Multidisciplinary Team Treatment of Penetrating Head and Neck Trauma.

Penetrating head and neck trauma could cause significant mortality because of many important structures located in the brain and neck. Although high-velocity penetrating brain injury is often reported, reports of low-velocity, combined head and neck penetrating injury are rare. Hereby, the authors present a case of an old man who had encountered a serious accident, a 29-cm iron fork penetrated into his neck, through the skull base and into brain. After treatment by multidisciplinary team, the patient was in rehabilitation. The multidisciplinary team assists rapid diagnosis and treatment of penetrating neck and head injury is the key to ensure a good outcome. Therefore, as the authors face such patients again, a multidisciplinary team is needed.

Penetrating head trauma represents about 0.4% of traumatic brain injuries[1] and results from both projectile and nonprojectile injury. Penetrating neck trauma can cause high mortality because of many important structures located in the neck.[2] Numerous low-velocity penetrating brain traumas have been reported already. Reports of low-velocity, combined head and neck penetrating injury are rare. We describe an unusual patient of penetrating trauma to the head and neck by a 29-cm agricultural iron fork. Meanwhile, some diagnosis and treatment key points are summarized from this patient.

CLINICAL REPORT

A 54-year-old man was admitted to our department by ambulance, with an iron fork being penetrated into his upper neck, through the skull base and into brain (Fig. 1A). On physical examination, the man had a Glasgow Coma Scale (GCS) score of 9, with hemiparesis on his right limbs, and right lower extremity Babinski sign positive. No active bleeding from the entry point and oral cavity was observed. The skull X-ray (Fig. 1B) and computed tomography scan (Fig. 1C) demonstrated that a foreign body penetrated from the right wall of oropharynx, upward to the left nasopharyngeal posterior wall, toward the clivus and penetrated into the intracranial space, passed through the left basal ganglia region to the left parietal lobe. Digital subtraction angiography examination showed occlusion of the right external carotid artery (Fig. 1D and E).

FIGURE 1

(A) Preoperative photograph showing an iron fork insert the right side of the neck (white arrow). (B) Skull x-ray. Note the metal fork inserting from the right neck to the intracranial space. (C) Brain CT. Note the agricultural fork passing through the right temporal lobe to the left basal ganglia region. (D, E) Digital subtraction angiography examination demonstrated occlusion of the right external carotid artery (white arrow). (F) Microscopic observation confirmed the metal fork pierced the brain parenchyma (white arrow). (G) Brain CT. Note the iron fork was removed, the left frontal and temporoparietal craniectomy with mild cerebral edema after operation. CT, computed tomography.

A multidisciplinary team was assembled to draw up a treatment plan. After general anesthesia, plastic surgeons cut off the fork tine close to the neck skin with a shear. Vascular surgeons exposed the bilateral carotid artery to control hemorrhage from the cerebral hemisphere. A large left temporoparietal flap was fashioned by neurosurgeons. The frontal lobe and temporal lobe were injury, the black metal foreign body was visualized lateral to the oculomotor nerve and trigeminal nerve and piercing the petrous bone, dura mater, and brain parenchyma (Fig. 1F). With the assistance of vascular surgeons to control the carotid arteries, the fork was slowly and carefully pulled out from the neck incision. A 29-cm fork with 15-cm intracranial segment was successfully removed. Owing to the brain tissue swelling, the bone flap was not replaced. Computed tomography scan showed mild cerebral edema after 2 days (Fig. 1G). The patient was conducted in the intensive care unit with antibiotic, antiepileptic, antiedema, and other routine cares.

At postoperative 12th day, the man discharged, with stable vital signs, normal consciousness, and a mild paresis of his right upper limb. After 24 months follow-up, his right limb has recovered to full strength nearly.

DISCUSSION

To our knowledge, this is the first patient describing a low-velocity penetrating head and neck injury with an iron fork and presents several challenges to optimize management in English literature. Multidisciplinary team is the key to save this patient.

The management principles of patients with penetrating injury differ from other injures. The protruding object should be protected from movement and stabilized during transportation to prevent further injury. The principles of surgical management for this patient are safe removal of the penetrating fork first from the neck and the brain parenchyma. Extensive hemorrhage during operation is one of the most important causes of dead. Rupture of the internal or external carotid artery, venous sinus, skull, and dura may be sources for severe bleeding. The muscle and gelfoam were used to control bleeding in our patient. Digital subtraction angiography examination should be performed for the penetrating neck and head trauma to exclude vessel injury and evaluate the adjacent relationship between the foreign matter and vessels.

Cerebral edema should be special attention in penetrating brain injury. In our patient, after removing the fork from the brain parenchyma, it encountered severe acute cerebral edema. The large craniotomy and dehydration drug facilitated to control cerebral edema.

Infection is a common complication following the contamination of foreign objects, which are also associated with significant mortality. Staphylococcus aureus is the most frequently associated organism. Intravenous prophylactic broad-spectrum antibiotic therapy is recommended and the sooner the better.[3]

On the other hand, seizure is also a common complication after penetrating brain injury. About 30% to 50% of patients develop seizures after penetrating brain injury. Antiseizure medications were recommended to use to reduce the incidence of early seizures in the first week after injury.[4]

In summary, we report a low-velocity penetrating head and neck trauma, with treatment successfully. Prompt diagnosis and treatment of penetrating neck and head injuries are essential to ensure a good outcome. Our patient illustrates a complicated, multidisciplinary surgical procedure, followed by intensive medical monitoring and treatment is the key to treatment of complex diseases. Hence, when we face such patients again, a multidisciplinary team should be established.