|Year : 2021 | Volume
| Issue : 1 | Page : 50-54
The unpredictable pathway of foreign bodies in penetrating neck trauma: A case report and review of the literature
Sara Alquorain1, Shatha Alshamsi2
1 Department of Otolaryngology Head and Neck Surgery, King Fahad Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
2 Department of Surgery, King Fahad Military Medical Complex, Dammam, Saudi Arabia
|Date of Submission||17-Mar-2020|
|Date of Decision||24-Apr-2020|
|Date of Acceptance||17-Jun-2020|
|Date of Web Publication||22-Apr-2021|
Dr. Sara Alquorain
Department of Otolaryngology Head and Neck Surgery, King Fahad Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam
Source of Support: None, Conflict of Interest: None
Saudi Arabia has the world's highest number of deaths due to road traffic accidents (RTAs). Penetrating neck trauma is a peculiar sequela of RTA, which may be complicated by the implantation of foreign bodies. Foreign bodies penetrating the neck have an unpredictable course, ranging from being completely asymptomatic to being fatal. We present an interesting case of penetrating neck trauma due to RTA that was complicated by implantation of sharp foreign bodies in the neck. These bodies migrated over time to penetrate major blood vessels. In this case, the authors discuss the current management of penetrating neck trauma and highlight the complications of residual foreign bodies in the neck and their management.
Keywords: Foreign bodies, migration, neck, penetrating, sharp, trauma
|How to cite this article:|
Alquorain S, Alshamsi S. The unpredictable pathway of foreign bodies in penetrating neck trauma: A case report and review of the literature. Saudi J Otorhinolaryngol Head Neck Surg 2021;23:50-4
|How to cite this URL:|
Alquorain S, Alshamsi S. The unpredictable pathway of foreign bodies in penetrating neck trauma: A case report and review of the literature. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2021 [cited 2021 Jun 25];23:50-4. Available from: https://www.sjohns.org/text.asp?2021/23/1/50/314387
| Introduction|| |
Trauma is the third most common cause of death worldwide and a leading cause among those aged 1–44 years. Saudi Arabia has a very high number of road traffic accidents (RTAs), resulting in 19 deaths per year and 4 injuries per hour. Collectively, RTAs have caused 86,000 deaths and 611,000 injuries over the past 25 years. RTAs often result in neck injuries, but penetrating neck injuries are relatively uncommon and account for 5%–10% of all trauma cases. Such injuries are usually serious and require urgent management. We present a case of a 36-year-old man who was involved in an RTA and had a penetrating neck injury with implantation of glass foreign bodies.
| Case Report|| |
A 36-year-old male was referred from a primary hospital with residual foreign bodies in the neck due to a penetrating injury caused by an RTA 5 weeks earlier. The patient had presented to the hospital immediately following the RTA and was found to have a 5-cm deep neck laceration in the left submandibular area. He had no symptoms of respiratory distress, difficulty in swallowing, neck pain, limitation of neck movement, or neurological deficits. He was managed according to the advanced trauma life support (ATLS) guidelines. The neck laceration was sutured and followed by a 24-h observation period, which was uneventful. One week later, when the neck sutures were removed, surprisingly, small fragments of glass were found. A neck biplane X-ray showed multiple small radiopaque structures in the soft tissue of the left submandibular area of the neck [Figure 1].
|Figure 1: Frontal neck X-ray showing radiopaque foreign bodies (yellow arrow) in the soft tissue in the left of the neck|
Click here to view
A subsequent enhanced neck computed tomography (CT) scan showed multiple small hyperdense structures (glass) on the left side of the neck. Of these, one piece of glass measuring 6 mm × 7 mm was located in the left vascular space, where it laterally penetrated 20% of the left internal jugular vein. Another piece measuring 5 mm was deeply seated within the left sternocleidomastoid muscle [Figure 2].
|Figure 2: Contrast-enhanced computed tomography scan of the neck; (a) coronal, (b) axial, (c) sagittal Blue arrow: Left internal jugular vein, Red arrow: Left common carotid artery, Yellow arrow: Foreign bodies/glass in close relation to the left internal jugular vein, with some parts seen within the vein|
Click here to view
Five weeks after the RTA, the patient was referred to King Fahad Military Medical Complex for further evaluation and management. On presentation to the outpatient clinic, the patient was in an overall good condition and was asymptomatic. On physical examination, the neck wound was found to have healed. Palpation over the wound revealed a small, subcutaneous, well-defined hard mass of <1 cm in size.
As the patient was asymptomatic, and surgical intervention posed a risk of severe bleeding, this case was presented for discussion among multiple surgical departments to decide on the management plan. The decision was made to proceed with surgical exploration of the neck.
During the operation, the subcutaneous glass particles were removed. However, the glass piece that appeared to be penetrating 20% of the left internal jugular vein on the CT scan was found to be completely penetrating the vein. This was explained by migration over a period of 5 weeks. This piece was extracted through a small venotomy followed by primary anastomosis of the vein, with minimal bleeding. The extracted glass was almost square in shape and was about 1 cm in size. The postoperative course was uneventful.
A CT angiography after the surgery revealed patent major cervical vasculature, with no evidence of significant narrowing or abnormal aneurysmal dilatation [Figure 3]. At the 2-week follow-up visit, the patient was found to be in good clinical condition.
|Figure 3: Computed tomography angiogram of the neck, coronal view Red arrow: Left common carotid artery|
Click here to view
| Discussion|| |
Penetrating neck injury is a serious traumatic injury that requires urgent management. It is defined as any neck injury that penetrates the platysma muscle. It is an uncommon injury, accounting for 5%–10% of all trauma cases. It is most commonly caused by RTAs, followed by gunshots and assaults. Penetrating neck trauma can cause significant morbidity and mortality because it can be injured vital structures; thus, it has a mortality rate of up to 9%.
The neck is a complex anatomical region that contains vascular, neural, and aerodigestive structures. It is horizontally divided into three zones.
Zone I spans the cricoid cartilage and the sternal notch/clavicles. As injuries in this zone are vascular in nature, and surgical interventions are difficult to perform, penetrating trauma in this zone has the highest mortality rate of 12%. Zone II spans the cricoid cartilage and the angles of the mandible. It is the most commonly injured zone (60%–75%). Zone III spans the angles of the mandible and the base of the skull, making it a difficult zone for surgical exploration. In our case, the trauma involved zones II and III.
Penetrating neck trauma has vast clinical presentations, depending on the injured structures, and may range from asymptomatic presentation to acute fatal status. As in any trauma case, penetrating neck trauma patients should initially be managed according to the ATLS guidelines, followed by a systemic evaluation (i.e., vascular, neural, respiratory, and aerodigestive structures) to avoid missing any injury. The vascular component is the most frequently injured structure (25%) and is also the most common cause of death (50%). Definite vascular injury signs, also known as “hard signs,” include pulsatile bleeding and expanding hematoma.
Management of penetrating neck trauma evolved from nonoperative management during World War 1 (WW1) to mandatory surgical exploration during World War 2 (WW2) and selective exploration now., These changes in management have resulted in the mortality rate dropping from 11% in WW1 to 7% in WW2 to 3%–6% in civilians presently. Mandatory surgical exploration is no longer standard management because of the large number of negative intraoperative findings (50%–70%). In addition to the recent advances in imaging techniques, selective exploration, which includes observation and frequent physical examination, is currently the most popular practice for stable penetrating neck trauma patients. Indications for surgical exploration are hemorrhage, hematoma, serious respiratory distress, subcutaneous emphysema, hemoptysis, hoarseness, and stridor.
An implanted foreign body in the neck is a unique sequela of penetrating neck trauma. RTAs are a cause of glass foreign bodies in the neck, as was the case in our patient. The glass currently used in the windshields of cars is different from that used previously; it is more resistant to breakdown and is always radiopaque in neck X-rays. CT scans are the most effective method for detecting all types of foreign bodies in the neck except wood, which can only be detected by ultrasonography. CT scans and plain X-rays have almost the same accuracy in detecting metallic foreign bodies. Magnetic resonance imaging is a less beneficial imaging modality.
Currently, there are no guidelines or consensus regarding the management of foreign bodies in the neck. To provide clarity, we identified five similar cases from the literature and discussed the management used in different circumstances in [Table 1].
|Table 1: Management of penetrating foreign bodies in the neck in other case reports in the literature|
Click here to view
In comparison to our case with [Table 2], the foreign body in our case was glass and was situated in zones II and III. The etiology of RTA was different from those reported. However, the clinical presentation in our case was similar to most cases, where patients were asymptomatic initially and were discharged and readmitted. Management was surgical removal of the FB in 100% of the cases, including ours.
In our view, mandatory surgical exploration for residual foreign bodies in the neck is necessary because foreign bodies can migrate through the soft tissues of the neck and reach the vascular or aerodigestive structures, likely because of swallowing and/or vigorous coughing. This may be lethal, depending on the direction in which the foreign body migrates. In our case, the foreign body initially penetrated 20% of the internal jugular vein, which progressed to 100% penetration during the 5-week period.
There are two similar cases that have reported foreign body migration in the neck. The first case had a 1-cm metallic rod that migrated from the right cervical region to the heart by penetrating the internal jugular vein, and the other case had a 1-cm metal foreign body migrated through the soft tissues from the anterior neck into the trachea. Based on such migration, Khan et al. recommended repeating X-rays immediately before exploratory procedures, especially in cases with delayed surgical intervention.
In addition to migration, another reason for mandatory surgical exploration is that any residual foreign body may cause early or late complications, such as infection, wound dehiscence, cosmetic deformity, and salivary fistulae, as well as the formation of arterial pseudoaneurysms and possible ruptures.
It should be noted that while early exploration reduces the risk of migration, late exploration reduces the risk of bleeding. In our case, the ease of intraoperative removal of the foreign body with minimal bleeding was likely because of delayed surgical exploration (5 weeks). This resulted in healing by secondary intention and the formation of fibrosis around the foreign body. Similar to our case, Zhao et al. reported a case of a glass foreign body that punctured the internal jugular vein; 3 weeks after the trauma, surgical exploration was done with easy removal of the glass and minimal bleeding. The authors concluded that increased durations of foreign body retention may be helpful by increasing fibrosis to surrounding tissues, thus decreasing the risk of active intraoperative bleeding.
| Conclusion|| |
Suspicion of residual neck foreign bodies following a penetrating neck trauma must be high. Residual foreign bodies in the neck are dangerous because of their unpredictable course and ability to migrate to major blood vessels. We recommend surgical exploration and removal of residual foreign bodies for all cases. However, it should be considered that early exploration can prevent the complications of migration, while delayed exploration can prevent fatal intraoperative bleeding. We recommend that studies should be conducted to determine the appropriate timing for surgical exploration.
Statement of ethics
The study was approved by the Regional Ethics Board. Informed consent has been obtained from participant(s).
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gulia J, Yadav S, Singh K, Khaowas A. Penetrating NeckInjury: Report Of Two Cases. The Internet Journal of EmergencyMedicine, 2009;6(1).
Mansuri FA, Al-Zalabani AH, Zalat MM, Qabshawi RI. Road safety and road traffic accidents in Saudi Arabia. A systematic review of existing evidence. Saudi Med J 2015;36:418-24.
Ghnnam, Wagih Almastour Ali et al. Penetrating Neck Trauma in a Level II Trauma Hospital Saudi Arabia. ISRN Emergency Medicine. 2011;2012: 1–6.
Barrett G, Williams C, Thomas D. Delayed presentation of a penetrating neck injury: Diagnostic and management difficulties with retained organic material. JRSM Short Rep 2010;1:19.
Lawrence PF, Bell R, Dayton M. Essentials of General Surgery. 5th
ed. Philadelphia: Lippincott Williams & Wilkins; 2012. p. 179.
Kaya KH, et al. Timely management of penetrating neck trauma: Report of three cases. J Emerg Trauma Shock 2013;6(4):289 92.
Islam S, Esmil T, Umapathy N, Hoffman GR. Foreign body (metal key) impacted in the upper neck. Injury Extra. 2006;37:109–112.
Singh RK, Bhandary S, Karki P. Managing a wooden foreign body in the neck. Journal of Emergencies, Trauma and Shock 2009;2.3:191-5.
Ozturk K, Keles B, Cenik Z, Yaman H. Penetrating zone II neck injury by broken windshield. Int Wound J 2006;3:63-6.
Javadrashid R, Fouladi D F et al. Visibility of different foreign bodies in the maxillofacial region using plain radiography, CT, MRI and ultrasonography: an in vitro study. Dentomaxillofac Radiol 2015;44 (4):20140229.
Khan MS, Kirkland PM, Kumar R. Migrating foreign body in the tracheobronchial tree: An unusual case of ﬁrework penetrating neck injury. J Laryngol Otol 2002;116:148-59.
Zhao YF, Liu Y, Jiang L, Liu J, Chen XQ, Shi RH, et al
. A rare case of a glass fragment impacted in the parapharyngeal space associated with neurovascular compromise. Int J Oral Maxillofac Surg 2011;40:209-11.
Bagheri R, Afghani R. Unusual Presentation of Metallic Foreign Body Aspiration after Penetrating Neck Trauma. J Cardiothoracic Med 2013;1:107.
Luo Y, Yuan H, Cao ZS. Residual foreign body in the neck after trauma results in the delayed rupture of the common carotid and internal jugular vein: A case report. J Med Case Rep 2013;7:13.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]