The Evolution of Foreign Bodies Management in a Case of Near-fatal Penetrating Neck Injury

Abstract

Penetrating wounds of the neck with foreign bodies retention are frequent and often life-threatening events, and their management has changed in recent years from an open approach to a conservative approach thanks to the possibility of performing minimally invasive radiologically guided surgery. We present a case of penetrating glass injury to zone III of the neck in which the foreign body go through the parotid region passing near, but without injuring, the facial nerve and the external and internal carotid arteries.

Introduction

Penetrating wounds of the neck are frequent occurrence (5–10% of all traumas [1]) whose management is based on a careful knowledge of the anatomy and dangerous zones of the neck in order to prevent possible damage deriving from laceration of vessels, nerves or the aero-digestive tract. Any penetrating neck wound should be examined for the possible presence of foreign bodies.

Case report

An 82-year-old man was addressed to our department after a fallen from a step ladder over a french door. At clinical examination a retro-auricular wound measuring about 3 cm was detected with some foreign bodies inside, suspicious for glass fragments. Despite the parotid gland was partially involved, no facial nerve impairment was noticed. After removal of the more superficial glasses a CT scan was performed to check for any other fragments in the deep planes.

CT revealed a 7 cm length piece of glass that entered from the wound, went deep in the soft tissues touching the styloid process and proceeded up to the nasopharynx where it was stopped by the contralateral skull base (Fig. 1).

Fig. 1.

CT scan showing the glass foreign body deviated by styloid process passing close to carotid arteries (axial and 3D views). 1-Glass foreign body (in green). 2-External carotid artery. 3-Internal carotid artery. 4-Common carotid artery. 5-Styloid process. 6-Mandible. 7-Zygomatic arch. 8-Controlateral medial pterygoid lamina

The most relevant finding was the close relation of the glass with the internal carotid artery that was only 1–2 mm distant. Basing on these data it looked like the styloid process deviated the glass thus protecting the carotid, saving patient’s life indeed.

An angio-CT was also performed to assess if any injury to the carotid artery occurred, to prevent massive bleeding in case of foreign body removal.

Being the carotid preserved, patient was transferred to angiographic operative room where under general anesthesia after femoral artery catheterization an explorative angiography was performed: vascular compensation from contralateral carotid artery in case of carotid emergency occlusion seemed to be inadequate, therefore this salvage option should be excluded in case of accidental injury to carotid artery and a stenting emergency placement was planned as alternative, leaving catheter in place.

Then after wound exploration and foreign body identification, it was removed with extreme care from the same wound without any further incision (Fig. 2). No complication occurred, the wound was sutured and patient was discharged the day after.

Fig. 2.

Foreign body removal through the entry hole and foreign body fragment

Discussion

Every penetrating neck wound should be examined for the possible presence of foreign bodies: 8.7–13% of all glass wounds and 7.7–15% of deep wounds contain foreign bodies; therefore, all wounds deeper than 5 mm should undergo routine radiological examination [2–4].

These injuries have a high mortality (0–11%) [1, 5] and are associated with vascular lesions in 25% (carotid artery in 80%, vertebral artery in 43%) and aero-digestive tract laceration in 23–30% of cases [1]. Facial nerve interruption has been reported in 1-6-1.8% of cases [6, 7].

As regards the management, current protocols for superficial lesions prefer the direct technique for foreign bodies removal, after wound exploration under local anaesthesia [8]. The foreign body perception by the patient is reported only sometimes (41%) [4] and therefore it is not a reliable parameter to evaluate its presence. For this reason, all glass wounds must be examined with radiological investigations for radiopaque materials such as X-ray or CT scan [9]. Contrast medium is useful to evaluate vessels anatomy and bleeding.

The management of penetrating neck wounds and foreign bodies removal has changed in recent years, promoting a multidisciplinary approach that sees the collaboration between the surgeon and the interventional radiologist to perform minimally invasive and radiologically guided surgical procedures with reduced comorbidities for patient. Our case is an example of the new approach, especially when compared to a similar case described by Khadivi et al. in 2007 [10]: in that case an open approach was chosen to obtain a better visualization of the foreign body, but the removal caused bleeding of the external carotid artery. In our case, however, through a radiologically guided conservative approach we were able to preserve the integrity of both the carotid artery and the facial nerve, with less comorbidities for the patient and a reduction of hospitalization period and costs.

Funding

No funding was received to assist with the preparation of this manuscript.

Declaration

Conflicts of interest

All the authors have no relevant financial or non-financial interests to disclose.

The approval of our ethics committee was considered not necessary as it is a case report. We have obtained the patient’s consent to publish his case. Furthermore, the patient’s face is not shown in the figures and the CT scans don’t reveal his data or those of our hospital.