Frontal penetrating arrow injury: A case report

Abstract

BACKGROUND

Penetrating arrow injuries of the head and neck are exceedingly rare in pediatric patients. This pathology has high morbidity and mortality because of the presence of vital organs, the airway, and large vessels. Therefore, the treatment and removal of an arrow is a challenge that requires multidisciplinary management.

CASE SUMMARY

A 13-year-old boy was brought to the emergency room after an arrow injury to the frontal region. The arrowhead was lodged in the oropharynx. Imaging studies showed a lesion of the paranasal sinuses without compromising vital structures. The arrow was successfully removed by retrograde nasoendoscopy without complications, and the patient was discharged.

CONCLUSION

Although rare, maxillofacial arrow injuries have high morbidity and mortality and require multidisciplinary management to preserve function and aesthetics.

Key Words: Arrow; Penetrating trauma; Maxillofacial injuries; Pediatrics; Pediatric emergency medicine; Case report

Core Tip: Penetrating maxillofacial trauma is a rare, life-threatening pathology. Managing injuries caused by arrows is challenging because their removal can cause greater damage; therefore, the approach and treatment must be multidisciplinary. We present a pediatric patient who suffered a penetrating arrow injury of the frontal region without affecting vital structures and with successful removal.

INTRODUCTION

Penetrating maxillofacial trauma caused by sharp objects, such as arrows, is infrequent but has high immediate morbidity and mortality[1]. Its incidence in the pediatric population is unknown; therefore, no standardized management exists[2]. Since this area has vital organs and large blood vessels, the approach and management must be immediate and multidisciplinary since extraction of the object can cause greater damage than the original trauma[3]. We report the case of a 13-year-old pediatric patient who suffered a frontal penetrating arrow injury with the tip lodged in the oropharynx without causing adjacent lesions. It was retrogradely removed by nasoendoscopy with excellent recovery.

CASE PRESENTATION

Chief complaints

A 13-year-old male adolescent came to the emergency room 30 min after a penetrating arrow lesion of the frontal region.

History of present illness

Thirty minutes before arriving at the emergency service, he was in an archery field practicing this sport. Another athlete accidentally shot him in the frontal region with an arrow. The blow caused him to fall. He had mild epistaxis without loss of consciousness or other neurological symptoms.

History of past illness

The patient had no history of other diseases.

Personal and family history

The patient had no relevant family history.

Physical examination

The patient weighed 60 kg, and his height was 160 cm. His heart rate was 85 beats per min, and his respiratory rate 18 breaths per min with a blood pressure of 110/80 mmHg and a temperature of 36.5 ºC. He was conscious with a cylindrical foreign body (arrow) 0.8 mm in diameter perpendicular to the plane of the forehead. The entry site was in the left frontal region, 1 cm from the supraciliary region, and 2 cm from the midline (Figure 1). There was no bleeding at the entry site and no neurological alterations.

Figure 1 Photographs of the patient with a foreign body penetrating the frontal region.

Laboratory examinations

A complete blood count, coagulation, and other laboratory tests were normal. PCR was performed for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) due to the epidemiological crisis. The result was negative.

Imaging examinations

Skull X-rays showed an arrow-shaped foreign body in the left frontal region penetrating the posterior pharynx through the ethmoid cells (Figure 2). A simple cranial computerized tomography (CT) scan confirmed the arrow´s inferior oblique path through the anterior and posterior ethmoid cells with the distal end in the nasopharynx in contact with the mucosa without a septal fracture. Other structures were not affected. In addition, a cranial angio-CT requested by the Neurosurgery Department did not show vascular lesions (Figure 2).

Figure 2 Radiological findings of the patient with a foreign body in the frontal region. A and B: Frontal and lateral skull X-rays show a foreign body (arrow) with an entry site in the left frontal region penetrating the posterior pharynx through the ethmoid cells; C: A simple computerized tomography (CT) scan of the skull shows the inferior oblique trajectory through the ethmoid cells of the foreign body (arrow) with the distal end in the nasopharynx; D and E: Cranial coronal CT-scan and angio-CT showing the foreign body (yellow arrows) medial to the middle and inferior turbinates with no evidence of nasal septum fracture or lesions in vascular structures; F: Postoperative simple cranial CT scan shows a fracture of the external wall of the left frontal bone (yellow arrow).

FURTHER DIAGNOSTIC WORKUP

Only the remains of blood were seen in the rhinoscopy of the left nostril in the otorhinolaryngology evaluation. A metal foreign object was seen by rigid nasoendoscopy lodged obliquely in the left nasopharynx at the level of the choana, causing a non-penetrating wound without active bleeding.

FINAL DIAGNOSIS

Frontal penetrating arrow injury without vital structure lesions.

TREATMENT

The foreign body was extracted 24 h after the accident by endoscopy. A 0º rigid endoscope was introduced through the right nostril up to the choana. The tip of the foreign body was seen medial to the middle and superior turbinates. It was retrogradely removed. The endoscope was reintroduced, and no evidence of active bleeding or lesions was found. The area was irrigated with ceftriaxone through a feeding tube, and a simple suture was placed in the frontal region.

OUTCOME AND FOLLOW-UP

The patient was monitored and managed with ceftriaxone during the postoperative period. His evolution was favorable. A follow-up cranial CT, the day after surgery, showed a fracture of the external wall of the left frontal bone that was treated conservatively with no further action (Figure 2). The patient was discharged on the fifth hospital day with no complications.

DISCUSSION

The main cause of injury and death in the pediatric population is trauma. Head trauma is most common, and maxillofacial trauma to a lesser extent[4]. Facial trauma includes soft, neurovascular, and bony tissue lesions of the eyes, nose, mouth, paranasal sinuses, teeth, and neck[1]. There are few reports of a penetrating wound in the maxillofacial region caused by arrows similar to the case reported herein. These lesions are more common in developing countries due to using these weapons in community conflicts[5]. In a study conducted in Nigeria to determine the prevalence of this type of maxillofacial trauma, four patients with penetrating injuries in the maxillofacial region by arrows were reported from January 1998 to December 2002[6]. This finding highlights the small number of patients described with this type of injury, which is even less frequent in pediatric patients. Most publications on penetrating injuries correspond to objects such as bullets, broken glass, or pieces of wood[6,7].

Arrows are low-velocity injuries that can be life-threatening when they affect vital organs and potentially devastating and fatal in head and neck injuries, depending on the distance the arrow is fired and the degree of penetration. The arrow can penetrate and injure a main blood vessel, causing hemorrhage, bruising, or laryngeal or tracheal lesions. In addition, it can manifest as respiratory distress due to obstruction requiring invasive airway management. If a brain or spinal cord injury occurs, the patient may present paraplegia, quadriplegia, hemorrhage, or death[1]. In our case, the arrow penetrated the frontal region, passing through the ethmoid sinuses until it reached the posterior wall of the pharynx without causing injury to vital structures.

This type of lesion in the maxillofacial region must be approached meticulously and systematically. Depending on the location of the injury, it may require multidisciplinary management that includes ophthalmology, otorhinolaryngology, neurosurgery, and maxillofacial surgery, among others[8]. The case reported herein was managed by the pediatric and otorhinolaryngology services and evaluated by the neurosurgery service. An otorhinolaryngologist extracted the foreign body.

Detailed knowledge of anatomy is one of the most important points in assessing penetrating maxillofacial injuries since the risk and expected complications depend on the location[9]. Penetrating head and neck injuries can affect three areas. The first is from the sternal notch to the cricoid cartilage. This area has the highest mortality due to the substantial risk of blood vessel injury and airway compromise[10]. The second extends from the cricoid cartilage to the mandibular angle. The most frequently injured structures here are the carotid arteries, the vertebral arteries, the jugular veins, the trachea, the larynx, and the esophagus. Penetrating injuries are more common in this region but with lower mortality than in Area 1 due to easier hemorrhage control[7]. The third area extends from the mandible angle to the base of the skull, involving the eyes, the distal carotid artery, the salivary glands, the pharynx, and the spinal cord[7,4]. The lesion occurred in the third area in our patient affecting the paranasal sinuses without involving any vital structure, so the prognosis was good.

A two-angle X-ray can be taken when there is clinical evidence or suspicion of a retained foreign body in this region to locate the object and define its relationship with vital structures. If the patient is hemodynamically unstable or has airway compromise, advanced life support must be provided. The airway, breathing, and circulation must be stabilized to continue with foreign body management[11]. This support was not required in this case, and imaging studies were directly conducted to locate the foreign body.

A CT scan is usually the study of choice to document the exact location and detail the penetrating foreign body and any associated injuries, especially in hemodynamically stable patients at the time of arrival to the emergency room. Subsequently, tomographic angiography can be performed to visualize suspected vascular damage if it is available[4,6,12]. A skull X-ray was initially performed on our patient. This study showed the arrow´s path through the paranasal sinuses to the pharynx. This path was later confirmed and determined in detail with tomography. A vascular lesion was ruled out by angio-CT.

Penetrating arrows in the head and neck region should be surgically removed considering tissue dissection, minimal hemorrhage, prevention of further injury, preservation of vital structures, wound irrigation, and drain placement according to depth[2,13]. The extraction route (retrograde or antegrade) depends on penetration, its relationship with vital structures, and the shape of the arrow[1,14]. A retrograde extraction was performed because it was easier to remove the arrow since it did not cause injuries to other structures during its trajectory. The otorhinolaryngology service mobilized the tip of the arrow by flexible nasoendoscopy and performed extraction without complications or sequelae.

The prognosis depends on the location of the foreign body, associated injuries, and timely multidisciplinary management[14]. Because there are multiple vital structures in the head and neck region, managing this type of injury is individualized according to the area involved. The prognosis also depends on the care provided during the injury. Unfortunately, qualified personnel are not always available for management when dealing with injuries commonly observed in developing countries. In these cases, help is delayed, leading to other complications or sequelae[8]. In the case of our patient, one advantage was the immediate attention in a tertiary-care center with most of the required studies available and joint management by the pediatric, radiology, and otorhinolaryngology services.

Recreational archery is a safe sport, even more than other popular sports such as soccer or baseball[15]. Among the most frequent injuries in archery are those related to wear or overuse of the hands and arms. Penetrating arrow injuries are rare due to the recommended protective equipment and safety protocols followed by each establishment[15]. Therefore, it is important to emphasize that the injury in our patient was preventable. It could have been avoided by properly following the safety protocols for shooting arrows. Fortunately, due to the path and location of the arrow, the patient had no complications or sequelae.

CONCLUSION

Penetrating head and neck injuries are rare in developed countries; however, medical personnel must be trained to manage this type of emergency. When caring for a patient with these characteristics, the main thing is to determine hemodynamic stability and later address the lesions caused by the foreign body and its trajectory to determine, together with other medical specialties, the best extraction route to minimize complications and sequelae. It is important to inform and educate parents on how to avoid these accidents.