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   Table of Contents      
CASE REPORT
Year : 2020  |  Volume : 6  |  Issue : 1  |  Page : 63-67

Management of Penetrating Arrow Neck Injury: A Report of Two Cases


1 Department of Otorhinolaryngology, Aminu Kano Teaching Hospital, Kano; Department of Otorhinolaryngology, Yobe State University Teaching Hospital, Damaturu, Nigeria
2 Department of Otorhinolaryngology, Yobe State University Teaching Hospital, Damaturu, Nigeria

Date of Submission08-Feb-2020
Date of Decision17-Mar-2020
Date of Acceptance23-Mar-2020
Date of Web Publication30-Apr-2020

Correspondence Address:
Dr. Auwal Adamu
Department of Otorhinolaryngology, Aminu Kano Teaching Hospital, Kano
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mamcjms.mamcjms_9_20

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  Abstract 


Arrow neck injuries are rare in the developed countries due to development of modern firearms and ballistic missiles. However, they are still occuring in developing nations, due to incessant community clashes. Neck region houses the airway, the great vessels and other vital structures, any penetrating injury may result in devastating outcomes. The management can be challenging to even a well-trained surgeon especially in a resource limited center. Therefore, we present our experience in the management of penetrating arrow injury to the neck.

Keywords: Arrow injury, neck exploration, penetrating neck injury


How to cite this article:
Adamu A, Ngamdu YB. Management of Penetrating Arrow Neck Injury: A Report of Two Cases. MAMC J Med Sci 2020;6:63-7

How to cite this URL:
Adamu A, Ngamdu YB. Management of Penetrating Arrow Neck Injury: A Report of Two Cases. MAMC J Med Sci [serial online] 2020 [cited 2020 May 31];6:63-7. Available from: http://www.mamcjms.in/text.asp?2020/6/1/63/283524




  Introduction Top


Nowadays, arrow injuries in the developed countries are rare due to development of modern firearms and ballistic missiles. However, they are still common among rural dwellers of developing countries, due to incessant community clashes. But, some researchers believed that the cases of arrow shot in the region are under reported.[1] Arrow injuries are classified as low velocity but can be life-threatening, especially when vital organs are affected. Arrow shot can affect any part of the body. Cases of arrow injury involving different region/organ of the body have been reported,[2],[3],[4] However, there is rarity of report of arrow shot to the neck region. Neck region houses the airway, the great vessels and other vital structures. It is the highway from the chest to the cranial cavity, any penetrating injury may result in devastating outcome, and the management can be challenging to even well-trained surgeon especially in a resource constraint setting. Therefore, we present our experience in the management of two patients with penetrating arrow injury to the neck.


  Case Report Top


Case 1

A 28 year old herdsman was seen at Yobe State University Teaching Hospital with arrow shot to the posterior neck of 3 days duration following farmers and herders fight. There was associated hoarseness, cough and hemoptysis but no fever, difficulty in breathing, stidor, dysphagia or upper limb weakness. The relatives of the patient bent the arrow and attempted removing it at home but it failed. On examination, he was conscious, not pale, not in distress, impacted arrow was seen at the posterior triangle of the neck on the left side, with pus discharge from the entry point [Figure 1]. Vital signs were stable and chest was clinically normal. Initial X-ray soft tissue neck showed impacted arrow in the neck, went circumferential from the posterior triangle to the anterior triangle of the neck at the level of C4–C6, no emphysema was seen [Figure 1]. Computerized tomography scan was requested to get more detail about the tract and relationship with vital structures, so as to facilitate safe removal of the arrow. It revealed an impaled arrow with two spikes pointing backward on the left side of the neck, extending from lower part of posterior triangle, it passed obliquely upward and medially through the soft tissues up to the supraglottic region of the larynx, no vascular injury was seen [Figure 2]. Complete blood count and serum electrolytes were within normal limit. Patient was prepared for surgery, under general anesthesia direct laryngoscopy was performed first to determine the extent and nature of the laryngeal injury. There was no significant endo-laryngeal injury so patient had orotracheal intubation, and tracheostomy was not required. Patient had neck exploration and arrow removed through the entry point [Figure 3], wound was irrigated thoroughly with normal saline, antibiotics and tetanus prophylaxis was given. Patient did well postoperatively, no complication recorded and he was discharged on fifth day post-operatively [Figure 3].
Figure 1 Clinical pictures and X-ray of case 1

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Figure 2 CT film of case 1

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Figure 3 Clinical pictures intra-op and post-op of case 1

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Case 2

A 7 year old boy was referred to Yobe State University Teaching Hospital with arrow impacted below the left ear of 6 hour duration. Child was accidentally shot with arrow by a friend while playing with crossbow and arrow. Patient sustained injury to the left infra-auricular region, there was associated bleeding, no difficulty in breathing, dysphagia, bleeding from ear or deviation of the mouth or inability to close his eyes. On examination his general condition was stable, arrow was seen impacted in the left infra-auricular region [Figure 4], no evidence of facial nerve paralysis. X-ray soft tissue neck revealed an impacted arrow in the left infra-auricular region [Figure 5]. CT scan showed an arrow impacted within the substance of parotid tissue, tip of the arrow was seen in the pterygopalatine fossa, about 9mm anterior to the branches of external carotid artery. The internal carotid artery and cervical spine are not affected. Surgical exploration and arrow removal was carried out through entry point. Patient recovered successfully, no complication recorded.
Figure 4 Clinical pictures of case 2

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Figure 5 X-ray of case 2

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  Discussion Top


Penetrating neck injury was defined as violation of skin and platysma muscle which may involve one or more deep neck structures and is prone to significant morbidity or mortality.[5] Prevalence of penetrating neck injury was reported to be 5–10% of all trauma cases.[5],[6] The etiology of penetrating neck injury are many, it can be from road traffic accident, bomb blast, assault with stab injury, armed robbery with gunshot, arrow shot and cut throat injury from homicide or suicide. Materials that can be retained in the neck include shrapnel or pellets of a bomb, glass fragments, bullet, knife, piece of wood or arrow.[1],[5] Penetrating Arrow injury can be superficial or deep. The deep arrow injuries may involve vital structures such as larynx, pharynx, esophagus or one of the great vessel of the neck, which can pose great challenge to the surgeon. In this study, we presented two cases of penetrating neck injury from arrow shot. Despite the fact that the condition is rare in the developed countries, it is quite common in our environment and we intended to share our experience in the management of such patients.

The two patients presented were male, aged 7 and 28 years respectively. Male preponderance was noted in most of the reports, Olasoji et al.[1] reported four cases of arrow shot to head and neck region, all of them were males between the ages of 18 and 45 years. Sandabe et al.[7] reported a case of arrow shot to the lateral side of the neck in a 15 year old boy, while Aremu and Dike[8] also reported a case of arrow shot to the anterior neck in a 48 year old man. Males usually have more aggressive behavior, they do most of the outdoor activities and they are the ones mostly involved in a fight.

The clinical presentation of patients with penetrating arrow injury to the neck depend on the structure affected and severity of the injury. The severity and degree of the injury depend on the range at which an arrow is fired, the trajectory and the degree of penetration.[9] Patient with vascular injury present with severe hemorrhage, expanding hematoma, unequal pulses or shock. Laryngeal injury manifests with hoarseness, cough, hemoptysis, difficulty in breathing or upper airway obstruction that may warrant emergency exploration. One of our patients presented with hoarseness, cough and hemoptysis. No features of vascular injury in the two patients.

Management of arrow injury to the neck region is challenging, it should be according to the Advanced Trauma Life Support (ATLS) protocol, and there should be rapid survey and assessment of airway, breathing and circulation. Patients with injuries that are immediate threat to life should be managed as an emergency. Patient with upper airway obstruction should have emergency tracheostomy to secure the airway. Vascular injuries with unstable hemodynamic status should be resuscitated with blood and emergency neck exploration and repair should be undertaken. This is the popular opinion, there is no debate among surgeons about the need of emergency neck exploration and repair for patient with life-threatening clinical signs.[10],[11] However, for a stable patient with penetrating neck injury, neck exploration is actually a controversial issue.[12],[13] Some authors advocated mandatory neck exploration for all patients,[10],[14] while others proposed conservative approach and selective neck exploration based on clinical and radiological findings.[15],[16] However, the current evidence-based opinion favor “no zone approach” to penetrating neck injury, in which patients with major signs undergo immediate surgical exploration regardless of the zone affected.[17] The hard signs of penetrating neck injury that indicate urgent surgical intervention include: major vascular injury, intractable shock, pulsatile bleeding or expanding hematoma, audible bruit or palpable thrill, upper airway obstruction, bubbling wound, subcutaneous emphysema, stridor, hoarseness, dysphagia and neurological deficits.[17]

Our patients presented with stable vital sign but they have impacted metallic arrow in the neck which warrant immediate neck exploration and removal. However, some basic investigations were conducted before the surgery, such as X-ray soft tissues neck/CT scan of the neck, complete blood count, grouping cross-matching of blood, and serum electrolytes. CT scan is a very important investigation; it helps in evaluating the tract of the penetrating arrow, the relationship of the arrow with vascular structures and to plan for removal of the arrow. CT scan was done in all the patients, to adequately delineate the relationship of the arrow to the vital structures.

Surgical exploration for arrow removal should be a guided procedure, attempt at blind extraction should be avoided, because if the arrow is impacted or it is near to a vital structure blind removal may damage the vital structures that were not involved before. During the surgical procedure for removal of an arrow in our patients, we were extremely careful to avoid internal injuries, meticulous surgical dissection was performed to achieve adequate exposure and prevent retraction of the arrow. Rotation of the arrow during the procedure was also avoided because it can cause more injuries. In our study none of the patients had major vascular injury. However, if vascular injury is suspected, there should be proximal and distal control with hemostatic vascular clamp so as to allow for adequate resection and anastomosis or vascular graft application. Additionally, the safety of the surgeon and the team is paramount, the surgeon has to be extremely careful to avoid inflicting injury to himself or the assistant.


  Conclusions Top


In conclusion, management of arrow injury is still relevant in otolaryngology practice, especially in the developing countries where the clashes between farmers and herders are frequent, within our resource-constrained setting the management is challenging. The general principles of resuscitation and surgery should be applied to all patients with penetrating arrow neck injury.

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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Olasoji HO, Tahir AA, Ahidjo A, Madziga A. Penetrating arrow injuries of the maxillofacial region. Br J Oral Maxillofac Surg 2005;43:329-32.  Back to cited text no. 1
    
2.
Lawan A, Danjuma SA. Arrow injuries to the eye. Ann Afr Med. 2012;11:116-8.  Back to cited text no. 2
    
3.
Aliyu I, Ismail MI. Arrow in the Heart: our experience. Niger J Cardiol 2014;11:54-56.  Back to cited text no. 3
    
4.
Aliyu S, Ibrahim AG, Ali N, Lawan AM, Bakari AA. Arrow shot injuries: experience in a referral centre in north eastern Nigeria. Int J Sci Res 2014;3:1822-5.  Back to cited text no. 4
    
5.
Nwawolo CC, Asoegwu CN. Experience with managing penetrating anterior neck injuries in Lagos,Nigeria. J West Afr Coll Surg 2017;7:1-23.  Back to cited text no. 5
    
6.
Naso RW, Assuras GN, Gray PR, Lipschitz J, Burns CM. Penetrating neck injuries: analysis of experience from a Canadian trauma centre. Can J Surg 2001;44:122-6.  Back to cited text no. 6
    
7.
Sandabe MB, Waziri AM, Akinniran AA, Jatta A, Chibuzo IM. Arrow shot injury to the neck. Int J Head Neck Surg 2012;5:1-5.  Back to cited text no. 7
    
8.
Aremu SK, Dike B. Penetrated arrow shot injury in anterior neck. Int J Biomed Sci 2011;7:77-80.  Back to cited text no. 8
    
9.
Madhok BM, Roy DDD, Yeluri S. Penetrating arrow injuries in Western India. Int J Care Injured 2005;36:1045-50.  Back to cited text no. 9
    
10.
Apffelstaedt JP. Results of mandatory exploration for penetrating neck trauma. World J Surg 1994;18:917-20.  Back to cited text no. 10
    
11.
Inaba K, Munera F, Mckenney M, Rivas L, Moya M, De, Bahouth H, Cohn S. Prospective evaluation of screening multislice helical computed tomographic angiography in the initial evaluation of penetrating neck injuries. J Trauma, Injury, Infection, Crit Care 2006;61:144-9.  Back to cited text no. 11
    
12.
Meyer JP, Barrett JA, Schuler JJ, Flaniyan DP. Mandatory vs selective exploration for penetrating neck trauma, a prospective assessment. Arch Surg 1987;122:592-7.  Back to cited text no. 12
    
13.
Asensio JA, Valenziano CP, Falcone RE, Grosh JD. Management of penetrating neck injuries: the controversy surrounding zone II injuries. Surg Clin North Am 1991;71:267-96.  Back to cited text no. 13
    
14.
Obeid FN, Haddad GS, Horst HM, Bevin’s BA. A critical re-appraisal of a mandatory exploration policy for penetrating wounds of the neck. Surg Gynecol Obstet 1985;160:517-22.  Back to cited text no. 14
    
15.
Biffl WL, Moore EE, Rehse DH et al. Selective management of penetrating neck trauma based on cervical level of injury. Am J Surg 1997;174:678-82.  Back to cited text no. 15
    
16.
Ngakane H, Muckart DJJ, Luvuno FM. Penetrating visceral injuries of the neck: results of a conservative management policy. Br J Surg 1990;77:908-10.  Back to cited text no. 16
    
17.
Nowicki JL, Stew B, Ooi E. Penetrating neck injuries: a guide to evaluation and management. Ann R Coll Surg Engl 2018;100:6-11.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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