Navigating Complex Maxillofacial Trauma: A Case Report on Arrow Shot Injury to the Face by a Speargun

Abstract

Trauma is a leading cause of death worldwide, with 25% of cases involving the head and neck region. Among various trauma types, impalement injuries caused by arrows and spearguns pose significant challenges due to their potential for severe damage to critical structures. This case report aims to present a case of a speargun arrow injury to the face and to discuss the mechanisms, implications, and management of such trauma.

A 44-year-old male presented with an impaled arrow in the right infraorbital area, accidentally shot by his son. Initial assessment showed a conscious patient with stable vital signs. Imaging revealed the arrow penetrating the nasomaxillary region and extending into the cervical spine. Surgical removal was performed successfully using a retrograde approach with a Foley catheter to avoid further tissue damage.

This case underscores the importance of individualized treatment strategies and the critical role of imaging in managing penetrating arrow injuries. A multidisciplinary approach, rapid assessment, and careful surgical planning are essential for positive outcomes. Reporting such cases contributes to medical research and improves safety regulations and treatment protocols.

Introduction

Globally, trauma ranks as the sixth leading cause of death, with 25% of these injuries affecting the head and neck region.¹ Despite its low-velocity impact, arrows are believed to have the capability of penetrating soft tissues and flat bones and claimed to have caused more fatalities.^2,3 The presence of vital structures in the maxillofacial regions may result in neurological, ophthalmic, vascular, oropharyngeal, and skeletal complications. Mortality is attributed to prehospital attempt to remove the impaled object and physical destruction of tissues, vital organs and from infection. Some arrows, particularly those used in wars, were dipped with poisons such as decomposed venomous snakes or fecal material which increases its lethal potential.

In the Philippines, the speargun (or panah), is one of the most widely used fishing gears particularly among coastal communities.⁴ Injuries due to this atypical weapon are declining in number especially in urban settings as weapons of assault have evolved into gun, gunpowder and explosives. This can lead to challenging problems and may involve a multidisciplinary approach. Although rare, most cases of arrow injuries in trauma centers are accidents or suicide attempts using crossbow mechanism involving the head and neck region. Rapid assessment of airway, breathing and circulation following the Advanced Trauma Life Support (ATLS) protocols are utilized as initial management. It is also emphasized to avoid manipulating the impaled object, keeping it in place while applying direct pressure and packing to control ongoing hemorrhage. Penetrating maxillofacial trauma caused by sharp objects, such as arrows, is infrequent but has high immediate morbidity and mortality.

This case report aims to present a penetrating facial injury by an arrow and highlight the role of emergency medicine in the management of penetrating arrow injuries in the head and neck regions.

Patient Information

This is a case of F.G., a 44-year old male, who was brought in by bystanders to the emergency department (ED) with an impaled arrow on the infraorbital area. Patient was unintentionally shot with a speargun by his alcohol intoxicated son while trying to mediate the fight between his son and nephew. When the patient's son was about to shoot the nephew with a speargun, the patient stood before the nephew and was shot instead. No prehospital manipulation nor attempts to remove the arrow done. On examination, the patient is conscious, airway is patent and breathing spontaneously, with a Glasgow Coma Scale (GCS) of 15/15, and stable vital signs with BP 120/80 mmHg, heart rate of 88 beats per minutes (bpm), respiratory rate of 18 cycles per minute (cpm), temperature of 36.6 °C, oxygen saturation of 98% at room air and capillary blood glucose of 114. The patient has no known allergies to food and medications nor comorbidities. Family history is unremarkable and the patient works as a fisherman.

Upon receiving the patient, a primary survey was done which revealed no exsanguinating wounds, a patent airway with no note of any secretions nor blood on the oral cavity. No cervical motion tenderness noted, however, a cervical collar was placed in consideration of a traumatic injury to the cervical spine. Patient has no external signs of injuries to the chest, with spontaneous breathing, clear breath sounds and equal chest expansion. Noted full equal pulses, capillary refill time of less than 2 seconds and warm extremities. Patient was hooked to a cardiac monitor which revealed sinus rhythm with a heart rate of 94 bpm. For the disability, the patient is awake with isocoric and reactive pupils, and bedside capillary blood glucose was checked which revealed 114. The patient is afebrile, has no edema and no deformities, with an impaled metal arrow head penetrating the right infraorbital area. Physical examination of the head revealed a normocephalic and atraumatic skull with well-distributed coarse hair on inspection, symmetric and non-tender. Face is symmetric with intact facial expression, symmetric nasolabial fold, with presence of 1 cm circumferential wound on right infraorbital area, and a protruding tail of the metal arrow head (Fig. 1A). The eyes and eyebrows are symmetric, no periorbital edema or hemorrhage and with icteric sclerae. Crepitus on the right supraclavicular area was noted. Neurologic examination is also unremarkable.

Fig. 1.

(A) Preoperative imaging. (B) Patient's infraorbital area was penetrated by an arrow without exiting the skull. (C) Assessment of the intraocular muscles. (D) Skull radiograph showing an arrow coursing from the right nasomaxillary region through the oral cavity and into the tracheo-esophageal shadow with its pointed end exiting and embedded within the level of C3 vertebra. (E) The chest radiograph of the patientshows pneumomediastinum and subcutaneous emphysema on the left supraclavicular region. (F) CT angiogram of the head and neck.

Partial trauma team activation was done and the patient was immediately seen by the general surgery trauma team on duty. Since there are no other threats to the primary survey, a secondary survey was done which revealed no allergies to food and medications, no known comorbidities and last meal intake consist of rice, vegetables and fish. The patient was inserted with an intravenous fluid of Plain Lactated Ringer's solution, given a dose of Tetanus Toxoid and Human Tetanus Immunoglobulin. Blood for laboratory tests was extracted in preparation for surgical removal of the impaled arrow. Imaging such as skull series x-ray anterior and posterolateral with towne's view, cervical x-ray, chest radiograph and CT angiogram was made.

Chest radiograph revealed pneumomediastinum and subcutaneous emphysema on the left supraclavicular region (Fig. 1D). An arrow was seen coursing from the right nasomaxillary region through the oral cavity and into the tracheo-esophageal shadow on skull radiograph, with its pointed end exiting and embedded within the level of C3 vertebra. The intrafacial segment of the impaled object measures 13.2 centimeters (Fig. 1C).

There is no evidence of extravasation, abnormal dilatation, stenosis, dissection or intimal flaps on CT angiogram (Fig. 1F), however, the arrow is noted entering the right orbital fossa fracturing the right inferior orbital, anterior, medial and posterior maxillary sinus walls, traversing the nasopharynx and transecting the soft palate and inferiorly into the oropharyngeal mucosa involving the pharyngeal, retropharyngeal and prevertebral neck spaces, the notched arrowhead tip located abutting the left superolateral border of C4 vertebral body (Fig. 1E). Extensive pockets of air were seen dissecting multiple deep neck space compartments which includes the retropharyngeal, prevertebral, visceral, bilateral carotid, posterior cervical spaces, retrosternal, and pre-vascular spaces of the thoracic aorta.

The patient was referred to General Surgery Trauma for admission and further surgical intervention. A referral for evaluation to ENT and Ophthalmology was also made. The patient was wheeled to the operating room approximately nine hours after being seen at the ED. The impaled arrow was removed under general anesthesia. The tip of the arrow was placed inside the lumen of a French 18 foley catheter covering the fangs of the arrow and was then removed in a retrograde direction (Fig. 2). A thirteen centimeters arrow was retrieved with two fangs on its arrowhead. Following the removal, primary repair of the soft palate was done.

Fig. 2.

Intraoperative images of the surgical removal of the arrow.

The entire procedure lasted for 50 minutes. Patient was transferred to surgical intensive care unit for post-operative monitoring. There were no post-operative complications. The patient was discharged ten days later after completion of antibiotics. No post-operative CT scan was done, however, cervical radiograph on post-operative day-3 showed resolution of the subcutaneous emphysema.

Discussion

Fishing is a major livelihood by Filipinos and the use of speargun as fishing gear are not uncommon especially among the coastal communities.⁵ This weapon operates through pneumatic compression in the barrel and static energy storage by stretching an elastic band. It is designed for underwater fishing hence, must overcome water resistance. When used as weapon of violence, it may cause serious penetrating cranial and facial injuries.¹ Some weapons are modified by adding some spikes and metal on the tips, or even poison to add its lethal potential. The lethal potential of arrow injuries comes from several factors related to the arrow design, the materials used, and the biological consequences of trauma such as possible complications arising from toxins and infections. These may pose challenges to the management of these cases.

Penetrating head injuries constitute 0.4% of all head injuries and foreign bodies produce injury to the brain. The orbital region, including areas such as the canthus of the eyelid, was the most frequently affected, accounting for 32% of the specific trauma locations. These are categorized into three regions. First, from the sternal notch to the cricoid cartilage, the area has the highest mortality due to significant risks of blood vessel injury and airway compromise. Next would be the area from cricoid cartilage to the mandibular angle involving the carotid arteries, vertebral arteries, jugular veins, trachea, larynx, and esophagus. Injuries are more common but less fatal than in Area 1 due to better hemorrhage control. Lastly, the mandibular angle to the base of the skull which involves the eyes, distal carotid artery, salivary glands, pharynx, and spinal cord. The prognosis is generally better if vital structures are not involved.⁷ Most cases attribute its high mortality rate to the extent of damage to the brain and neurovascular structures and pre-hospital attempts to remove the arrow contribute to mortality of patients thus, it is best to keep the object in place.¹

Prehospital emergency medical services (EMS) play a vital role in trauma care by delivering timely resuscitation and transporting critically injured patients to healthcare facilities. The "golden hour" concept, introduced in the 20th century, emphasizes the importance of providing definitive treatment to critically injured patients within the first 60 minutes. Essential elements for effective trauma care include quick EMS team response and transportation, protocol- driven on-scene management, and prompt decision-making in directing patients to appropriate medical centers equipped with specialized trauma care systems. Deciding whether EMS should focus on immediate transport (load and go) or provide on-scene treatment (stay and play) remains a challenging issue. A study by Chen et.al.⁸ highlighted the importance of rapid transportation for all trauma patients, as extended prehospital time is linked to a higher risk of poor functional outcomes; the likelihood of poor outcomes increases by 6% with every additional 10-minute delay in total prehospital time (TPT), and a TPT exceeding 50 minutes is predictive of poor outcomes. Managing trauma patients is a fundamental aspect of emergency medicine training and practice,⁹ with most trauma care being provided by emergency physicians. They play a vital role in managing severely injured trauma patients, particularly in assessment, resuscitation, airway management, point-of-care ultrasonography, and performing bedside procedures. Following ATLS protocols is crucial, involving rapid assessment of airway, breathing, circulation, disability and exposure which are vital to trauma care.¹⁰ For maxillofacial or head trauma, it is essential to assume that there may be an associated cervical spine injury. Therefore, movement of the cervical spine should be minimized to prevent further harm. In cases of upper airway obstruction, an emergency tracheostomy is performed to secure the airway. For vascular injuries in patients with unstable hemodynamics, resuscitation with blood and emergency neck exploration and repair are necessary.

Tertiary centers have a trauma team composed of various healthcare professionals, including a team leader, airway manager, trauma nurse, residents, and medical students. Their roles typically involve patient assessment, airway management, applying monitoring equipment, securing IV access, drawing blood, and recording resuscitation activities.¹⁰ In Southern Philippines Medical Center, a trauma team activation protocol was established to ensure a rapid and coordinated response to severe traumatic injuries. Early activation of a specialized trauma team guarantees that high-quality care is delivered promptly at the scene, during transport, and upon arrival at the hospital, speeding up the assessment, stabilization, and necessary interventions for critically injured patients. The trauma team consists of a Trauma Physician, Trauma Critical Care Surgeon, Senior Emergency Medicine Resident, Senior Trauma Surgery Resident, Junior Emergency Medicine Resident, and Junior Trauma Surgery Resident. Additionally, the team includes a Trauma/Resuscitation Nurse, a member from the Cardio-Pulmonary Service (CPS) or a Respiratory Therapist, and Nursing Attendants, all of whom work together to provide comprehensive care for trauma patients.

The criteria for activation include trauma team I activation (full), trauma team II activation (partial), and no activation. A Trauma Team I Activation (full) occurs when the trauma team is fully mobilized for patients meeting at least one of the following criteria: a confirmed systolic blood pressure below 90 mmHg (or below 70 mmHg for infants under one year old) at any point in the field, a heart rate exceeding 120 bpm at any time in the field, or a respiratory rate falling below 10 cpm or rising above 29 cpm at any point in the field, GCS score of less than 9 or a drop of 2 points, if linked to trauma; severe uncontrolled bleeding or patients being transferred while receiving blood products to maintain stability; airway compromise or the placement of an emergency airway at the scene or in a referring hospital; major vascular injuries, including significant crush injuries or amputations proximal to the wrist or ankle, or the application of a prehospital tourniquet; penetrating injuries to the neck, chest, abdomen, or extremities proximal to the wrist or ankle; major impalement injuries to the torso; suspected spinal cord injuries; open or unstable pelvic fractures; pregnancy beyond 20 weeks gestation in the presence of other Level II or higher activation criteria; and any case of traumatic arrest. For patients who do not necessitate full trauma team activation, the emergency medicine senior resident will take charge of the patient until the Trauma Physician or Trauma Critical Care Surgeon takes over. Once the patient arrives at the ED, a full assessment is conducted, and the Trauma Surgeon or Trauma senior resident is notified. This procedure applies to patients who don't meet the criteria for Level I activation but exhibit at least one of the following conditions: penetrating injuries to extremities beyond the wrist or ankle, chest wall deformities such as flail chest or multiple rib fractures, major burns exceeding 20% of the total body surface area or suspected inhalational injury, head injury with a GCS score below 14 due to a high-risk mechanism of injury, open or depressed skull fractures, multiple long bone fractures, extremity injuries with loss of distal pulses or sensation, severe maxillofacial injuries with a stable airway, near drowning, trauma patients younger than 15 or older than 65, trauma patients on anticoagulants, pregnancy beyond 20 weeks gestation without other Level II criteria, involvement in major motor vehicle crashes (ejection from the vehicle, extrication taking more than 20 minutes, death of another occupant, or impact speeds exceeding 30 km/h), pedestrians or bicyclists struck by a vehicle traveling over 12 km/h, falls over 20 feet or 2–3 times the patient's height, trauma patients showing a "seat belt sign" or other significant external injuries on the torso, single system injuries with high suspicion based on the mechanism, and cases where the senior emergency medicine resident deems it necessary. Those who do not meet the two criteria do not necessitate an activation.¹¹

Arrow removal is a surgical procedure that involves careful planning and consideration of various anatomical and structural factors. Before deciding on the route of removal, the surgeon must assess the proximity of vital structures, such as blood vessels, nerves, and organs. Plain skull radiographs can reveal information on the depth and direction of penetration.¹² CT scan is also an essential diagnostic tool for patients with an arrow injury to the head or neck. It is typically used in patients who are hemodynamically stable and do not show severe signs of vascular or aerodigestive tract injury. Being noninvasive, a CT scan helps in assessing the arrow's trajectory and its proximity to critical structures. Clinically stable patients with optimal hemodynamic status undergo further investigations before deciding on surgical exploration.¹³ In this case, imaging through skull and chest radiographs, and CT angiogram of the head and neck was done showing detailed images of the arrow's trajectory and its relationship with major arteries and veins which assisted in planning for surgical approach to safely remove the impaled arrow. Pneumomediastinum, the escape of air into the mediastinal space, typically from the lungs, esophagus, trachea, or neck, occurring spontaneously or due to trauma was also evident. In cases of isolated facial trauma, air can be forcefully introduced into the parapharyngeal and retropharyngeal spaces, travel along prevertebral and fascial planes, and result in emphysema of the neck and mediastinum.⁹

Each case is unique, and strategies are tailored based on the severity and specifics of the injury.¹³ According to Bill J H, the intact shaft provides a guide to the arrowhead; if it is separated from the shaft, the fixating tendon may cause infection and abscesses. The removal of the arrowhead should follow an antegrade direction to avoid tearing the blood vessels and other structures. Retrograde removal may result in an arrow "hitting all it had missed on its way in".¹² Even if there is no bleeding initially, foreign body removal can cause vessel wall disruption and pseudoaneurysms leading to severe bleeding if disturbed during removal.¹⁴ If there are both entry and exit wounds, the path of an arrow and orientation of the fangs may indicate how it is pulled out. Imaging may also be utilized to visualize the arrow's position and any associated injuries.

On the contrary, the surgical approach done for this patient involved removing the arrow in a retrograde direction. In order to avoid piercing through the related structures, the tip of the arrow was inserted into a lumen of a Foley catheter while carefully pulling the arrow. The foley catheter also served as a tamponade. Arrow was successfully removed without any complications such as severe bleeding.

Conclusion

The case underscores the importance of individualized treatment strategies based on the specific injury characteristics and the critical role of imaging in the management and successful outcome of penetrating arrow injuries. It demands a multidisciplinary approach, tailored to the specifics of each case. As emergency medicine physicians, our role in such cases in both pre- hospital and in-hospital setting is vital. Rapid and accurate assessment, appropriate imaging, and careful surgical planning are essential to improve patient outcomes. Because of its rarity, this case emphasizes the importance of reporting such injuries to contribute to medical research by promoting evidence-based practices in emergency care, improve future safety regulations and standardized treatment protocols.