IMPALEMENT HEAD INJURY WITH A SPEAR

Abstract

Impalement injuries to the craniofacial region are uncommon due to the fact that the face is a smaller target in relation to the rest of the body. We report a case of a 26-year old man who was attacked on the face with a spear. He was promptly evaluated and resuscitated; the blade of the spear was successfully extracted under general anaesthesia. He was discharged home after 2 weeks hospitalization; he has been followed up for three months with good outcome.

Introduction

Impalement injury is said to occur when a foreign object penetrates and embeds in a body part with the object still remaining in a part of the wound and mostly conspicuous1. Penetrating cranial and facial injuries caused by foreign objects are quite uncommon1,2. This is because the face presents a much smaller target when compared to the rest of the body, with the protective reflexes of the face allowing the potential victim to move away from the coming object1. Impalement injury to the craniofacial region is also known as Jael syndrome3. Most cases of stab injuries to the face occur on the left side and usually involve the zygomatico-temporal area4. We report the case of a 26-year old unemployed man who was impaled with a spare on the face while escaping after burglarising a house; he had escaped after previous burglary incidents in the neighbourhood and the night guards were keeping watch for him. The sharp tip of the spare penetrated his nasal region through the bridge of the nose on the right and punctured the face just below the left ear. The eyes were intact with good vision and his hearing and facial nerves were not affected; he was not in respiratory distress but breathed mostly with his mouth.

Case Reports

History

T.B was a 26-year old unemployed man who presented with a history of a spear thrown at him 6 hours prior to presentation.

He had gone at night to burgle a nearby restaurant and while trying to escape a spear was thrown on the face by a security guard. He escaped with the spare still attached to his face and he bled profusely from the nose and mouth but the bleeding had stopped before he presented to a nearby clinic. A good length of the wooden handle of the spear was sawn off before he was brought to Bingham University Teaching Hospital, Jos, Nigeria. There was no loss of consciousness or other systemic complaints. He was not a known diabetic, hypertensive or psychiatric patient but admitted to smoking marijuana habitually.

On presentation

he was fully conscious, but in painful distress with a locally made spear consisting of a metallic blade and a partially sawn off wooden handle penetrating obliquely from the right side of his nasal bridge just below the medial canthus with about 6cm length of blade exiting just below the left ear with crusts of blood in the nostrils and over the skin of the left parotid region (Figs. 1 & 2). No active bleeding was observed and there was limited mouth opening.

He was not pale, febrile, cyanosed, or dehydrated and his pulse rate was 80bpm, regular, full volume with a BP of 130/90mmHg. His respiratory rate was 24cpm, regular with stuffy nostrils containing crusts of dried blood and he used his mouth to breathe; his oxygen saturation was 92% in room air. There were no other significant systemic findings.

The admitting diagnosis

was impalement injury to the face. The patient was then admitted to the intensive care unit of the hospital and had the following investigations: skull x-rays, haematocrit, white blood cells and differentials, grouping and cross matching of 3 units of blood and computerized tomographic scan. He was promptly resuscitated and rehydrated, and appropriate antibiotics and tetanus toxoid administered.

Fig. 1. The entry point of the spear.

Fig. 2. The exit point of the blade of the spear.

CT brain scan

shows a sharp pointed object of metallic density traversing the face in a linear diagonal trajectory, entering through the right aspect of the nasal bridge, crossing the midline and the roof of the left maxillary sinus, below the inferior orbital margin and above the left supramandibular notch, before exiting below the left zygomatic arch. The left maxillary sinus is filled with isodense hemosinus. The cranium and its contents and the left mandible are spared.

Fig. 3. Pre-operative skull x-ray of the patient.

Fig. 4. Brain CT scan (volume rendering image) showing the course of the knife through the skull.

The operation was carried out by a team of surgeons consisting of a maxillofacial surgeon, an otorhinolaryngologist, a neurosurgeon and a general surgeon after an elective tracheotomy was first performed out under local anesthesia. Thereafter, the foreign body was traced from its entry in the right nasofrontal region where it was observed to transverse the left maxilla to fracture the zygoma and then pass through the supramandibular notch to exit at the inferior pinna region.

Prior to the skin incision, the superior labial vessels were ligated, and intravenous Dycemone 500mg and 8mg of dexamethasone were administered. A left Weber-Fergusson-Blair incision was made down to the facial bone to expose the hemi-face. Torrential bleeding was encountered from the anterior and posterior ethmoidal vessels at the entry point of the knife which was arrested by ligating the vessels with 3.0 Vicryl.

Bleeding was also noticed from the right maxillary antrum. Nasal anstrostomy was done; the right antrum was packed with ribbon gauze impregnated with povidone iodine while the left was packed with Merocoel to achieve hemostasis. Surgicel was used to enhance hemostasis from the bleeding bony edge of the nasal bridge. Intraoperatively the incisions were closed using 3-layered suturing using vicryl 3.0 while proline 4.0 was used for the skin.

The immediate post operative vital signs were as follows: pulse rate of 110/min, blood pressure of 140/82 mmHg, respiratory rate of 24 cycles per minute. The estimated blood loss was 300mls; one unit of whole blood was transfused intra-operatively. Post operatively he had his vital signs monitored every 15 minutes until he became fully conscious. The tracheostomy cuff was deflated for 5mins every hour and then re-inflated and deflated completely after 24 hours, suctioned when necessary and bicarbonate was instilled into the tracheostomy as required. The gauze in the right nostril was removed on the 4th post op day. Active mouth exercise was commenced within 24 hours using a wooden spatula and chewing gum. The patient was then placed on intravenous 5% dextrose/saline to alternate with normal saline for the first 72 hrs. He was also placed on ocular chloromphenicol twice daily.

On the 1st postoperative day he was observed to be stable with moderate facial oedema, the mouth opening was limited to one finger breath with good interdigitation of occlusion. He was commenced on supervised mouth exercise with wooden spatula and chewing gum, warm saline mouth rinse 7 times a day. He progressively improved and was discharged home on the 14^th post-operative day after removal of the tracheostomy tube on the 7th day post-op without respiratory distress.

Fig. 5. The patient intra-operatively showing Weber-Fergusson-Blair incision and preservation of the infra orbital nerve.

Fi. 6. The impalement object.

Fig. 7. The patient on the first day post operatively.

Fig. 8. Facial profile of the patient 2 weeks after surgery.

Discussion

Impalement injury to the face also referred to as Jael syndrome3,5 though uncommon, is usually on the left side of the face. This has been attributed to the fact that the assailants are usually right handed4. It has also been reported to occur commonly in the zygomatico-temporal region3. However in this patient, the impalement was more to the midline and on the right. This may be due to the surprise nature of the attack and the position of the assailant while the patient tried to escape.

The choice of an elective tracheostomy in this patient was the need to maintain a patent airway under general anaesthesia and a good visual field as the surgeons extracted the knife from the face of the patient. This approach agreed with that of Cooper et al6 who reported studies examining airway management in penetrating neck and face injuries. The general recommendation is direct laryngoscopy where feasible, with rapid progression to surgical airways6. The expected post operative collateral oedema that could lead to compromise of the upper airway was also considered.

A left Weber-Fergusson-Blair incision was used to expose the face in this patient. The advantage of this procedure was that it allowed a wider access and visualization of the infraorbital nerve preventing its damage. An alternative Moure incision (lateral rhinotomy) could have been used, however this would have provided a limited access and the distance to the exit of the blade close to the temporomandibular joint where the pterygoid venous plexus and the internal maxillary artery are situated would not have been visualized.

The fact that these types of injuries to the face should be explored in the theater cannot be over emphasized. The torrential bleeding encountered when the knife was being extracted retrogradely further supports this practice. The knife most likely acted as a tamponade. This is further supported by the work of Salomone7 who also emphasized that in the pre-hospital setting, the key principle for managing an impalement object was not to attempt to remove it outside the operating theatre. The reasoning being that the object could have damaged major blood vessels, which were tamponaded by the object and therefore if removed, the pressure would be released, and life-threatening hemorrhage could result. Besides, removing an impalement object blindly is not advisable as it could lacerate vital structures as it is being pulled out blindly8,9. The surgeons had also kept in mind that the midface contained some major blood vessels like the palatine artery, infra-orbital artery, maxillary artery, facial artery and the nasopalatine artery10. So the possibility of encountering heavy bleeding during the surgery was envisaged and prepared for, hence the recommendation of general anaesthesia for removal of impalement injuries.

In this patient, no major neurologic deficits occurred from this type of injury except for paraesthesia in the low half of the left side of the face. It is also of note that the left parotid gland was spared including the important structures that pass through or close to it like the facial nerve, retromandibular vein, external carotid artery, superficial temporal artery, branches of the great auricular nerve and the maxillary artery11.

The patient has been followed up with counseling for three months; he is now a farm help but with paraesthesia on the left side of the face and some degree of anosmia - a common consequence of craniofacial trauma12.

Conclusions

Despite the severity of impalement injuries to the craniofacial region - Jael syndrome – adequate pre-operative management and prompt operation by a multi-disciplinary surgical team under general anaesthesia could lead to a satisfactory outcome.