Introduction
Multiorgan-penetrating trauma to the head and neck are relatively uncommon and are associated with a high mortality rate. Penetrating head trauma account for approximately 0.4% of all head trauma.1 Penetrating neck trauma, meanwhile, account for 5-10% of all trauma cases and are associated with a significant burden of mortality (up to 6%).2 Patients with trauma to important blood vessels or organs often die within a short time, while those who arrive at a hospital in time have the chance of treatment; however, often, the treatment required is quite difficult. There is currently no international consensus on the management due to its low incidence. Therefore, the case reports on multiorgan-penetrating trauma to the head and neck are valuable for proposing appropriate management strategies. In this study, we report a case series of these penetrating trauma and describe our experience of successfully treating these patients; two patients with wooden foreign bodies underwent intraoperative DSA.
Methods
After obtaining approval from the institutional review board, a retrospective chart review of all cases of multiorgan-penetrating trauma to the head and neck between the years 2016 and 2022 was performed. The following data were collected for the analyzed cases: demographic characteristics; nature, path, and retention time of the foreign bodies; radiologic images, surgical treatment; sequelae; and outcome. Below, two representative cases have been described in detail.
Case 1
A 56-year-old woman was transferred to the emergency department caused by penetration of an umbrella rib from the left orbit to the right chest 3 hours ago. The patient experienced nausea, vomiting, hematemesis, and chest tightness; however, she was conscious and did not have breathing difficulty. Her left eyeball was fixed and responded slightly slowly to light reflection; the orbital pressure was slightly high, and an umbrella rib was visible in the left orbit (Figure 1a). Enhanced CT of the head, neck, and chest showed a metal foreign body penetrating the left orbit, left nasopharynx, pharynx, right neck, and upper right chest successively, with gas in the surrounding soft tissue (Figure 1b). The foreign body was close to the right common carotid artery, jugular vein, and right subclavian artery. A multidisciplinary team (MDT) involving the relevant departments was immediately sought by the hospital to determine the best surgical plan.
Under general anesthesia, in the first, the patient was performed tracheotomy prophylactically by otorhinolaryngologists; an exploratory neck incision was performed to locate the foreign body, and found the deep surface of the right carotid sheath without damage. Then, an ophthalmologist performed eye exploration finding the left eyeball unbroken. Next, thoracoscopic exploration was performed by thoracic surgeons finding the tip of the umbrella rib had pierced into the right thoracic cavity, causing damage to the apex of the right lung and the oblique fissure; and removed the foreign body (Figure 1c). Last, another thoracoscopic exploration was performed finding a white plastic sunshade cap in the oblique fissure of the right lung and removed it.
After consultation with the Department of Clinical Pharmacy, an anti-infective treatment comprising cephalosporin combined with metronidazole was administered for 9 days. On postoperative day 10, the patient was discharged from the hospital. Her vision was similar to that before the trauma, and there was no obvious organ or nerve damage. The 12-month follow-up showed that the patient had recovered well and could perform normal physical activities.
Case 2
A 55-year-old man was brought to the emergency department with a 4 hours’ trauma to the right orbit from below the temporal side of the eyeball caused by a Chinese rose branch (Figure 1d). The patient had schizophrenia. His right eyeball was prominent and its movement was restricted. Computerized tomography angiography (CTA) of the eyes and neck showed two columns of low-density foreign body shadows in the right orbit (Figure 1e), extending along the inferior orbital wall to the left and back, passing through the inner wall of the right maxillary sinus and nasal septum, and continuing to the left side of the nasopharynx. The foreign body was adjacent to the left internal carotid artery.
After the MDT had evaluated the patient’s condition, the interventional physician performed digital subtraction angiography (DSA) of right common carotid artery and found no damage. Then, the ophthalmologist removed the foreign body (Figure 1f) and removed the residual Chinese rose branch dander and fracture fragments carefully. The wound was rinsed with hydrogen peroxide followed by gentamicin. Next, the otorhinolaryngologist performed transnasal endoscopic hemostasis. Finally, the interventional physician performed DSA again, and found the branches of carotid arteries unbroken.
The patient was administered antifungal treatment with fluconazole and anti-infective treatment with cephalosporin for 3 days postoperation, and was discharged on postoperative day 10. At the time of discharge, he had good depth of his right anterior chamber, and round pupil, and an approximately 3 mm diameter without vision loss.
Results
During the study period, 5 patients with multiorgan-penetrating trauma to the head and neck were treated at our institution. The patients’ details are summarized in Table 1. The patients’ mean age was 41 years. The most common cause of penetrating trauma was an accident (60%), and the orbit (80%) was the most common penetrated region. These penetrating traumas were mainly caused by wooden (60%) or metallic (40%) foreign bodies. All patients underwent initial CT scans for identification of the trajectory of foreign bodies, and all of them received surgical treatment within 24 h of trauma. Among the five cases, only one case underwent external approach surgery; endoscope-assisted surgery was performed in the other four cases, and of which 2 cases underwent DSA of common carotid arteries. All five patients were treated successfully, and only one patient showed visual impairment in the left eye due to the damage caused by the foreign body.
Discussion
Compared with trauma to other regions, penetrating trauma to the head and neck, is the second most common type.3 The management of multiorgan-penetrating trauma to the head and neck is often complex and nonstandardized. The treatment strategy employed in the cases managed by us is described. After admission to the hospital, patients with penetrating trauma underwent CT scans through the emergency green channel. We recommend computerized tomography (CT) scans as the first option for foreign bodies. CT images show greater detectability, detecting radiopaque objects easily like metal, and can provide good osseous delineation.4 If it is a wooden foreign body, magnetic resonance imaging (MRI) can be added.5 CT angiography (CTA) can also be added if vascular damage is suspected. And relevant departments such as otorhinolaryngology, ophthalmology, neurosurgery, vascular surgery, and interventional surgery, were contacted for consultation according to the trauma site, and the departments for treatment were selected according to the examination results. The emergency surgical treatment was performed next to MDT.
In the management of multiorgan-penetrating trauma to the head and neck, the involvement of an MDT is of paramount importance. Because of the complications caused by multiorgan trauma, a single department is often unable to optimally complete the treatment. The management of major head and neck trauma requires the simultaneous involvement of many different disciplines and surgical subspecialties.6 An appropriate MDT can expedite the preoperative disease assessment, create conditions for the early and safe completion of surgery, and reduce intraoperative risks and the incidence of postoperative complications.7 Careful anamnesis, physical examination, and inspection of preoperative imaging data along with an MDT consultation are of high importance for optimal emergent surgical planning and execution. In this study, multidisciplinary consultations involving an ophthalmologist, an otorhinolaryngologist, a thoracic surgeon, an interventional radiologist, and other involved department physicians was rapidly initiated after emergency admission.
Early surgical exploration by an MDT approach is essential for the management of these penetrating traumas. Especially, wooden foreign bodies should be taken out as soon as possible because their porous consistency and organic nature serves as a medium for microbial proliferation.8 The surgical approaches reported in previous cases were divided into external approach and endoscopy-assisted surgery. In case 1, the metal foreign body was found to be closely related to the blood vessels of the neck. To clarify the route of the foreign body and the degree of injury to the great vessels, the otorhinolaryngologist used an external cervical approach to fully expose the cervical sheath. In case 2, endoscopy-assisted surgery was chosen to remove the foreign body directly to minimize injury. CTA scans showed that the foreign body was closely related to the left internal carotid artery. Since the foreign body was a Chinese rose branch, the local sharpness was not clear. Then, DSA of right common carotid artery was performed to provide immediate support for potential vascular injuries. It confirmed that the foreign body did not involve blood vessels before and after its removal.
An individualized surgical approach should be performed under safe conditions. Through the literature review, we found DSA can help the surgeon to stop bleeding quickly by controlling the common carotid artery. Besides, it can help to find the integrity of the vessels before and after the removal of foreign bodies. DSA is the “gold standard” for examining potential vascular injury, and it can also help optimize vascular control through balloon occlusion.9 According to statistics, the edge of wooden foreign bodies is more irregular or bifurcation appears in the process of entering. Removal of these foreign bodies, especially with endoscope-assisted surgery, may induce a secondary injury to the blood vessels and lead to a disastrous ending. Therefore, for these penetrating traumas with irregular wooden foreign bodies, we advocate routine intraoperative DSA of common carotid arteries in endoscopy-assisted surgery.
Infection is a common complication following contamination of foreign bodies and is also associated with significant mortality.7 We suggest that preoperative broad‑spectrum antibiotics may be used in cases with a long preoperative duration. If the patient can be operated on within a short time after admission, the use of postoperative antibiotics is sufficient. If foreign bodies were metallic, effective antibiotics were administered postoperatively; if foreign bodies were wooden, antibiotics and antifungal agents were used in combination; if other types, broad-spectrum antibiotics were administered first, and fungal infection would be considered if subsequent infection worsened. Fungal infections are rare but should be considered, especially in cases of traumas from foreign bodies such as thorns and branches.10 Besides, the patient should be injected with tetanus globulin if the penetrating traumas were deep and heavily polluted.
In conclusion, we reported cases in which multiorgan-penetrating trauma to the head and neck were successfully treated. Depending on the characteristics of the foreign bodies and the anatomic locations of penetrating trauma, MDT is pivotal in the management of such cases. Preoperative imaging studies, combined with early surgical exploration is essential for good recovery and favorable outcomes. In endoscope-assisted removal with irregular wooden foreign bodies, we advocate intraoperative DSA of common carotid arteries as a routine surgical procedure.
Ethics Statements
The Ethics Committee of Yantai Yuhuangding Hospital (Yantai, China) approved this study (approval number 2022-006).
Statement of Informed Consent
The patients or their families provided written informed consent for the publication of their anonymized information.
Funding sources
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflict of Interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Availability of data and materials
The datasets used and/or analyzed during the present study are available from the corresponding author on reasonable request.
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