale), each of which, in turn, is divided by the anterior belly of the scapular-hyoid muscle (m. omohyoideus) into the scapular-tracheal (trigonum omotracheale) and sleepy triangle (trigonum caroticum) (Fig. 84).

Rice. 85. Muscles and fascia of the neck (according to V.N. Shevkunenko): 1 - m. platysma, 2 - t. sternocleidomastoideus, 3 - t. sternohyoideus, 4 - t. sternothyreoideus, 5 - gl. thyroidea, 6 - m. omohyoideus, 7 - oesophagus, 8 - m. scalenus anterior, 9 - m. Trapezius

Layered structure(Fig. 85). The skin is thin and mobile. The superficial fascia (the first fascia of the neck according to V. N. Shevkunenko) forms a sheath for the subcutaneous muscle (m. platysma). Under the muscle and the first fascia are superficial vessels and nerves (v. jugularis anterior, n. cutaneus colli) (Fig. 86). Next is the own fascia of the neck (the second fascia according to V.N. Shevkunenko), which is attached at the top to the edge of the lower jaw, at the bottom - to the front edge of the sternum handle. In the lateral direction, this fascia forms a vagina for m. sternocleidomastoideus, and then passes into the lateral triangle of the neck and m. trapezius.

Rice. 86. Veins of the neck (according to M.G. Prives et al.): 1 - a. facialis, 2, 3 - a. facialis, 4 - v. jugularis interna, 5 - v. jugularis externa, 6 - v. jugularis anterior, 7 - arcus venosus juguli, 8 - v. brachiocephalica sinistra, 9 - v. subclavia

The next fascia of the subhyoid region - the scapular-hyoid (the third fascia according to V.N. Shevkunenko) - has a limited extent. At the top, it fuses with the hyoid bone, at the bottom - with the posterior edge of the sternum handle, from the sides - ends, forming a sheath for the scapular-hyoid muscle (m. omohyoidei). In the midline, the second and third fascia are fused with each other, forming a "white line". Only at a height of 3-4 cm above the sternum, the fascia sheets are separated by a well-defined accumulation of fatty tissue (spatium interaponeuroticam suprasternale). Directly above the sternum in the fiber of this space is the arcus vetiosus juguli. The third fascia forms a sheath for four pairs of muscles: mm. sternohyoidei, sternothyreoidei, thyreohyoidei (located on both sides of the midline of the neck in front of the trachea) and mm. omohyoidei (pass in an oblique direction from the large horns of the hyoid bone to the upper edge of the scapula).

Under these muscles is located fascia endocervicalis (the fourth fascia according to V.N. Shevkunenko), consisting of parietal and visceral sheets. The latter surrounds the organs of the neck and forms fascial capsules for them. Between the parietal and visceral sheets of the fourth fascia in front of the trachea there is a cellular space - spatium previscerale (pretracheale), continuing downward into the fiber anterior mediastinum. The parietal sheet of the fourth fascia on the sides of the trachea forms a sheath for the neurovascular bundle of the neck (a. carotis communis, v. jugularis interna, n. vagus), known as spatium vasonervorum. The fiber contained in this vagina, along the neurovascular bundle, also communicates with the cellular space of the anterior mediastinum, which predetermines the possibility of the spread of an infectious-inflammatory process into the mediastinum and the development of mediastinitis.

Behind the larynx, trachea and esophagus on the deep long muscles of the neck (mm. longus colli, longus capitis) is the prevertebral fascia (the fifth fascia according to V.N. Shevkunenko). Between the fourth and fifth fascia, behind the esophagus, there is a retrovisceral cellular space (spatium retroviscerale), which has direct communication with the cellular tissue of the posterior mediastinum.

Thus, in the anterior part of the neck there are interfascial spaces containing accumulations of fiber, in which a purulent-inflammatory process can occur (Fig. 87). These cellular spaces can be divided into two groups: 1) relatively closed and 2) communicating with neighboring areas. A closed cellular space is the suprasternal interaponeurotic space (spatium interaponeuroticum suprasternale). The open cellular spaces include spatium previscerale (communicating with the anterior mediastinum), spatium retroviscerale (communicating above - with the peripharyngeal space, below - with the posterior mediastinum), as well as spatium vasonervoram (communicating with the anterior mediastinum).

Rice. 87. Variants of localization of purulent-inflammatory process in the anterior sublingual region of the neck:
1 - in the subcutaneous fat, 2 - in the suprasternal interaponeurotic cellular space, 3 - in the pregracheal cellular space, 4 - in the interfascial cellular space of the anterolateral part of the sublingual part of the neck, 5 - in the tissue of the fascial sheath of the neurovascular bundle of the neck, 6 - in the periesophageal space , 7 - in the paratracheal space, 8 - in the retrovisceral space

The spread of purulent-infectious processes in the neck can also occur through the lymphogenous route (Fig. 88).

Rice. 88. Lymphatic vessels and nodes of the neck (according to M.G. Prives et al.): 1 - nodi lymphatici submentales, 2 - nodi lymphatici submandibulares, 3 and 6 - nodi lymphatici cervicales profundi, 4 - nodi lymphatici cervicales anteriores superficiales, 5. - nodi lymphatici supraclaviculares

Abscess, phlegmon of the subcutaneous fat of the anterior sublingual part of the neck

Purulent- inflammatory diseases skin (folliculitis, furuncle, carbuncle), infected wounds, the spread of an infectious-inflammatory process from the subcutaneous fat of neighboring anatomical regions (submental, submandibular, sternocleidomastoid regions).

Characteristic local signs of an abscess, phlegmon of the subcutaneous fat of the anterior sublingual part of the neck

Complaints of pain in the anterior neck of moderate intensity.

Objectively. Swelling of the tissues of the anterior part of the neck. On palpation, an infiltrate is determined, limited in area, with clear contours (with an abscess), or occupying a significant area, without clear contours (with phlegmon). The skin over the infiltrate is hyperemic, the pressure exerted on the infiltrate during palpation causes pain. fluctuation can be detected.

Subcutaneous fat of adjacent anatomical regions of the neck and anterior surface chest.

The technique of the operation of opening an abscess, phlegmon of the subcutaneous fat of the anterior section of the sublingual part of the neck

1. Anesthesia - local infiltration anesthesia against the background of premedication, anesthesia.

2. To open purulent-inflammatory foci in the subcutaneous tissue (Fig. 89, A), incisions are used, oriented towards the direction skin folds- horizontal skin incisions passing through the center of the inflammatory infiltrate throughout its entire length (Fig. 89, B, C).
3. Stratifying the subcutaneous fat with a hemostatic clamp, open the purulent-inflammatory focus, evacuate the pus (Fig. 89, D).
4. After hemostasis, tape drainage from glove rubber or polyethylene film is introduced into the wound (Fig. 89, E).

Rice. 89. The main stages of the operation of opening an abscess, phlegmon of the subcutaneous fat of the anterior section of the sublingual part of the neck

5. Apply an aseptic cotton-gauze bandage with a hypertonic solution, antiseptics.

Abscess, phlegmon of the suprasternal interaponeurotic cellular space(spatium interaponeuroticum suprasternale)

The main sources and routes of infection

Infected wounds, suppuration of the hematoma, the spread of the infectious and inflammatory process along the length from adjacent anatomical regions.

Characteristic local signs

Complaints of pain, pulsating nature in the lower part of the anterior neck, aggravated by extension of the neck, swallowing.

Objectively. The swelling of the tissues in the lower part of the anterior neck above the sternum is determined due to the inflammatory infiltrate, the palpation of which causes pain. The skin over the inflammatory infiltrate is moderately hyperemic or has a normal color.

Ways of further spread of infection

Due to the relative closeness of the suprasternal interaponeurotic space, the spread of the infectious-inflammatory process beyond its limits occurs relatively late, after purulent fusion of the second or third fascia of the neck occurs. In the first case, when the integrity of the lamina superficialis fasciae colli propriae is violated, the purulent-inflammatory process spreads along the superficial fascia of the neck (fascia colli superficialis) along the subcutaneous fat to the anterior surface of the chest. In the second case, if the integrity of the lamina produnda fasciae colli propriae is violated, the purulent-inflammatory process spreads along the fourth fascia of the neck (fascia endocervicalis) beyond the sternum, and if the integrity of the parietal sheet of this fascia is violated, it spreads into the pretracheal cellular space (spatium pretracheale) and further into the anterior mediastinum.

The technique of the operation of opening an abscess, phlegmon of the suprasternal interaponeurotic cellular space

2. To open the abscess of the suprasternal interaponeurotic space (Fig. 90, A), a skin incision is used parallel to the upper edge of the sternum handle (Fig. 90, B, C).
3. Dissect the skin, subcutaneous tissue with superficial fascia (fascia colli superficialis) and, spreading the edges of the wound with hooks up and down, expose the surface of the second fascia of the neck (lamina superficialis fasciae colli propriae) (Fig. 90, D).
4. To prevent damage to the veins and jugular venous arch (arcus venosus juguli) located in the suprasternal interaponeurotic cellular space, through a small incision up to 0.5 cm long, a hemostatic clamp is brought under the second fascia of the neck and dissected over the diluted jaws of the clamp throughout the inflammatory infiltrate (Fig. 90, D).

Rice. 90. The main stages of the operation of opening an abscess, phlegmon of the suprasternal interaponeurotic cellular space

5. Stupidly exfoliating the tissue with a hemostatic clamp (to avoid damage to the jugular venous arch!), Move to the center of the purulent-inflammatory focus, open it, evacuate the pus (Fig. 90, E).
6. Stupidly exfoliating the fiber in the lateral directions, carry out an audit of the so-called blind bags (recessus lateralis), located behind the lower end of m. sternodeidomastoideus (Fig. 90, G). Hemostasis.
7. Tape drains made of glove rubber or polyethylene film are inserted through the wound into the purulent-inflammatory focus (Fig. 90, 3).
8. An aseptic cotton-gauze bandage with a hypertonic solution and antiseptics is applied to the wound.

Abscess, phlegmon of the pretracheal cellular space(spatium pretracheale)

The main sources and routes of infection

Infected wounds penetrating into the pretracheal cellular space, a secondary lesion as a result of the spread of an infectious and inflammatory process along the extension from neighboring anatomical regions (lateral parapharyngeal space, sheath of the neurovascular bundle of the neck, suprasternal interaponeurotic cellular space), as well as by the lymphogenous pathway (in the tissue of the space there are lymph nodes).

Characteristic local signs of an abscess, phlegmon of the pretracheal cellular space

Complaints of pain in the lower part of the anterior neck, aggravated by swallowing, coughing, turning and tilting the head.

Objectively. The position of the patient is forced - the head is tilted forward. The jugular cavity is smoothed due to swelling of the tissues of the lower part of the anterior neck. On palpation, an inflammatory infiltrate over the trachea is determined, pressure on which causes pain. Lateral displacement of the larynx also causes pain. Due to the deep localization of the purulent-inflammatory process, hyperemia of the skin may be absent. If there is swelling of the subglottic space of the larynx, hoarseness of voice, shortness of breath may appear.

Ways of further spread of infection

The most likely route for the spread of the infection is to the anterior mediastinum (!). In addition, the purulent-inflammatory process can spread to the peripharyngeal cellular space, and from there to the retropharyngeal space and posterior mediastinum.

The technique of opening an abscess, phlegmon of the pretracheal cellular space

1. Anesthesia - anesthesia (intravenous, inhalation), local infiltration anesthesia against the background of premedication.

Rice. 91. The main stages of the operation of opening an abscess, phlegmon of the pretracheal cellular space

2. With an isolated lesion of spatium pretracheale (Fig. 91, A, B), an abscess is opened, phlegmon is performed with a median approach. The skin incision is made from the middle of the upper edge of the manubrium of the sternum along the midline to the cricoid cartilage (Fig. 91, C, D).
3. After dissection of the superficial fascia of the neck (Fig. 91, D, E, F), the edges of the wound are peeled off with the help of a gauze tupfer and spread with hooks to the right and left, exposing the surface of the second fascia (lamina superficialis fasciae colli propriae).
4. To prevent damage to the veins and jugular venous arch (arcus venosus juguli), located in the suprasternal interaponeurotic cellular space, through a small incision up to 0.5 cm long under the second fascia of the neck (lamina superficialis fasciae colli propriae). a hemostatic clamp is brought in and it is cut over the divorced branches of the clamp along the entire length of the wound.
5. With the help of a hemostatic clamp and a gauze tupfer, the tissue with the vessels in it (arcus venosus juguli) is bluntly stratified and peeled off from the third fascia of the neck (lamina profunda fasciae colli propriae). Carry out hemostasis.
6. Pushing the fiber aside with hooks and finding lamina profunda fasciae colli propriae, dissect it (Fig. 91, G, H). The parietal sheet of the fourth fascia of the neck (fascia endocervicalis) located under it is dissected in the same way - over the diluted branches of the hemostatic clamp placed under it (Fig. 91, I, K). Such layer-by-layer dissection of tissues under visual control reduces the likelihood of damage to the vessels located in this cellular space (a. thyreoidea ima et plexus thyreoideus impar) and the isthmus of the thyroid gland.
7. Stupidly exfoliating the fiber with a hemostatic clamp, they move towards the center of the inflammatory infiltrate, open the purulent-inflammatory focus, evacuate the pus (Fig. 91, L).
8. After the final hemostasis, tape or tubular drainages are introduced into the purulent-inflammatory focus through the wound (Fig. 91, M).
9. Aseptic cotton-gauze dressing with hypertonic solution, antiseptics, and when using tubular drains, connecting them to an apparatus (system) that provides the possibility of dialysis of the wound and vacuum drainage without removing the dressing.

The technique of opening a phlegmon in a secondary lesion of the pretracheal cellular space associated with the spread of an infectious and inflammatory process from the lateral parapharyngeal space or the sheath of the neurovascular bundle of the neck

1. Anesthesia - anesthesia (intravenous or inhalation).

Rice. 92. The main stages of the operation of opening a phlegmon in a secondary lesion of the pretracheal cellular space as a result of the spread of an infectious and inflammatory process from the lateral parapharyngeal space and the fascial sheath of the neurovascular bundle of the neck

The neck incision is made along the anterior edge of the sternocleidomastoid muscle of the corresponding side from the sternoclavicular joint to the lower edge of the thyroid cartilage (Fig. 92, A, B).
3. The subcutaneous fat, superficial fascia of the neck (fascia colli superficialis) is dissected in layers over the entire length of the skin wound. The second and third fascia of the neck, forming the vagina for m. sternocleidomastoideus, m. omohyoideus, m. thyreohyoideus, m. sternothyreoideus (Fig. 92, C, D, E).
4. Stupidly exfoliating the tissue with a hemostatic forceps and pulling it with hooks to the sides, expose the surface of the parietal sheet of the fourth fascia of the neck (fascia endocervicalis) (Fig. 92, E).
5. The parietal leaf of the fascia endocervicalis is incised for 4-5 mm, and then, having brought a hemostatic clamp under it through this incision, under the control of vision, the fascial leaf is dissected over the divorced branches of the clamp throughout the wound (Fig. 92, G).
6. Stupidly exfoliating the tissue with a hemostatic clamp, they move towards the center of the inflammatory infiltrate in the pretracheal cellular space, open the purulent-inflammatory focus, evacuate the pus (Fig. 92, 3).
7. From the same access, exfoliating the fiber with a forceps, they penetrate into the lateral parapharyngeal space, carry out its revision and, if there is a purulent-inflammatory focus in it, open it, evacuate the pus.
8. After hooking m. sternocleidomastoideus laterally expose the surface of the fascial sheath of the neurovascular bundle of the neck, formed by the leaves of fascia endocervicalis.
9. In the presence of infiltration of the tissue of the neurovascular bundle of the neck, the wall of the fascial vagina is incised, a hemostatic clamp is inserted under it, thereby pushing the internal jugular vein, the common carotid artery (v. jugularis interna, a. carotis communis), and under the control of vision, dissect the wall fascial sheath over slightly diluted branches of the clamp, throughout the entire inflammatory infiltrate (Fig. 92, I).
10. In order to create better conditions for drainage of a purulent-inflammatory focus, it is advisable to complete the operation by cutting off the medial pedicle m. sternocleidomastoideus from the place of its attachment to the sternoclavicular joint, as recommended by N.A. Gruzdev (Fig. 92, K).
11. After the final hemostasis, tubular drainages made of soft-elastic plastic are brought through the wound to the purulent-inflammatory foci (Fig. 92, L).
12. Aseptic cotton-gauze bandage with hypertonic solution. Connecting tubular drains to a device (system) that allows dialysis of the wound and vacuum drainage without removing the dressing.

Abscess, phlegmon of the carotid triangle of the neck(trigonum caroticum)

The main sources and routes of infection

Secondary lesion as a result of the spread of an infectious-inflammatory process along the paravasal tissue from neighboring anatomical regions (submandibular, peripharyngeal, retromaxillary), as well as by the lymphogenous route with a delay in the pathogens of purulent infection in the lymph nodes located on the internal jugular vein (nodus lymphaticus jugulodigastricus) (Fig. 93). Purulent-inflammatory diseases of the skin, infected wounds of the area of ​​the carotid triangle.

Characteristic local signs of an abscess, phlegmon of the carotid triangle

Complaints of pain in the area of ​​the carotid triangle of the neck, aggravated by movements of the head, extension of the neck.

Objectively. Swelling of tissues in the region of the carotid triangle of the neck. On palpation under the front edge of m. sternocleidomastoideus in the region of its upper third, a dense infiltrate is determined, the pressure on which causes pain. Pulling m. sternocleidomastoideus outside is also accompanied by the appearance of pain.

Rice. 93. The main stages of the operation of opening an abscess, phlegmon of the region of the carotid triangle of the neck

Ways of further spread of infection

From the carotid triangle, the infectious-inflammatory process along the paravasal tissue can spread to the lower parts of the spatium vasonervorum, then to the anterior mediastinum and to the supraclavicular, and then the subclavian region.

Operation technique for opening an abscess, phlegmon of the carotid triangle of the neck

With the localization of a purulent focus in the carotid triangle (Fig. 93, A, B):

1. Anesthesia - anesthesia (intravenous, inhalation), local infiltration anesthesia against the background of premedication.
2. The skin incision is carried out along the front edge m. sternocleidomastoideus from the level of the angle of the lower jaw to the middle of this muscle (Fig. 93, C, D).
3. The subcutaneous fat, superficial fascia of the neck (fascia colli superficialis) is dissected in layers with the subcutaneous muscle of the neck (m. platysma) enclosed between its sheets (Fig. 93, E, E).
4. Spreading the edges of the wound with hooks and peeling them off with a hemostatic clamp from the surface sheet of the own fascia of the neck (lamina superficialis colli propriae), expose the front edge of m. sternocleidomastoideus (Fig. 93, G).
5. Near the front edge m. sternocleidomastoideus is cut for 4-5 mm lamina superficialis fasciae colli propriae, a hemostatic clamp is inserted through this incision and the fascia is dissected over the diluted jaws of the clamp along the front edge of the muscle throughout the entire wound (Fig. 93, H).
6. Stratifying the underlying tissue with a hemostatic forceps and removing the hooks m. sternocleidomastoideus upwards and backwards, expose the outer wall of the fascial sheath of the neurovascular bundle of the neck, formed by the fourth fascia of the neck (fascia endocervicalis).
7. The outer wall of the fascial sheath of the neurovascular bundle of the neck is incised for 3-4 mm, and then, having passed a Billroth hemostatic clamp between the fascia and the internal jugular vein (v. jugularis interna) through this incision, the wall of the fascial sheath is dissected.
8. Stratifying the paravasal tissue with the help of a hemostatic clamp, the purulent-inflammatory focus is opened, the pus is evacuated (Fig. 93, I).
9. After the final hemostasis, tape or tubular drainages made of glove rubber or polyethylene film are introduced into the spatium vasonervorum (Fig. 93, K).
10. An aseptic cotton-gauze bandage with a hypertonic solution and antiseptics is applied to the wound.

MM. Solovyov, O.P. Bolshakov
Abscesses, phlegmon of the head and neck

Neck phlegmon is one of the most dangerous diseases which, if not treated promptly, can be fatal. This is a purulent inflammation of the soft tissues of the neck, caused by pathogenic bacteria. With phlegmon, a diffuse accumulation of pus develops, which can expand.

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The site provides background information. Adequate diagnosis and treatment of the disease is possible under the supervision of a conscientious physician. All drugs have contraindications. You need to consult a specialist, as well as a detailed study of the instructions! .

Reasons for the development of phlegmon

Diffuse inflammation of the tissues of the neck develops a second time. First, a bacterial infection occurs in other organs.

Then, with the flow of blood and lymph, the bacteria enter the soft tissues neck. The reason is Staphylococcus aureus.

Lead to the development of phlegmon:

• Diseases of the teeth of the lower jaw, in which there are foci of infection, are caries, pulpitis, periodontitis, inflammatory diseases of the tissues surrounding the teeth.
• Infectious processes in the throat and trachea, tonsillitis, pharyngitis and laryngitis. Role plays chronic course these diseases, they require frequent treatment antibiotics.

  The body develops resistance to a large number of bacteria, antibiotics have little effect, the infection can spread to the neck.

• Inflammatory diseases of the lymph nodes of the neck, which, with an unfavorable course, can move to neighboring areas.
• Boils, wounds and scratches on the neck will cause superficial phlegmon.
• General infectious diseases, measles, scarlet fever, diphtheria. The infection enters the neck with blood or lymph.
• The transition of purulent inflammation from the bottom of the mouth.

Classification

Depending on the depth of development of the purulent process, neck phlegmons are superficial and deep.

Superficial - located in the subcutaneous tissue, and deep under the muscular fascia of the neck.

Depending on the place of development, phlegmon are distinguished:

• Chin.
• Submandibular. Often occurs as a complication of infectious processes in the lower molars.
• Superficial, running along the anterior edge of the sternocleidomastoid muscle.
• Interfascial. Formed between the superficial and deep fascia of the neck.
• Superficial phlegmon of the anterior and lateral surface of the neck.
• Phlegmon of the anterior surface of the trachea.
• Posterior surface of the esophagus.
• The pits of the chest.
• Lateral cervical triangle, which is bounded by the sternocleidomastoid muscle, trapezius muscle, and clavicle.
• Anterior surface of the neck.

Phlegmon are:

• Unilateral and bilateral;
• Front, side and back of the neck.

They are primary and secondary. Primary are those that develop on the neck. Secondary - occur during the transition of inflammation from other anatomical areas.

Phlegmon, which develops as a complication of diseases of the lower teeth, is called odontogenic.

Clinical manifestations of the disease

Almost always for phlegmon of the neck moderate or heavy.

Symptoms depend on the location of its localization:

1. Patients complain of neck pain. It can be pain localized on the front surface of the neck or somewhere deep in the neck, pain in the submandibular region.
2. The patient complains of pain when swallowing, eating and talking.
3. Due to the compression of the larynx by the purulent contents of the phlegmon and edema, breathing may become difficult.
4. Suffering general state sick. He often sits with his head tilted forward.
5. Body temperature rises to 38-39.5 degrees Celsius.
6. Blood pressure may drop.
7. Speech is slurred, the face lengthens due to a large number purulent exudate.
8. If the phlegmon is superficial, there is reddening of the skin in this area, it cannot be taken into a fold.
9. With a deep location of suppuration, the skin may be of a normal color, taken in a fold, only look shiny.

Local edema is observed, the severity of which depends on the size and depth of the phlegmon. The more superficially it is located, the more pronounced and localized edema.

If the phlegmon is located deep, the edema looks diffuse, the neck is enlarged. With phlegmon located in front of the trachea or behind the esophagus, hoarseness of the voice is noted.

When probing, phlegmons are dense, sharply painful infiltrates.

Video

Necessary research and diagnostics

Diagnosis of phlegmon includes an examination by a doctor, and, if necessary, the appointment of laboratory and instrumental studies.

On examination, the doctor notes an increase in the patient's neck. With deep phlegmon, the general condition is severe.

The patient is pale, breathing heavily, arterial pressure low, high temperature. The position is forced, with the head tilted forward. On palpation (palpation) of the neck, there is a sharp pain and the presence of a dense infiltrate, without fluctuation.

Puncture is the most reliable method for diagnosing phlegmon. Using a special syringe, the doctor sucks out the contents of the purulent focus. If a yellowish-greenish liquid appears, this is a reliable sign of purulent inflammation.

Puncture is not possible with deep placement of phlegmon, due to the possibility of damage to vital organs, blood vessels and nerves.

AT general analysis blood, there is an acceleration of ESR to 40-50 mm, an increase in the number of leukocytes. Since a blood test takes some time, in a serious condition of the patient, it is not prescribed.

Treatment methods for the disease

Treatment of phlegmon of the neck is carried out by a conservative and surgical method.

1. The conservative method is to use antibacterial drugs. It is rarely used in isolation, with diffuse purulent inflammation this is not enough.
2. The main method of treatment is surgical intervention which is performed under general anesthesia. The surgeon opens the purulent focus, followed by its drainage with tubular drainage.

   Due to the location in the neck of many vital organs and vessels that feed main brain, opened phlegmon is accompanied by a number of complications.

   Arrosion may occur - damage to blood vessels, or damage to vital organs located in the neck. Often there is asphyxia (suffocation), requiring a tracheotomy.

   For surgical access, incisions are often made along the anterior edge of the sternocleidomastoid muscle or in the region of the jugular fossa.

After stabilization of the patient's condition, appoint drug treatment. It is aimed at destroying the bacteria that caused inflammation and the formation of pus, at general strengthening of the body and accelerating healing.

On the first day after surgery, the patient may need intramuscular injection of painkillers.

The doctor decides which antibiotic to prescribe after determining the causative agent of phlegmon. Antibiotic therapy is continued until the patient's condition is completely normalized.

Effective prevention of phlegmon

Prevention of neck phlegmon is reduced to minimizing the possibility of injuries in this area, and if they do occur, they must be urgently treated with an antiseptic solution.

Carious and inflammatory processes must be treated in time. An important role in prevention is played by timely detected and cured inflammatory processes and diseases of internal organs.

What is the difference between phlegmon and abscess

Inflammatory processes with the release of pus in tissues that are locked in a certain place under the skin are called abscesses. Not localized inflammation with pus appearing under the skin - phlegmon. Have you heard of cellulite? When it is mentioned, they mean serous inflamed processes of fatty tissue, but without pus.

If these diseases cannot be distinguished, a puncture is used for diagnostic purposes, pus and tissue are taken. Bacteriological analysis will help determine the pathogen and its resistance to antibiotics. We have determined that cellulitis and abscesses are similar but different diseases.

The main cause of phlegmon is the division of pathogens. Staphylococci, streptococci, Pseudomonas aeruginosa, coli and this is not the whole list.

Diffuse swelling of the neck appears only at the second stage of development. The infection settles in other organs. After it spreads through the blood into soft tissues. The cause of development is Staphylococcus aureus.

More precise reasons for development:

1. Diseases of the teeth in the lower jaw, along with a developed inflammatory process. For example, pulpitis, caries, gum disease, periodontitis.
2. Infections of the respiratory tract and organs, inflammation in the throat and trachea. Especially when such inflammations take chronic form their treatment will require frequent use of antibiotics. The body will not be able to fight bacteria, and they can get into the neck.
3. Inflammation of the lymph nodes in the neck.
4. Various wounds on the neck, possibly boils, will help to become the cause.
5. General infectious diseases. The infection is carried by blood to the neck.
6. Purulent inflammation can descend from the oral cavity down the neck.

The rudiments, which as a result can turn into phlegmon on the neck - abscesses on the face or inflammation in the mouth, upper paths breathing, osteomyelitis of the cervical vertebrae, wounds on the neck.

The appearance of tumors on the neck is determined by factors:

• The network of lymph nodes is well developed;
• An individual feature of the structure of the cervical fascia.

A swelling of the lower jaw, chin is formed on the neck. The tumor is at first dense, later it acquires a bumpy appearance.

Possible complications and deep forms of phlegmon

The most common infections will cause the development of serious diseases:

• Lymphadenitis;
• Lymphangitis;
• erysipelas;
• thrombophlebitis;
• Sepsis.

Facial swelling may be exacerbated by purulent meningitis.

If the inflammation begins to spread to nearby tissues, development is possible:

• osteomyelitis;
• Purulent pleurisy;
• tendovaginitis;
• Purulent arthritis.

The last one is the most dangerous complication. Since the arterial wall becomes inflamed, it then dissolves and severe arterial hemorrhage occurs.

Deep phlegmon of the limbs are inflammations with pus that diverge through the intermuscular spaces. The source of such inflammation will be various wounds on the skin. For example, a bite, scratch, burn, or illness, panaritium, purulent arthritis, or osteomyelitis.

The disease is characterized by pain in the limbs, increased body temperature, there is a general weakness of the body. The disease does not wait long and develops rapidly. As a result, tissue edema is seen, the lymph nodes in the region increase and the limb increases greatly. If the phlegmon is located on the surface, hyperemia and swollen skin can be observed.

Purulent mediastinitis. It is a purulent inflammatory process located in the tissue of the mediastinum.

Often mediastinitis is a form of perforation complication:

• Esophagus and trachea;
• Purulent formations in the mouth;
• In the pulmonary tract;
• A complication of phlegmon of the neck;
• The result of obtaining a hematoma;
• Osteomyelitis of the sternum or spine.

This problem develops rapidly, the patient may experience severe pain behind the sternum, the body temperature will rise. The pain will move to the back and neck. The neck and chest will swell. To reduce pain, people often sit in a seated position and tilt their head forward, apparently this method works.

Increased in people heartbeat, decreased blood pressure, dilated veins in the neck, and they complained of pain when swallowing.

Treatment with folk remedies

Let's start with propolis, St. John's wort and cloves.

Recipe one

Ingredients:

• 150 ml of vodka;
• 25 g of propolis;
• 50 g St. John's wort.

Cooking:

• Grind propolis in a mortar;
• Pour vodka into it;
• Finely chop St. John's wort and mix;
• This must be carefully closed and left to infuse for about a week;
• Sometimes you need to shake off the bottle.

After a week, you need to strain the resulting product and rinse your mouth. To do this, 50 drops should be diluted in a glass of water, rinsed about 5 times a day.

Second recipe

Cooking:

• Pour cloves (a tablespoon) into a glass of water;
• Boil for about 3 minutes (slow fire);
• The resulting product must be insisted for about 1 hour and filtered;

The decoction can be used as a compress, or drink 4 times a day for a tablespoon.

Third recipe

• Pour 3 tablespoons of cloves into 1 liter of boiled water;
• Leave to infuse for about 1 hour, strain.

A decoction can be used for a compress, applied to an inflamed joint. If taken orally, then you need to drink in small sips in a warm state.

Eucalyptus and birch buds.

Cooking:

• Pour 10 grams of kidneys into a glass of boiled water;
• Boil 15 minutes (slow fire);
• Strain and apply to the problem area;
• Take about 4 times a day for a tablespoon.

Second recipe.

• Take a thermos and pour 2 tablespoons of blue eucalyptus into it;
• Pour 500 ml of boiling water;

4.6 / 5 ( 9 votes)

With the localization of a purulent focus in the carotid triangle (Fig. 93, A, B):

1. Anesthesia - anesthesia (intravenous, inhalation), local infiltration anesthesia against the background of premedication.

2. The skin incision is carried out along the front edge m. sternocleidomastoideus from the level of the angle of the lower jaw to the middle of this muscle (Fig. 93, C, D).

3. The subcutaneous fat, superficial fascia of the neck (fascia colli superficialis) is dissected in layers with the subcutaneous muscle of the neck (m. platysma) enclosed between its sheets (Fig. 93, E, E).

4. Spreading the edges of the wound with hooks and peeling them off with a hemostatic clamp from the surface sheet of the own fascia of the neck (lamina superficialis colli propriae), expose the front edge of m. sternocleidomastoideus (Fig. 93, G).

5. Near the front edge m. sternocleidomastoideus is cut for 4-5 mm lamina superficialis fasciae colli propriae, a hemostatic clamp is inserted through this incision and the fascia is dissected over the diluted jaws of the clamp along the front edge of the muscle throughout the entire wound (Fig. 93, H).

Rice. 93. Continued

6. Stratifying the underlying tissue with a hemostatic forceps and removing the hooks m. sternocleidomastoideus upwards and backwards, expose the outer wall of the fascial sheath of the neurovascular bundle of the neck, formed by the fourth fascia of the neck (fascia endocervicalis).

7. The outer wall of the fascial sheath of the neurovascular bundle of the neck is incised for 3-4 mm, and then, having passed a Billroth hemostatic clamp between the fascia and the internal jugular vein (v. jugularis interna) through this incision, the wall of the fascial sheath is dissected.

8. Stratifying the paravasal tissue with the help of a hemostatic clamp, the purulent-inflammatory focus is opened, the pus is evacuated (Fig. 93, I).

9. After the final hemostasis, tape or tubular drainages made of glove rubber or polyethylene film are introduced into the spatium vasonervorum (Fig. 93, K).

10. An aseptic cotton-gauze bandage with a hypertonic solution and antiseptics is applied to the wound.

7.2.2. Abscesses, phlegmon of the lateral neck (regio cervicalis lateralis) and
region of the sternocleidomastoid muscle (regio sternocleidomastoidea)

Outside of the anterior region of the neck is the sternocleidomastoid muscle, the projection of which corresponds to the region of the same name (regio sternocleidomastoidea). A characteristic feature of this area is the presence of a dense relatively closed fascial case of the sternocleidomastoid
muscles formed by the second fascia of the neck. In the subcutaneous fatty tissue of this area, crossing the posterior edge of the muscle, the external jugular vein (v. jugularis externa) passes. Under the muscle in the lower part of the region, the main neurovascular bundle of the neck (a. carotis communis, v. jugularis interna, n. vagus) is projected. Behind him under the fifth fascia of the neck is a sympathetic trunk (truncus sympathicus).

Rice. 94. Muscles of the lateral sublingual part of the neck: 1 - m. sternocleidomastoideus, 2 - t. omohyoideus (venter inferior), 3 - t. scalenus anterior, 4 - t. Sptenius capitis, 5 - m. longus capitis, 6 - m. levator scapulae, 7 - m. scalenus posterior, 8 - m. scalenus medius

The lateral neck (trigonum colli laterale) is limited: in front - by the posterior edge of the sternocleidomastoid muscle, behind - by the edge of the trapezius muscle, from below - by the clavicle. The scapular-hyoid muscle divides trigonum colli laterale into two more triangles: trigonum omoclaviculare and trigonum omotrapezoideum (Fig. 94).

layered structure. The skin is thin, superficial fascia contains fibers m. platysma. In fatty tissue under the fascia are branches nn. Supraclaviculares (from the cervical plexus), innervating the skin of the area, as well as the external jugular vein, which is in the angle between the clavicle and m. sternocleidomastoideus perforates the fascia and flows into subclavian vein. The second fascia of the neck within the lateral triangle, and especially above the clavicle, is represented by a dense sheet and fuses with the upper edge of the clavicle. The third fascia with the muscle wrapped in it (m. omohyoideus) extends only in the supraclavicular region of the lateral triangle. Between the second and third fascia is fatty tissue (saccus coecus retrosternocleidomastoideus), which is a continuation to the lateral side of the tissue of the suprasternal interaponeurotic space.

Under the third fascia there is a cellular space closed behind the prevertebral (fifth) fascia of the neck. The latter covers the scalene muscles here (mm. scaleni anterior, medius et posterior). Directly above the clavicle under the fifth fascia passes the subclavian artery and the brachial nerve plexus, which enters the supraclavicular region through the gap between the anterior and middle scalene muscles (spatium interscalenum). The lower wall of the subclavian artery in this area is adjacent directly to the dome of the pleura. Anterior to the artery behind the clavicle lies the subclavian vein, which runs into the spatium antescalenum. The phrenic nerve (n. phrenicus) passes along the anterior surface of the anterior scalene muscle in a vertical direction. Along the course of the artery and vein, the supraclavicular cellular space through the pre- and interstitial spaces communicates with the tissue of the anterior neck and anterior mediastinum. In the lateral direction, through the gap between the clavicle and the first rib, the paravasal tissue continues into the axillary region. Above the clavicle from a. subclavia depart a. thoracica interna, a. vertebralis, tr. thyreocervicalis. In addition to the tributaries of the arterial branches of the same name, the external jugular vein flows into the subclavian vein, and the ductus thoracicus (thoracic lymphatic duct) flows into the venous angle formed by the internal jugular and subclavian veins on the left side.

In the lateral triangle of the neck above the scapular-hyoid muscle from under the posterior edge of m. sternocleidomastoideus branches out of the cervical plexus.

In the lateral part of the neck, as can be seen from the above, there are interfascial and intermuscular fissures containing abundant accumulations of fiber:

1) relatively closed fascial sheath of the sternocleidomastoid muscle,

2) deep interfascial space of the supraclavicular region (along the subclavian artery and vein, it communicates with the tissue of the anterior region of the neck, mediastinum, axillary region, paravasal tissue of the general carotid artery and internal jugular vein)

3) the cellular space of the upper part of the lateral triangle of the neck (tr. omotrapezoideum) located between the second and fifth fascia of the neck.

It should also be borne in mind that during the destruction (purulent fusion) of the posterior wall of the vagina m. sternocleidomastoideus, it is possible to form a purulent flow in the spatium vasonervorum of the main neurovascular bundle of the neck (a. carotis communis, v. jugularis interna, n. vagus).

13.1. TRACHEOSTOMY

Tracheostomy is an operation to form an artificial external fistula of the trachea (tracheostomy) after opening its lumen. The incision of the wall of the trachea is called a tracheotomy, and it is a step in performing a tracheostomy.

Tracheostomy is divided into upper, middle and lower. The reference point for the subdivision is the isthmus of the thyroid gland. It is adjacent to the trachea in front at the level from the 1st to the 3rd or from the 2nd to the 4th of its cartilages.

In case of upper tracheostomy, the opening of the tracheal lumen is performed above the isthmus of the thyroid gland by dissection of the 2nd and 3rd semirings, in the case of the middle one, at the level of the isthmus after its intersection and dilution of the stumps to the sides, in case of lower tracheostomy, the trachea is opened below the isthmus, usually 4- e and 5th cartilaginous semirings.

A special type of tracheostomy is percutaneous puncture microtracheostomy (tracheocentesis). Microtracheostomy (micro + tracheostomy) - tracheal puncture through the skin, produced by a thick surgical needle along midline neck under the thyroid cartilage. Through a puncture with the help of a conductor, a thin elastic tube is inserted into the lumen of the trachea to suck the contents from the trachea and bronchi, introduce medicines or high-frequency injection ventilation of the lungs.

Indicationsto tracheostomy: upper airway obstruction - to prevent mechanical asphyxia; violation of the patency of the lower respiratory tract due to the ingress of aspiration and secretion products - for drainage and sanitation of the respiratory tract; violation of spontaneous breathing due to trauma to the chest, cervical segments of the spinal cord, acute vascular pathology brain, etc. - for artificial ventilation of the lungs; carrying out intubation anesthesia if it is impossible to intubate through the mouth or nose.

Depending on the timing of tracheostomy, it is divided into emergency, urgent, planned and preventive.

Emergency tracheostomy is performed as soon as possible with minimal or no preoperative preparation, in some cases without anesthesia at the patient's bedside, and in field conditions with improvised means.

Indications for emergency tracheostomy are: obstructive asphyxia when closing the lumen of the larynx with a foreign body, tight tamponade of the oral cavity and pharynx in order to stop massive bleeding, aspiration asphyxia when it is impossible to suction the aspirated masses, stenotic asphyxia due to compression of the larynx and trachea by a rapidly growing hematoma, wounds of the larynx . Emergency tracheostomy is performed with paralysis and spasm of the vocal folds, acute stenosis of the larynx III-IV degree. Acute stenosis is most often caused by inflammatory and toxic-allergic lesions of the larynx, phlegmon of the floor of the mouth, tongue, peripharyngeal space, and neck.

Urgent tracheostomy is performed after short-term (within several hours) conservative treatment of acute respiratory failure, if the measures taken do not lead to an improvement in the patient's condition, for tracheal intubation and anesthesia in case of urgent operations for diseases accompanied by restriction of mouth opening, severe swelling of the tissues of the floor of the mouth, pharynx, larynx, preventing intubation. It is performed for long-term artificial ventilation of the lungs in violation of spontaneous breathing caused by chest injuries, traumatic brain injury, spinal injury, disorder cerebral circulation, poisoning, poliomyelitis, tetanus.

A planned tracheostomy is performed for intubation anesthesia through a tracheostomy during elective operations, if intubation through the mouth or nose is not possible or the operation is performed on the larynx. Indications for planned tracheostomy may occur with chronic progressive stenosis of the larynx, its gradual compression by neck tumors, with impaired patency of the lower respiratory tract by inflammation and secretion products for drainage and sanitation of the trachea and bronchi.

Prophylactic tracheostomy is performed as a stage of extended surgical intervention for tumors of the floor of the mouth, tongue and lower parts of the face, neck organs, during operations on the lungs, heart, trachea, esophagus. The need for a tracheostomy arises

in these cases, due to the possibility of developing severe edema in the laryngopharynx and larynx due to surgical trauma, for artificial ventilation of the lungs and performing endotracheal or endobronchial therapeutic interventions in postoperative period.

Tracheostomy is a high-risk operation because it is performed close to main vessels and vital organs of the neck.

Tools.To perform a tracheostomy, a set of general surgical and special instruments is required: a scalpel - 1, hooks for expanding the wound - 2, sharp single-toothed hooks - 2, a grooved probe - 1, hemostatic clamps - 6, a needle holder - 1, scissors - 1, a two- or three-bladed Trousseau dilator - 1, tracheotomy tubes? 1, 2, 3, 4, 5, 6, surgical and anatomical tweezers, surgical needles (Fig. 13.1). In addition to this kit, an anesthetic solution for infiltration anesthesia, suture threads, 1% dicaine solution, a towel, gauze balls and napkins are needed.

Fig.13.1.Percutaneous Dilated Tracheostomy Kit

Patient position: on the back, under the shoulders at the level of the shoulder blades, a roller 10-15 cm high is placed, the head is thrown back (Fig. 13.2).

Upper tracheostomy technique. The surgeon is located to the right of the patient, the assistant is on the other hand, the operating nurse is to the right of the assistant at the table for surgical instruments. After processing the surgical field, the midline of the neck is marked on the skin, from the lower edge of the thyroid cartilage to the notch of the sternum, usually with a brilliant green solution. This line serves as a guide for the direction of the cut.

The skin incision for access to the trachea can be vertical and transverse. A transverse incision is used by some surgeons, making it 1-2 cm below the cricoid arch. They believe that the transverse wound on the neck gapes less, heals faster, and the scar after healing is less noticeable. In clinical practice, a vertical skin incision is more often used.

Identification points when performing a tracheostomy are the angle of the thyroid and the arc of the cricoid cartilage. The surgeon places the 1st and 3rd fingers of the left hand on the lateral surfaces of the thyroid cartilage, and places the 2nd finger in the gap between the thyroid and cricoid cartilages. This achieves reliable fixation of the larynx,

Fig.13.2.The position of the patient during tracheostomy and the location of the surgeon's fingers for fixing the larynx (from: Preobrazhensky B.S. et al., 1968)

and with it the trachea and keeping them in the median plane. A skin incision is made along a predetermined midline; it starts under the protrusion of the thyroid cartilage and continues down 6-7 cm in adults and 3-4 cm in children. Cut through the skin with subcutaneous tissue, superficial fascia of the neck. Bleeding from the skin vessels is stopped by clamping with hemostatic forceps and bandaging them or by electrocoagulation. The assistant stretches the edges of the wound with blunt hooks.

Look for the white line of the neck. It is formed by the second and third fasciae of the neck, which merge with each other at the level of the isthmus of the thyroid gland along the midline, forming an aponeurosis. The width of the white line is 2-3 mm, downwards it does not reach the notch of the sternum by about 3 cm, where the fasciae diverge and form the interaponeurotic suprasternal space. The white line of the neck is usually clearly visible, it corresponds to the gap between the right and left sternohyoid muscles. In its projection, the fused sheets of the second and third fascia of the neck are incised strictly along the midline with a scalpel in the lower part of the wound, peeled off from the underlying tissues with a curved hemostatic clamp, dissected along a grooved probe. When carrying out this stage of the operation, it should be borne in mind that the anterior jugular veins descend down the anterior surface of the sternohyoid muscles, and sometimes they merge into one vessel - the median vein of the neck, which is located in the midline. This vein is either taken aside with a blunt hook, or crossed between two ligatures.

Rice. 13.3.Scheme of the location of injection points and directions for introducing an anesthetic solution during infiltration anesthesia during tracheotomy; the arrows show the direction of advancement of the needle and the introduction of the anesthetic solution (from: Babiyak V.I., Nakatis Ya.A., 2005).

trachea. To do this, the right and left sternohyoid muscles are separated along the midline with a clamp, then pushed apart with blunt hooks along with the anterior jugular veins. Visually and by palpation, the cricoid cartilage and the isthmus of the gland located under it are determined. It should be remembered that above the cricoid cartilage is the cricoid muscle, which can be mistaken for the isthmus. On the sides of the trachea is the thyroid gland, which differs from the surrounding tissues in a softer texture and a peculiar brown-red color.

The surgeon's next task is to move the isthmus downward to expose the upper tracheal rings. A sheet of the fourth fascia of the neck is dissected along the lower edge of the cricoid cartilage, connecting the isthmus and cartilage (Bose's ligament) (Fig. 13.4 and 13.5).

With a blunt instrument (Buyalsky's scapula, closed Cooper's scissors), the isthmus is separated, together with the fascia covering it from behind, from the cricoid cartilage and trachea, with a blunt hook they are displaced downward and the three upper half-rings of the trachea are exposed. Certain difficulties in performing an upper tracheostomy can be created by the pyramidal lobule of the thyroid gland, which

Rice. 13.4.The line of dissection of the quarter Rice. 13.5. Isthmus retraction

that fascia of the neck along the lower edge of the thyroid gland downward blunt

cricoid cartilage (from: Yermola - hook and exposure of the upper rings

ev V.G., Preobrazhensky B.S., 1954) trachea

occurs in 1/3 of people. To perform an upper tracheostomy, the lobule should be cut between two hemostatic forceps, the stumps should be stitched and tied with catgut.

The next step is to open the lumen of the trachea. Even a slight bleeding must first be stopped. Bleeding vessels, if the patient's condition allows, it is better to tie up before opening the trachea, otherwise they should be left under clamps; the wound is dried with gauze pads. Failure to comply with this rule leads to blood entering the trachea, which causes coughing, increased intrathoracic and arterial pressure, increased bleeding, and in the postoperative period, pneumonia may occur.

To facilitate the opening of the trachea in the midline, its fixation is necessary. For this purpose, a sharp single-toothed hook is used to pierce the arch of the cricoid cartilage or the ligaments of the latter - cricotracheal, cricoid, or capture the 1st ring of the trachea. The assistant pulls the larynx and trachea up with a hook and fixes them in the middle position, the isthmus is retracted downward with a blunt hook.

Before opening the trachea, it is advisable to inject into its lumen with a syringe through the gap between the cartilages 0.25-0.5 ml of a 1-2% dicain solution to suppress the cough reflex. Cotton wool is wound around the scalpel blade, which delimits the free sharp end 1 cm long, so that when dissecting the trachea, it does not damage its back wall.

The anterior wall of the trachea is dissected by vertical, horizontal, patchwork incisions or a section with a diameter of 10-12 mm is excised in it to form a permanent tracheostomy.

The 2nd and 3rd tracheal rings are crossed with a vertical incision (Fig. 13.6). In this case, a pointed scalpel is pushed into its lumen to a depth of not more than 1 cm above the isthmus of the thyroid gland and advanced from the bottom up, and not vice versa, so as not to damage the gland and its venous plexus. It is not recommended to cross the 1st cartilage of the trachea and the cricotracheal ligament because of the possibility of subsequent development of chondroperichondritis of the larynx.

Signs of opening the lumen of the trachea are a short-term breath holding, a characteristic whistling sound due to the passage of air through a narrow gap, the appearance of a cough, accompanied by the release of mucus and blood. Opening the lumen of the trachea is a critical step in the operation. The mucous membrane of the trachea with its inflammatory and infectious diseases easily exfoliates from the perichondrium, which can create a false

Rice. 13.6.Dissection of the cartilage of the larynx with a vertical incision at the upper tracheostomy. The trachea is fixed with a sharp hook, the isthmus of the thyroid gland is moved downward with a hook

the impression of penetration into the lumen of the trachea, which entails a gross mistake - inserting a tracheotomy tube not into the lumen of the trachea, but between its wall and the exfoliated mucous membrane (Fig. 13.7). This leads to a rapid increase in the phenomena of asphyxia in the patient. In such cases, a sharp hook should be injected into the mucous membrane, pulled up, and cut with a scalpel in a vertical direction.

With a longitudinal section of the soft tissues above the trachea, it is possible

Rice. 13.7.Error when opening the lumen of the trachea - the mucous membrane is not dissected, the tracheotomy tube is inserted between it and the wall of the trachea

opening its lumen with a transverse incision of the anterior wall (longitudinal-transverse tracheostomy according to V.I. Voyachek). The dissection is made between the 2nd and 3rd rings, while the scalpel is injected into the gap between them, consisting of dense fibrous tissue, from the side, with the blade up to a depth that allows you to immediately penetrate the tracheal cavity.

Method of patchwork opening of the lumen of the trachea according to Bjork consists in cutting out a rectangular flap on its front wall on the lower feeding leg, while holding the trachea on both sides with sharp hooks. This flap is turned forward and downward and sutured to the skin at the bottom of the wound.

A tracheostomy for long-term or permanent use is formed by cutting out a hole with a diameter of 10-12 mm in the tracheal wall at the level of the 2nd-4th cartilage (Fig. 13.8). The edges of the hole are sutured to the skin with 4-6 nylon sutures. The edges of the skin, when tightening the sutures with two surgical forceps, are screwed into the lumen of the trachea.

Rice. 13.8.Scheme of cutting a hole on the anterior wall of the trachea for the formation of a permanent tracheostomy:

1 - cricoid cartilage; 2 - thyroid gland; 3 - excised section of the tracheal wall; 4 - isthmus of the thyroid gland

Many methods have been proposed for the formation of a permanent tracheostomy, functioning without a tracheostomy tube with complete removal of the larynx. The generally accepted method is A.I. Kolomiichenko, along which the median incision on the neck is completed by excision of the skin in the form of a racket above the jugular notch of the sternum. At the final stage of the laryngectomy operation, the tracheal stump is sutured into an oval skin defect and a tracheostomy is formed.

An important detail when performing a tracheostomy is the size of the incision in the wall of the trachea. It should correspond to the diameter of the tracheostomy tube. With a cut that is much larger than the diameter of the tube, air penetrates from the trachea into the tissue gaps under the sutures on the wound and subcutaneous emphysema occurs. The introduction of the tube into a narrow incision leads to necrosis of the mucous membrane and sections of the cartilage of the trachea, followed by the development of granulations and its stenosis.

After opening the trachea, a Trousseau dilator is inserted into its lumen, the edges of the wound are parted, and a tracheostomy cannula is inserted under its protection (Fig. 13.9).

The tracheostomy cannula is inserted in three stages. At the first stage, the end of the cannula is inserted from the side, the shield is in a vertical position; at the second stage, the cannula with the end inserted into the trachea is turned 90? clockwise down and rotating in

Rice. 13.9.Scheme of insertion of the Trousseau dilator and the initial stage of introducing a tracheostomy tube into the lumen of the trachea (from: Grigoriev G.M. et al., 1998)

the sagittal plane is moved into the lumen of the trachea; on the third - the tracheostomy cannula is completely inserted into the tracheal cavity until the shield comes into contact with the skin.

After the introduction of the tracheostomy tube, guide sutures are placed on the upper and lower corners of the wound.

The operation is completed by fixing the tracheostomy tube. To do this, two long gauze ties are threaded into the ears of the shield of the tracheostomy cannula, which form 4 ends. They are tied around the neck in a knot with a bow on the side so that the index finger can fit between the ties and the neck. Under the shield from below, several gauze napkins folded together with an incision in the middle to half, into which the tube lies, are placed. A second napkin folded in several layers is placed under the upper ends of this napkin. Then a gauze bandage is applied above the opening of the tracheostomy tube. After that, an apron made of medical oilcloth with a cutout for the tube is brought directly under the shield so that the discharge from it does not soak the bandage. The apron, with the help of ties attached to its upper ends, is tied to the neck in the same way as a tracheostomy cannula.

Technique for performing a middle tracheostomy. The technique for performing this operation is basically similar to the technique of upper tracheostomy, it includes only one additional step - the intersection of the isthmus of the thyroid gland. After the isthmus is exposed and the ligament between it and the cricoid cartilage is dissected, it is bluntly separated from the trachea. Then two hemostatic clamps are applied to the isthmus and crossed between them. The stump of the isthmus is stitched, tied with catgut and bred to the sides with hooks. The remaining stages of the operation are performed as in the upper tracheostomy.

Technique of the lower tracheostomy. The lower semirings of the cervical trachea are separated from the skin of the anterior surface of the neck by subcutaneous tissue, superficial and proper fascia of the neck, suprasternal cellular space, sheet of the third fascia, pretracheal cellular space, the trachea itself is covered with a visceral sheet of the fourth fascia.

The position of the patient on the back with a cushion placed under the shoulders and the head thrown back. The surgeon fixes the larynx with the fingers of the left hand. The incision is made strictly along the midline of the neck from the tubercle of the cricoid cartilage to the jugular notch of the sternum. Dissect the skin, subcutaneous tissue, superficial fascia of the neck, under which

the median vein of the neck may be located. It is isolated from the fiber with a clamp, taken outward or crossed between two ligatures.

The fiber of this space along the midline is bluntly separated with a clamp, while the jugular venous arch is found in the lower part of the wound. With blunt hooks, the fiber is pulled apart, the venous arch is moved downward, after which the third fascia of the neck is exposed.

It is dissected in the middle in the longitudinal direction and somewhat separated on the sides of the incision, which makes it possible to detect the sternohyoid and sternothyroid muscles. With blunt hooks, the muscles are bred to the sides, under them is the parietal sheet of the fourth fascia of the neck.

This sheet is carefully incised or bluntly separated in a small area, peeled off through the incision with a curved clamp and dissected along a grooved probe, the edges of the wound are bred with hooks, after which the pretracheal cellular space is opened.

It is advisable to examine the space with a finger, which will help the surgeon navigate the position of the trachea and timely detect large arteries abnormally located in front of it, feeling their pulsation (Fig. 13.10).

The fiber of the pretracheal space is bluntly separated along the midline to the anterior wall of the trachea and bred to the sides, the meeting vessels are moved aside, protected with blunt hooks, or crossed between ligatures. It is especially necessary to manipulate near the sternum because of the danger of injuring large venous and arterial vessels.

The trachea is bluntly released from the visceral sheet of the fourth fascia of the neck that envelops it. In the upper corner of the wound, the isthmus of the thyroid gland is found, it is separated from the trachea and pulled up with a blunt hook to expose the 4th-5th cartilaginous semirings. Produce a thorough stop bleeding, the wound is dried with gauze napkins.

A sharp single-toothed hook is injected into the anterior wall of the trachea, it is pulled up and towards the surgical wound and fixed in this position. 0.25-0.5 ml of 1% dicaine solution is injected into the lumen of the trachea through a puncture of the wall with a needle.

The isthmus of the thyroid gland is protected with a blunt hook. With the movement of the scalpel from the bottom up, two tracheal rings are cut, usually the 4th and 5th or 5th and 6th. The size of the incision should correspond to the diameter of the tracheostomy tube. In addition to the vertical one, a horizontal (transverse) incision is also made, a patchwork incision according to Bjork, excision of the tissues of the anterior wall of the trachea to create an opening in it.

The edges of the wound of the trachea are diluted with a Trousseau dilator or a curved clamp introduced into it, a tracheostomy cannula is inserted into the hole.

The final stage of the operation is the same as for the upper tracheostomy.

Complications of tracheostomy and their prevention. Complications during tracheostomy often occur with the restless behavior of the patient and the performance of an emergency operation during the onset or onset of clinical death.

If the incision was not made strictly along the midline, then the assistant can grab the trachea along with the soft tissues with a hook, move it to the side, which prevents its detection. The situation in this case can become threatening, especially with an emergency tracheostomy. If the trachea cannot be found within 1 min, and the patient is in a state of complete or almost complete airway obstruction, then the cricoid ligament is immediately dissected together with the cricoid cartilage arch, in some cases the thyroid cartilage is dissected.

After restoration of breathing and carrying out the necessary resuscitation measures, a typical tracheostomy is performed, and the dissected parts of the larynx are sutured.

The occurrence of complications during tracheostomy is facilitated by violations of the topographic relationships of the anatomical structures of the neck due to various pathological processes. Violations cause pronounced edema and tissue infiltration in purulent-inflammatory diseases and injuries of the neck, floor of the mouth, tongue, cancer metastases in the paratracheal lymph nodes, previously undergone surgery on the neck. With asphyxia, numerous veins of the thyroid gland overflow with blood, which significantly increases its volume and aggravates difficulties during tracheostomy. As already mentioned, the abnormal location of large arterial trunks in front of the lower cervical

Rice. 13.10.Variants of the relationship between the cervical part of the trachea and large arteries (from: Zolotko Yu.L., 1964): 1 - common carotid arteries are located on the sides of the trachea; 2 - brachiocephalic trunk partially covers the cervical part of the trachea; 3 - the brachiocephalic trunk is located in front of the trachea; 4 - the left common carotid artery partially closes the trachea; 5 - above the jugular notch of the sternum handle protrudes the aortic arch; 6 - in front of the trachea is the lowest thyroid artery

parts of the trachea creates the possibility of injury and the occurrence of dangerous bleeding.

To the most frequent complications tracheostomy includes respiratory arrest after opening the lumen of the trachea, bleeding from the lower thyroid veins, the isthmus and the thyroid gland itself in case of accidental injuries. In case of bleeding, the veins are tied up, the bleeding areas of the gland and the isthmus are sheathed with catgut sutures. There may be injuries to the posterior wall of the trachea and esophagus and, as already indicated, detachment of the mucous membrane and the introduction of a tube between it and the tracheal rings (Fig. 13.11 and 13.12).

Rice. 13.11.Scheme of the formation of the valve mechanism in the tracheostomy tube. A torn and collapsed obturator cuff prevents exhalation

Rice. 13.12.Scheme of the mechanism of pressure of the tracheostomy tube on the wall of the trachea

Cases of damage to the dome of the pleura with the occurrence of pneumothorax, erroneous opening of the esophagus instead of the lumen of the trachea, complete rupture of the trachea with a rough insertion of a tracheostomy tube into a hole of insufficient diameter are described. These complications can be avoided by carefully performing the technique of surgical intervention.

13.2. CONYCOTOMY

Conicotomy - dissection of the median cricothyroid (conical) ligament (lig. Cricothyroideum medianum), located between the lower edge of the thyroid and the upper edge of the cricoid cartilage of the larynx.

Between the conical ligament and the skin along the midline of the neck there is a thin layer of subcutaneous tissue and there is an insignificant layer of muscle fibers, there are no large vessels and nerves. The middle laryngeal artery runs along the lower edge of the thyroid cartilage. In order not to damage this artery during the conicotomy operation, a transverse incision of the median cricoid (conical) ligament should be made closer to the cricoid, and not to the thyroid cartilage. Sometimes the middle part of the ligament is perforated by relatively thin cricoid arteries.

To detect the median thyroid-hyoid ligament in men, a protrusion of the thyroid cartilage is felt, the finger is moved down the middle line and the tubercle of the cricoid cartilage is determined,

Rice. 13.13.Scheme for finger detection of the cricoid cartilage and the cricoid ligament:

1 - thyroid cartilage; 2 - cricothyroid ligament; 3 - cricoid cartilage

above which the ligament is located (Fig. 13.13). In women and children, the thyroid cartilage may be less contoured than the cricoid. It is advisable for them, by moving the finger up the midline from the jugular notch of the sternum, to initially detect the cricoid cartilage, and above it, the median cricoid ligament.

Indications.Conicotomy is performed for sudden asphyxia when there is no time to perform a typical tracheostomy or intubation.

Advantageconicotomy before tracheostomy lies in the speed (within a few tens of seconds) of execution, technical simplicity and safety. With conicotomy, the possibility of damage to the main vessels, pharynx, and esophagus is excluded, since the back wall of the larynx at the level of the incision is formed by a dense plate of the cricoid cartilage. The vocal folds are located above the cricothyroid membrane, so they are not damaged when it is cut.

Flawsconicotomy. The presence of a cannula in the lumen of the larynx can lead to the rapid development of chondroperichondritis of its cartilage, followed by persistent stenosis. Therefore, after the restoration of breathing, a typical tracheostomy is performed and the cannula is moved into the tracheostomy.

Rice. 13.14.Scheme of performing puncture conicotomy (from: Popova T.G., Grebennikov V.A., 2001)

Patient position: on the back, a roller 10-15 cm high is placed under the shoulder blades, the head is thrown back. If possible, the surgical field is processed and infiltration anesthesia is performed.

Operation technique. The doctor, standing to the right of the patient, with the index finger of his left hand gropes for the tubercle of the cricoid cartilage and the depression between it and the lower edge of the thyroid cartilage, corresponding to the location of the conical ligament. The thyroid cartilage is fixed with the thumb and middle fingers of the left hand, pulling the skin over the cartilages of the larynx and displacing posteriorly the sternocleidomastoid muscles with the cervical vascular bundles located under them, the second finger is located between the cricoid arch and the lower edge of the thyroid cartilage. A scalpel is used to make a horizontal transverse incision of the skin and subcutaneous tissue of the neck about 2 cm long at the level of the upper edge of the cricoid cartilage. The second finger is inserted into the incision so that the tip of the nail phalanx rests against the membrane. On the nail, touching it with the plane of the scalpel, perforate the ligament and open the lumen of the larynx. The edges of the wound are diluted with a Trousseau dilator or a hemostatic forceps, a cannula of a suitable diameter is inserted through the hole into the larynx.

Stopping bleeding is usually not required, and manipulation usually takes 15-30 seconds. The tube inserted into the lumen of the trachea is fixed to the neck.

In primitive conditions, in an emergency, a penknife can be used to cut tissue. To expand the wound after dissection of the conical ligament, a flat object of a suitable size is inserted into it and turned across the wound, increasing the hole for air to pass through. As a cannula, you can use a cylinder from a fountain pen, a piece of rubber tube, etc.

Puncture conicotomy (Figure 13.14). A typical conicotomy in children is dangerous due to the high likelihood of damage to the cartilage of the larynx. Damaged cartilage lags behind in development, which leads to narrowing of the airways. Therefore, in patients under the age of 8 years, a puncture (with a needle) conicotomy is performed. When using a needle, the integrity of only the conical ligament is violated.

Patient position: on the back with a cushion placed under the shoulders and the head thrown back.

Operation technique. The larynx is fixed with the thumb and middle finger on the lateral surfaces of the thyroid cartilage, with the index finger

define the thyroid ligament. A needle with a wide lumen is inserted into the membrane strictly along the midline until a "failure" is felt. This indicates that the end of the needle is in the cavity of the larynx. The needle is fixed with a strip of adhesive tape. Multiple needles can be inserted in succession to increase respiratory flow. Microconicostomy is performed in a few seconds.

Currently, special conicotomy kits are produced, which consist of a razor-sting for cutting the skin, a trocar for inserting a special cannula into the larynx, and the cannula itself, put on the trocar.

13.3. OPERATIONS FOR PURULENT PROCESSES

ON THE NECK

13.3.1. Characteristics of phlegmon of the neck and the distribution of purulent streaks

Abscesses and phlegmon of the neck are divided into superficial and deep. Superficial phlegmons arise, as a rule, as a result of penetration into the subcutaneous fat layer of the neck of the infection through the skin during its damage, boils, carbuncles.

Deep phlegmons of the anterior neck most often develop in the cellular space of the neurovascular bundle, cellular spaces around the trachea and esophagus, prevertebral cellular space. Most often they occur as a complication of phlegmon of the floor of the mouth and peripharyngeal space, as well as pharyngeal abscess, suppuration of neck cysts, injuries of the cervical esophagus and trachea, purulent inflammation of the lymph nodes of the neck.

Surgical treatment of deep phlegmons of the neck should include the opening of the primary abscess and purulent streaks spreading through the cervical cellular-fascial spaces. Pus from the bottom of the oral cavity penetrates into the neurovascular bundle of the neck through the tissue surrounding the lingual vein and artery, from the submandibular region through the facial vein and artery. This spread is also possible through the lymphatic vessels connecting the submandibular lymph nodes with the upper group of deep cervical nodes. Through the cellular space of the neurovascular bundle of the neck, the infection penetrates into the anterior mediastinum; if it breaks down

vascular vagina, the inflammatory process also spreads to the tissue of the supraclavicular fossa.

The second way pus spreads to the neck with diffuse phlegmon of the floor of the mouth and the root of the tongue occurs when a deep sheet of the own fascia of the neck melts, in this case the purulent exudate overcomes the barrier in the hyoid bone and enters the pretracheal tissue of the neck between the parietal and visceral sheets of the fourth fascia. Through the gap between the trachea and the fascial case of the neurovascular bundle of the neck, the previsceral cellular space, pus descends down into the anterior mediastinum.

From the peripharyngeal space (posterior section), the inflammatory process spreads to the neck and to the anterior mediastinum, also along the course of the neurovascular bundle. The breakthrough of pus from the pharyngeal abscess leads to the development of phlegmon of the retrovisceral cellular space, from which the inflammatory process along the esophagus quickly spreads to the posterior mediastinum.

13.3.2. Operation technique for abscesses and phlegmon of the neck

Surgical treatment of superficial abscesses and phlegmon is usually carried out under local anesthesia. Skin incisions to open the phlegmon of the subcutaneous cellular spaces of the neck are made over the abscess along the cervical folds and large vessels and continue to its lower border. After dissection of the skin, the tissues are bluntly separated with a clamp, the abscess is opened. Its cavity is examined with a finger to separate the fascial septa and detect possible leakage of pus into neighboring areas; in the latter case, additional incisions are made. The wound is washed with antiseptic solutions, drained with rubber tubes or rubber gauze swabs.

The operation of opening a deep phlegmon of the neck is performed under general anesthesia. If breathing is disturbed, a tracheostomy is applied to implement anesthesia and prevent asphyxia in the postoperative period.

Patient position: on the back, a roller is placed under the shoulders, the head is thrown back and turned in the direction opposite to the side of the operation.

Operation technique (Figure 13.15). When performing the operation, it is necessary to separate the tissues in layers, spread the edges of the wound wide with hooks, and ensure thorough hemostasis. It matters for

Rice. 13.15.Incisions for opening and draining superficial abscesses of the neck (from: Ostroverkhov G.E., 1964)

prevention of accidental damage to large vessels and nerves, a detailed examination of the cellular spaces in order to identify additional pus streaks.

Surgical intervention for purulent inflammatory processes odontogenic nature begins with the opening of the phlegmon of the floor of the oral cavity, the peripharyngeal space through incisions in the submandibular triangles, submental region or through a collar-shaped incision.

Then a skin incision is made along the inner edge of the sternocleidomastoid muscle, starting above the angle of the mandible and continuing to the jugular notch of the sternum. The length of the incision may be shorter if the abscess does not extend into the lower neck.

Dissect the skin, subcutaneous tissue, superficial fascia and superficial muscle. In the upper corner of the wound, the external jugular vein is found, it must be displaced laterally or crossed between two ligatures. The outer sheet of the fascial sheath of the sternocleidomastoid muscle is dissected, its inner edge is cut off, and it is pulled outward with a blunt hook (Figure 13.16).

A deep sheet of the sternocleidomastoid muscle is carefully incised, peeled off from the underlying tissues with a grooved probe and dissected along it. For orientation in the topographic relationships in the wound, it is advisable to feel the pulsation of the common carotid artery with your finger at its bottom and determine the position of the vascular bundle of the neck. The fascia and tissue above it are stratified with a hemostatic clamp, the bundle is exposed.

When the streak spreads along the beam, pus is released at this moment. Next, the fiber with purulent-necrotic changes is bluntly stratified to healthy tissues, the purulent cavity is examined with a finger to detect possible streaks that are widely opened. Visually and by palpation examine the internal jugular and facial veins. If thrombi are found in them, then the vessels are tied up above and below the boundaries of the thrombosed areas and excised.

If it is necessary to open abscesses in the pre- and behind-visceral spaces in the lower half of the wound, the scapular-hyoid muscle is found and crossed, which runs in the direction from back to front and from bottom to top. Crossing the muscle facilitates access to the trachea and esophagus. The common carotid artery and trachea are first felt for, then the fiber between them is stratified, the neurovascular bundle is retracted with a blunt hook outward.

In front of the trachea below the thyroid gland, an abscess is opened in the pretracheal cellular space with a clamp or a finger. Continuing to pull the vascular bundle outward, the assistant displaces the trachea with a blunt hook in the medial direction. Between the bundle and the esophagus, the tissues are stratified in the direction

Rice. 13.16.Scheme of the incision for opening a deep phlegmon of the neck, dissection of the outer leaf of the fascial sheath of the sternocleidomastoid muscle

to the cervical vertebrae to the prevertebral fascia and open an abscess in the lateral part of the periesophageal cellular space. Near the esophagus is the common carotid artery: 1-1.5 cm to the right, 0.5 cm to the left of its walls. Behind the common carotid artery and the internal jugular vein, the inferior thyroid artery and veins pass, which at the level of the VI cervical vertebra make an arc and go to the lower pole of the thyroid gland. To prevent injury to these vessels, tissues in the circumference of the esophagus are separated only in a blunt way. After pulling the esophagus in the medial direction, between it and the prevertebral fascia, an abscess is opened with a clamp in the tissue of the posterior visceral space.

With purulent leakage in the supraclavicular region and supraclavicular interaponeurotic space, along with the vertical one, a second wide horizontal incision of the tissues above the clavicle is made. Horizontal incisions in the submandibular triangle and above the clavicle, combined with a vertical one, form a Z-shaped wound. With putrefactive-necrotic phlegmon, skin-fat flaps at the corners of the wound are cut off, turned away and fixed with a suture to the skin of the neck. The wide exposure of inflamed tissues creates conditions for their aeration, ultraviolet irradiation, washing with antiseptic solutions. The operation ends with the washing of purulent cavities and their drainage. It is dangerous to bring tubular drains to the vascular bundle because of the possibility of a decubitus ulcer of the vessel wall and arrosive bleeding.

With common phlegmon, surgical interventions are performed on both sides of the neck.

13.3.3. Cervical mediastinotomy

The technique of opening the mediastinum in its upper section through the cervical access was proposed in 1889 by V.I. Razumovsky.

Indications.The presence of clinical and radiological signs mediastinitis in odontogenic inflammatory processes, the detection of purulent leakage into the mediastinum at the opening of a deep phlegmon of the neck are indications for mediastinotomy.

Anesthesia:intubation anesthesia, if intubation through the mouth is impossible, it is performed through a tracheostomy.

Patient position: on the back, a roller is placed under the shoulders, the head is thrown back and turned in the direction opposite to the side of the operation.

Operation technique. The skin incision is carried out in the projection of the anterior edge of the sternocleidomastoid muscle from the level of the upper edge of the thyroid cartilage and 2-3 cm below the sternocleidomastoid joint. After dissection of the skin, subcutaneous tissue and subcutaneous muscle, the outer sheet of the fascial sheath of the sternocleidomastoid muscle is dissected, which is mobilized and retracted laterally. Next, the inner leaf of the fascial sheath of the sternocleidomastoid muscle is dissected and the upper belly of the scapular-hyoid muscle is cut. The fascia and tissue of the neurovascular bundle of the neck are stratified, the bundle is exposed, in the presence of a deep phlegmon of the neck, a purulent focus is opened.

The neurovascular bundle of the neck is pulled outward, the finger is moved along the lateral and anterior surfaces of the trachea down into the chest cavity and an abscess is opened in the tissue of the anterior mediastinum. By moving a finger along the walls of the esophagus, the tissue of the posterior mediastinum is opened.

A cervical mediastinotomy can be performed through a transverse tissue incision just above the manubrium of the sternum. The finger is inserted through the wound into the anterior mediastinum between the sternum and the anterior surface of the trachea, the abscess is opened, tubular drains are introduced into it.

13.4. EXPOSING AND LIDDING THE BLOOD VESSELS OF THE NECK

13.4.1. Indications for ligation of neck vessels

An indication for ligation of blood vessels in the neck is the need to stop bleeding from wounds. maxillofacial area and neck with mechanical damage to both the arteries and veins themselves, and their large branches, or a purulent inflammatory process that has arisen due to erosion of the vessel wall by a tumor.

The internal and common carotid arteries are ligated when they are injured near the bifurcation if it is impossible to apply a vascular suture, surgical treatment their aneurysms, removing the chemodectoma if it cannot be separated from the arterial wall.

Ligation of the internal jugular vein is indicated when a septic thrombus forms in it to prevent its spread into

cranial cavity, lung metastasis, etc. internal organs. She is bandaged and excised during Crile's operation.

13.4.2. Ligation of the facial artery

The shortest distance between the skin and the facial artery is determined at the site of its passage near the lower edge and the outer surface of the body of the lower jaw, which the artery crosses from the outside in the upward direction at the anterior edge of the masticatory muscle. In this anatomical zone, a finger is pressed and the facial artery is ligated. The facial artery is accompanied by the facial vein, located posterior to it.

Operation technique. A skin incision 5 cm long is made in the submandibular region parallel to the base of the lower jaw and retreating 2 cm down from it. The beginning of the incision is 1 cm anterior to the angle of the mandible. The skin, subcutaneous fatty tissue, superficial fascia of the neck, subcutaneous muscle, second cervical fascia are dissected, which in this area forms the surface sheet of the capsule of the submandibular salivary gland. The dissected tissues are separated and pulled up along with the marginal branch of the facial nerve passing in this layer. Under the lower edge of the body of the lower jaw in the projection of the anterior edge of the masticatory muscle itself, the facial artery is isolated and ligated.

13.4.3. Ligation of the lingual artery

The lingual artery is ligated in Pirogov's triangle. It is a small section of the region of the submandibular triangle, bounded from above by the hypoglossal nerve and the lingual vein located parallel to it, from below by the intermediate tendon of the digastric muscle, in front by the free posterior edge of the maxillohyoid muscle. The bottom of the triangle forms the hyoid-lingual muscle, inside of which the lingual artery is located.

Patient position: on the back, a roller is placed under the shoulders, the head is thrown back and maximally deflected in the opposite direction. In this position, the Pirogov triangle is best revealed.

Operation technique. Under infiltration anesthesia, a 6 cm long incision is made in the submandibular region parallel to the lower edge of the lower jaw and retreating from it down by 2-3 cm. Beginning

incision 1 cm anterior to the anterior edge of the sternocleidomastoid muscle. The skin with subcutaneous tissue, superficial fascia and subcutaneous muscle of the neck are dissected in layers. Then, a sheet of the second fascia is cut along the grooved probe, forming the outer part of the capsule of the submandibular salivary gland, which is released from the capsule and pulled upward with a hook. The inner leaf of the capsule is bluntly separated, and the surgeon orients himself in the location of Pirogov's triangle. The fascial cover is stratified and the intermediate tendon of the digastric muscle, the anterior edge of the maxillohyoid muscle and the hypoglossal nerve are isolated. The tendon of the digastric muscle is pulled downward, and the hypoglossal nerve upward. Within the triangle, the fibers of the hyoid-lingual muscle are bluntly disconnected and the lingual artery is found. The artery is isolated, a Deschamps needle with a ligature is brought under it from the nerve in the direction from top to bottom and it is tied up. The stratification of the fibers of the hyoid-lingual muscle must be done carefully, since the muscle is thin, adjacent to the middle constrictor of the pharynx, and with a gross intervention, it is possible to open the lumen of the latter.

13.4.4. Exposure of the neurovascular bundle of the neck

Indications.The exposure of the neurovascular bundle of the neck is a common stage in the operations of ligation of the common, internal, external carotid arteries and the internal jugular vein.

Operation technique. The incision is made along the anterior edge of the sternocleidomastoid muscle from the level of the angle of the lower jaw to the level of the lower edge of the thyroid cartilage or to the sternoclavicular joint. The skin, subcutaneous tissue, superficial fascia, subcutaneous muscle of the neck are dissected in layers. In the upper corner of the wound, the external jugular vein is retracted laterally or ligated and transected. The anterior leaf of the fascial sheath of the sternocleidomastoid muscle is dissected along the grooved probe, which is isolated from its sheath with a blunt instrument (clamp, closed Cooper scissors) and pushed outward with a blunt hook. In the lower corner of the wound, the scapular-hyoid muscle becomes visible, forming an angle with the sternocleidomastoid muscle. The bisector of the angle usually corresponds to the course of the common carotid artery. Through the inner sheet of the fascial sheath of the sternocleidomastoid muscle, its pulsation is determined with a finger, a bluish inner is usually translucent from the artery.

jugular vein. Along the wound along the grooved probe, carefully, so as not to damage the vein, dissect the posterior leaf of the sheath of the sternocleidomastoid muscle, stupidly stratify the fiber and fascia of the neurovascular bundle, the tissues are bred with hooks, after which the vessels and nerves that form it become visible.

13.4.5. Ligation of the common and internal carotid arteries

Operation technique. After the exposure of the neurovascular bundle of the neck, the facial vein is isolated, which crosses the initial sections of the external and internal carotid arteries in the direction from the top from the inside down and outwards, shifts it upwards or ties it up and crosses it. The descending branch of the hypoglossal nerve (upper root of the cervical loop) located on the anterior wall of the common carotid artery is retracted in the medial direction. The artery is bluntly separated from the internal jugular vein and vagus nerve, which is located between these vessels and somewhat posteriorly. Further, the common carotid artery is isolated from all sides, a Deschamps needle with a ligature is brought under it in the direction from the internal jugular vein, tied 1-1.5 cm below the bifurcation or the wound site.

The internal carotid artery is located laterally from the external carotid artery, does not give off branches on the neck, is isolated and ligated by similar techniques.

13.4.6. Ligation of the external carotid artery

Operation technique. After exposure of the neurovascular bundle of the neck, the facial vein and its branches are isolated, bandaged or displaced downward. Expose the bifurcation of the common carotid artery and initial departments external and internal carotid arteries. Ahead of them in the oblique direction is the hypoglossal nerve, which is displaced downward. Next, the external carotid artery is identified. Its distinguishing features are the location medial and anterior to the internal one, the absence of the descending branch of the hypoglossal nerve on it (it runs along the anterior surface of the internal carotid artery), the cessation of pulsation of the superficial temporal and facial arteries or bleeding from the wound after temporary clamping of its trunk. The external carotid artery, unlike the internal one, has branches on the neck that are found when it is mobilized. The first vessel departing from the external carotid artery is the superior thyroid artery, above it the lingual artery is separated.

The external carotid artery is bluntly separated from the internal carotid artery, the jugular vein and the vagus nerve, under it, from the side of the internal jugular vein, a Deschamps needle with a ligature is brought in from the outside. The artery is ligated in the area between the origin of the lingual and superior thyroid arteries. The ligation between the superior thyroid artery and the bifurcation of the common carotid artery may be complicated by the formation of a thrombus in the short stump of the vessel with its subsequent spread into the lumen of the internal carotid artery.

The external carotid artery is crossed in case of inflammation in the area of ​​the neurovascular bundle and metastases of malignant tumors in the lymph nodes of the neck to prevent ligature eruption. At the same time, two piercing ligatures are applied to each segment of the artery.

13.4.7. Ligation of the internal jugular vein

Operation technique. After exposure of the neurovascular bundle of the neck, the scapular-hyoid muscle is pulled downward or crossed if it interferes with the further course of the operation.

The internal jugular vein is separated and bluntly separated from the carotid artery and vagus nerve. The Deschamps needle is inserted under the vein from the side of the artery. The vein is tied up with two ligatures above and below the boundaries of the spread of the thrombus or the site of its resection, while the facial vein is tied up and excised. A purulent thrombus is removed from the lumen of the vein after dissection of its wall, in this case, the postoperative wound is drained, sutures are not applied.

13.5. OPERATIONS ON THE CERVICAL ESOPHAGUS

The operation includes online access to cervical region the esophagus, then, depending on the nature of the damage, various techniques are performed on it: dissection (esophagotomy) and suture of the esophagus, imposition of an esophageal fistula (esophagostomy), drainage of the periesophageal cellular space ..

It is more convenient to perform surgery on the left side of the neck, since the cervical esophagus deviates to the left of the midline.

Patient position: on the back, a roller is placed under the shoulders, the head is thrown back and turned to the right.

Operation technique. The surgeon becomes to the left of the patient. The incision is made along the inner edge of the left sternocleidomastoid muscle from the level of the upper edge of the thyroid cartilage to the notch of the sternum. Dissect the skin with subcutaneous tissue, superficial fascia and subcutaneous muscle of the neck. Under the muscle bandage and cross the external jugular vein and the branches of the anterior jugular vein. The anterior wall of the vagina of the sternocleidomastoid muscle is opened, which is separated from the fascia and displaced outwards. Then, the posterior wall of the muscle sheath, the third fascia, the parietal sheet of the fourth fascia are dissected in the longitudinal direction, while the dissection line is located medially from the common carotid artery. Also cross the upper abdomen of the scapular-hyoid muscle. The neurovascular bundle, together with the lower stump of the muscle, is carefully moved outwards. The left lobe of the thyroid gland, together with the trachea and the muscles lying in front of it (sternohyoid and sternothyroid), is pulled medially with a blunt hook. Between the trachea and the neurovascular bundle, the soft tissues are bluntly stratified towards the cervical vertebrae.

The prevertebral fascia opens with the inferior thyroid artery passing first under it and then above it. The latter is isolated, tied with two ligatures and crossed between them. Next, a sheet of the fourth fascia is bluntly separated at the left edge of the trachea, and the fiber of the tracheoesophageal sulcus (sulcus tracheooesophageus) is exposed, in which the left recurrent nerve passes. Trying not to damage it, with care, the fiber, together with the nerve and the left lobe of the thyroid gland, is pushed up and medially. Between the trachea and the spine, the esophagus is found, which is recognized by the longitudinally running muscle fibers and brownish-red color.

On the wall of the esophagus, without piercing the mucous membrane, a ligature-holder is applied, with its help the esophagus is slightly pulled into the wound. The posterior wall of the esophagus is exfoliated from the prevertebral fascia, the anterior - from the trachea. A rubber catheter is placed under the esophagus, at the ends of which the esophagus is displaced into the wound to perform the necessary surgical procedures on it. Before removal of a foreign body in the area of ​​its location, two ligatures are applied to the esophagus, without capturing the mucous membrane, its wall is cut between them in the longitudinal direction in layers - first the muscle layer, then the mucous membrane.

After removal of the foreign body, the wound of the esophagus is also sutured in layers. Before suturing the wound, a sterile gastric tube is inserted through the nasal passage to feed the patient.

13.6. SURGERY FOR METASTASIS OF MALIGNANT TUMORS IN THE LYMPH NODES OF THE NECK

Metastases to the lymph nodes of the neck occur when malignant tumors oral cavity and maxillofacial region, ENT organs, cervical esophagus, thyroid gland; tumors of the gastrointestinal tract and lungs metastasize to the lower group of deep cervical lymph nodes.

4 types of operations have been developed for the treatment and prevention of metastases in the lymph nodes of the neck: Vanach operation (upper cervical excision according to the first option), upper fascial-case excision of the cervical tissue (upper cervical excision according to the second option), fascial-case excision of the cervical tissue, Crile's operation .

The Vanakh operation is named after the author, Russian doctor R.Kh. Vanakh, who first described it in 1911. The purpose of the operation is to remove the submandibular salivary glands, lymph nodes with tissue in the submandibular and submental areas.

When performing the upper case-fascial excision of the cervical tissue, the lymph nodes of the submandibular and mental triangles, the submandibular salivary gland, as well as the upper deep cervical lymph nodes are removed from the bifurcation level of the common carotid artery, including those located along the accessory nerve.

Sheath-fascial excision of the cervical tissue consists in the removal of all superficial and deep lymph nodes on this half of the neck, together with the surrounding tissue and submandibular salivary gland. This type of operation is used most often.

Crile's operation is named after the author (G. Cril), who first described it in 1906. Crile's operation differs from fascial-case excision of cervical tissue in that, together with all superficial and deep lymph nodes, tissue,

submandibular salivary gland on half of the neck, the sternocleidomastoid muscle and the internal jugular vein are removed. In this case, the additional, large ear, small occipital nerves are inevitably damaged. The trapezius muscle subsequently ceases to function. The operation is performed simultaneously on only one side of the neck.

13.7. THYROID OPERATIONS

Indications.surgical interventions for thyroid gland perform with thyrotoxic nodular or diffuse goiter, not amenable to conservative treatment, euthyroid nodular goiter, increasing against the background of conservative therapy, causing compression of the neck organs and its cosmetic deformity, benign and malignant tumors. In some cases, operations are performed for autoimmune thyroiditis and Riedel's fibrous thyroiditis.

Depending on the volume of tissues to be removed, the glands are distinguished: economical resection - removal of the node with adjacent tissues; subtotal resection - almost complete removal of the gland, leaving 3-6 g of its tissues in each lobe; hemithyroidectomy (lobectomy) - removal of a lobe of the gland; hemithyroidectomy with removal of the isthmus; thyroidectomy - complete removal of the thyroid gland with a common malignant tumor.

13.7.1. Subtotal resection of the thyroid gland

Most often, subtotal subfascial resection of the thyroid gland according to O.V. Nikolaev.

Operation technique. A collar-shaped skin incision with subcutaneous tissue is carried out from the medial edge of one sternocleidomastoid muscle to the medial edge of the other 1.5 cm above the jugular notch of the sternum. Dissect the superficial fascia with the subcutaneous muscle of the neck. The edges of the incision are pulled upwards and downwards, the superficial jugular veins located between the first and second fascia are captured and crossed between two clamps. A novocaine solution is injected under the second and third fascia to facilitate the next step - separation and dissection of the fascia.

Then the sternohyoid, sternothyroid and scapular-hyoid muscles covering the thyroid gland are exposed.

front. With the help of Kocher's clamp, the medially located sternohyoid muscles are bluntly separated from the rest of the muscles, they are captured by two clamps superimposed in the transverse direction, and cut between them.

Novocaine solution is injected under the parietal sheet of the fourth fascia on both sides of the midline so that it spreads under the fascial capsule of the thyroid gland and blocks the nerves approaching the gland. This facilitates the next stage of the operation - the selection of the right lobe of the gland and its dislocation into the wound. To do this, the edges of the sternothyroid muscles are bred, the parietal sheet of the fourth fascia is vertically dissected along the midline, and the parietal sheet of the gland fascia is bluntly (partly with a tool, partly with a finger) peeled off the parietal sheet of the fascia of the gland from the visceral. Then the surgeon dislocates a lobe of the gland into the wound with a finger. Next, the visceral sheet of the fourth fascia surrounding the gland is incised, it exfoliates from its own capsule from front to back within the boundaries of the resection zone of the lobe, while its upper and lower poles are released. In the process of preparation, they are captured with clamps and cross the vessels passing between the outer fascial and inner own shell of the gland.

The isthmus is crossed, the bleeding vessels are seized with clamps. Then, a partial phased cutting off of the lobe of the gland is performed, starting from the trachea in the lateral direction, while the lobe is fixed with a finger. The gland tissue, together with its own capsule, is sequentially captured in small portions with clamps and cut off. If the patient is operated on under local anesthesia, then after each seizure of the parenchyma of the gland, voice control of the state of the recurrent nerve is performed. A change in the timbre of the voice indicates irritation of the nerve and the need to reduce the volume of trapped tissues.

The dissected parts of the outer capsule of the gland are sutured, thereby closing the stump of the right lobe. Then, the left lobe of the gland is resected by similar methods.

The stumps of the lobes of the gland are covered with sternothyroid muscles, the roller is removed from under the patient's shoulders, the sternohyoid muscles are sutured with mattress sutures. The wound cavity is again washed, drains from a strip of rubber are brought to the stumps of the gland, sutures are applied to the skin and subcutaneous tissue.

Complications during surgery: bleeding, removal of the parathyroid glands, damage to the recurrent nerve, air embolism due to transection of veins without prior ligation.

Prevention of complications lies in the thoroughness of the implementation of surgical techniques

13.7.2. Endoscopic operations on the thyroid gland

Endoscopic or endovideoscopic operations on the thyroid gland are interventions performed through a skin incision or trocar with endosurgery instruments under visual control through an optical system. During the operation, the image of the anatomical structures is displayed on the monitor using a video camera.

Operation technique. To perform the operation, the so-called mini-access is usually used, in which the length of the skin incision is 2-5 cm. When it is performed, the superficial veins of the neck and the sternohyoid muscles do not cross, which prevents the development of pronounced tissue edema after the operation and the formation of a rough scar. The observation system provides an optical increase in the operating field and facilitates the surgeon's orientation in the topographic relationships of anatomical structures. Endosurgical instruments with a diameter of 2 to 12 mm allow you to perform all surgical techniques inherent in traditional surgical techniques. The capture of the organ is carried out with a clamp, the separation of tissues - with a dissector, the dissection of tissues - with endoscopic scissors or electrosurgical method. Before crossing, the vessels are tied with ligatures or titanium clips are applied to them, they are stitched with staples with an endoscopic stapler, and electro-, laser-, ultrasonic coagulation is used. The advantages of endoscopic operations over traditional ones are to reduce the intensity of pain in the postoperative period, reduce the number of complications, reduce the duration of inpatient treatment, and form an inconspicuous skin scar.

13.8. TESTS

13.1. Indications for tracheostomy:

1. Swelling of the larynx.

2. Terminal States with dysfunction of the respiratory center.

3. True diphtheria croup.

4. Respiratory disorders in diseases and pathological conditions.

5. Foreign bodies of the trachea.

13.2. Special tools for the production of tracheostomy:

1. Scalpel.

2. Sharp single-toothed hook.

3. Hemostatic clamp.

4. Luer cannula.

5. Tracheo dilator.

13.3. An instrument used to widen the tracheal wound in a tracheostomy:

1. Jansen expander.

2. Passov expander.

3. Expander Trousseau.

4. Lamellar S-shaped Farabef hook.

5. Rack expander.

13.4. In relation to what anatomical formation are distinguished upper, middle and lower tracheostomy?

1. To the cricoid cartilage.

2. To the thyroid cartilage.

3. To the hyoid bone.

4. To the isthmus of the thyroid gland.

5. To the tracheal rings - upper, middle and lower.

13.5. What type of tracheostomy is performed on children?

1. Top.

2. Bottom.

3. Average.

4. Microtracheostomy.

5. Conicotomy.

13.6. What type of anesthesia is performed during a tracheostomy?

1. Inhalation anesthesia.

2. Endotracheal anesthesia.

3. Intravenous anesthesia.

4. Local anesthesia.

5. Conduction anesthesia.

13.7. When performing a tracheotomy, the patient should be given the position:

1. On the back, the head is thrown back, a roller is placed under the shoulder blades.

2. On the back, the head is turned to the left, a roller is placed under the shoulder blades.

3. On the back, head turned to the left, right hand pulled down.

4. Half-sitting with head thrown back.

5. Lying on the right or left side.

13.8. To make an incision during a tracheostomy exactly along the midline, two landmarks must be aligned on the same line in the neck area:

1. Upper notch of the thyroid cartilage.

2. The middle of the body of the hyoid bone.

3. The middle of the chin.

4. Isthmus of the thyroid gland.

5. The middle of the jugular notch of the sternum.

13.9. Determine the sequence of actions of a surgeon performing an upper tracheostomy after dissection along the midline of the skin with subcutaneous tissue and superficial fascia:

1. Blunt separation and downward displacement of the isthmus of the thyroid gland.

3. Dissection of the white line of the neck.

5. Dissection of the wall of the trachea.

6. Fixation of the larynx.

13.10. Determine the sequence of actions of the surgeon who performed the lower tracheostomy after dissection along the midline of the skin with subcutaneous tissue and superficial fascia:

1. Pushing down the jugular venous arch.

2. Extension of the sternohyoid and sternothyroid muscles.

3. Dissection of the scapular-clavicular fascia.

4. Dissection of the parietal sheet of the intracervical fascia.

5. Dissection of own fascia.

6. Dissection of the wall of the trachea.

13.11. Performing a lower tracheostomy, the surgeon, passing the suprasternal interaponeurotic space, must beware of damage to:

1. Arterial vessels.

2. Venous vessels.

3. Nerves.

13.12. With subtotal resection of the thyroid gland, the part of the gland containing the parathyroid glands should be left. Such part are:

1. Upper pole of the lateral lobes.

2. The posterior part of the lateral lobes.

3. The posterior part of the lateral lobes.

4. Anterior part of the lateral lobes.

5. Anterolateral part of the lateral lobes.

6. Lower pole of the lateral lobes.

13.13. What nerve can be damaged during thyroid resection?

1. Sympathetic trunk.

2. Vagus nerve.

3. Phrenic nerve.

4. Hypoglossal nerve.

5. Recurrent laryngeal nerve.

13.14. Name the mistake made when opening the trachea, when breathing is not restored after the introduction of a tracheostomy cannula:

1. Damage to the esophagus.

3. The mucous membrane has not been opened.

4. Tracheostomy placed low.

5. Damage to the recurrent laryngeal nerve.

13.15. When performing a lower tracheostomy by median access after penetration into the pretracheal space, severe bleeding suddenly occurred. Identify the damaged artery:

1. Ascending cervical.

2. Lower laryngeal.

3. Inferior thyroid.

4. Unpaired thyroid.

13.16. During a strumectomy performed under local anesthesia, when applying clamps to the blood vessels of the thyroid gland, the patient developed hoarseness due to:

1. Violations of the blood supply to the larynx.

2. Compression of the superior laryngeal nerve.

3. Compression of the recurrent laryngeal nerve.

13.17. The victim has severe bleeding from the deep parts of the neck. In order to ligate the external carotid artery, the surgeon exposed in the carotid triangle the place of division of the common carotid artery into external and internal. Determine the main feature by which these arteries can be distinguished from each other:

1. The internal carotid artery is larger than the external one.

2. The beginning of the internal carotid artery is located deeper and outward relative to the beginning of the external carotid artery.

3. Lateral branches depart from the external carotid artery.

13.18. Establish a correspondence between violations of the tracheal dissection technique during tracheostomy and possible complications.

1. Non-through dissection of the anterior A. Necrosis of the tracheal rings. tracheal walls.

2. The incision is larger than the diameter of the cannula. B. Tracheoesophageal fistula.

3. The incision is smaller than the diameter of the cannula. B. Closing the lumen of the trachea.

4. Damage to the posterior wall of the trachea. G. Subcutaneous emphysema.

13.19. Phlegmon of what cellular space of the neck can be complicated by posterior mediastinitis?

1. Suprasternal interaponeurotic.

2. Previsceral.

3. Retrovisceral.

4. Paraangial.

5. The cellular spaces of the neck do not communicate with the tissue of the posterior mediastinum.

13.20. At what level is a conicotomy performed?

1. Above the hyoid bone.

2. Between the 1st ring of the trachea and the cricoid cartilage.

3. Between the cricoid and thyroid cartilages.

4. Between the hyoid bone and the thyroid cartilage.

13.21. Identify three statements characterizing the operative access to the cervical esophagus:

1. It is performed in the lower part of the neck on the left.