Authors: Sami Tanbouzi Husseini, MD FEBORL-HNS*, Jihad Achkar, MD**, Charbel Rameh, MD**, Tamama Almutair MD*** and Usamah Hadi , MD, FACS**
Institution: *Department of Otology and Skull Base Surgery, Gruppo Otologico, Piacenza-Italy; **Department of Otolaryngology Head and Neck Surgery, American University of Beirut Medical Center, Beirut, Lebanon; ***Leiden University Medical Center (LUMC), Leiden-The Netherlands
Sami Tanbouzi Hussseini , M.D, FEBORL-HNS
Department of Otology and Skull Base Surgery
Gruppo Otologico, Piacenza-Italy
Via Emmanueli, 42
29100 Piacenza – Italy
Penetrating head and neck injuries occurring in civilian life are usually caused by low-velocity foreign bodies and can lead to intracranial, ocular, vascular, aerodigestive and neurological complications. We present a case of an unusual transcervical penetrating injury of the orbit caused by a metallic rod (rebar) with complete recovery.
Penetrating injuries of the head and neck are common occurrences in war and are usually caused by high-velocity penetrating bodies. They are less common in civilian life where most are due to low-velocity foreign bodies acting as missiles. We are presenting a case of an unusual penetrating injury of the neck and orbit caused by an unpolished metallic rod (rebar) with complete recovery and no sequelae.
A 40 year old construction worker was brought to the emergency room after he fell off a 2 meter high wall onto a vertical construction steel rod that penetrated his posterior right neck, to exit his face through the left orbit (Figure 1). The rod was cut off from its base, by an electrical saw and the patient was rushed to the emergency room at our center. On physical exam, he was fully awake, cooperative and oriented with stable vital signs and Glasgow coma score of 14.
Figure 1 (right) Penetrating metallic rod through the neck and orbit.
The head and neck exam revealed a metallic rod (rebar), 12 mm in diameter, penetrating his right neck at level II and exiting through the left orbit. There were blood clots in both nostrils and in the oral cavity, but no active bleeding was encountered. The left eye couldn’t be examined due to the presence of the rod. Otherwise, the patient had normal head and neck exam.
A CT scan of the head and neck with IV contrast delineated the trajectory of the rod (Figure 2). It had entered the right neck inferior to the angle of the mandible, anterior to the parapharyngeal and carotid spaces, crossing through the nasopharynx and the ethmoid air cells, fracturing the lamina papyracea as well as the medial wall of the left maxillary sinus, and exiting through the left orbit. The right jugular vein and the internal carotid artery could not be assessed from the skull base to the level of C2 due to the artifact from the metallic object. At the level of the left eye, the globe was compressed and displaced superiorly in the orbit. Intracranially, no gross collection or mass effect was seen (Figure 3). The patient was taken to the operating room and underwent orotracheal intubation. A right neck exploration was done, and the metallic rod was removed through the orbit. No major bleeding was encountered during the surgery. The rod was abutting the anterior surface of the internal jugular vein, but the vein was intact. The oral cavity and pharynx were inspected, and a nasopharyngeal laceration was identified and sutured using 3.0 vicryl sutures. Then, the ophthalmology team explored the left orbit and globe. The left medial rectus was repaired, and a fragment of ethmoidal bone was removed from the nasal canthus. Finally, suturing of the left upper lid margin and tarsus was done. The sclera was intact, the globe was not ruptured and intra-operative retinal exam was normal. The patient was extubated and kept on nasogastric tube feeding for 7 days, then started on PO diet. The patient was discharged home on post-op day 10 in good condition. Follow-up after 2 months, revealed a normal retinal scan and vision of 20/20, bilaterally. (Figure 4)
Click on Picture to Enlarge
Figure 2: Preoperative CT scan (3D Reconstruction) showing the trajectory of the rod
Figure 3: Preoperative serial CT scans (Coronal views)
Penetrating injury to the neck is a common problem and was first described in The Edwin Smith Surgical Papyrus written about 5,000 years ago.1 Penetrating neck trauma mechanisms are divided into two categories: High and low-velocity injuries.
High-velocity injuries include bullet wounds from handguns, rifles, and shotguns. Long-range injuries (greater that 7 meters) are characterized primarily by subcutaneous and deep fascia injuries, whereas close-range injuries (less than 2.5 meters) typically create massive tissue destruction and contamination of soft tissue with the “wadding” material from the shotgun shell. The second type is the low-velocity mechanism of injury that generally leads to a straight trajectory of tissue damage, with minimal collateral damage. Most of the injuries occur in civilian trauma and are caused by glass or metallic shrapnel from motor vehicle accidents, stab injuries using knives, ice picks, toys, pencils, and metallic sharp objects such as scissors, nails, and drills.2-6
The penetrating neck injuries are also classified into 3 categories depending on the patterns of vascular injury.
Zone I: Extends from the clavicle to the cricoid cartilage and contains the following structures: The proximal carotid arteries, subclavian vessels, major vessels in the chest, lung, thorax, esophagus, and trachea.
Zone II: Extends from the level of the cricoid cartilage to the angle of the mandible; included here are the carotid arteries, jugular veins, larynx, and hypopharynx.
Zone III: Extends from the angle of the mandible to the base of skull; included in this zone are the distal carotid arteries, jugular vein, and hypopharynx.
Zone II, in comparison with zones I and III, is the largest of the three and the most common site of entry in penetrating neck trauma; it has the easiest surgical exposure and intraoperative evaluation whereby structures are easily accessible for surgical exploration. Such wounds have lower mortality rates since hemorrhage can often be controlled with direct pressure.7
There are many alarming symptoms and physical findings suggesting serious neck injury. Homodynamic instability, shock, profuse bleeding, expanding hematoma, hemoptysis, hematemesis, presence of a bruit or thrill over the wound, and unequal upper extremity pulses are among the frequent signs encountered. Other findings include subcutaneous emphysema, pneumothorax, and neurological deficits such as Brown Sequard syndrome, quadriparesis, and spinal shock.
Management of penetrating neck trauma is often a controversial issue. There are multiple treatment algorithms that have been set to channel patients according to their injury and its seriousness, but no standardized plan has been accepted yet.
The management starts with cervical spine immobilization, establishment of an airway, and circulatory support with intravenous fluids along with direct pressure on the wound. CT scan of the head and neck is recommended for the evaluation of cervical spine injury, penetrating intracranial injury, as well as for aerodigestivetract injuries. MRI can be dangerous in cases of retained ferromagnetic objects.8 To rule out vascular injury, neck exploration was recommended for patients with neck injury penetrating the platysma. Recently, arteriograms have replaced neck exploration for asymptomatic injuries in zones I and III..9-11
Penetrating trauma to the head can lead to intracranial, ocular, vascular, aerodigestive and neurological injuries. However, symptoms may be subtle in some cases.12 The overall reported mortality rate for penetrating neck trauma at major centers is 3% to 6%. The major cause of death is exsanguinating hemorrhage from vascular injuries. Removal of any type of foreign body at the site of the accident may result in critical complications. In our case, the use of CT scanning with 3D reconstruction was advantageous in demonstrating the track of the rod (Figures 2 and 3). In the case of a penetrating orbital injury, several surgical approaches to remove the foreign body exist, and inferior orbitotomy is described to be the safest technique for gaining access to the floor, medial, and lateral orbital walls.13,14 Finally, to prevent any postoperative infections, wide spectrum antibiotic therapy is recommended starting with a combination of metronidazole and cephalosporins.
The interesting features in this case include comminuted fractures of the ethmoid air cells and violation of orbital fat with no intraocular hematoma or extraocular muscle injury. To our knowledge, our case is the first reported case with such findings. Our patient presented to the emergency room fully conscious, and was discharged with no neurological, aerodigestive, or visual deficits.
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