Retained Crossbow Bolt After Penetrating Facial Trauma

Retained Crossbow Bolt After Penetrating Facial Trauma
Manan U. Shah, M.D.,1 Shankar K. Sridhara, M.D.,2 Jeffrey S. Wolf, M.D.,1 Bryan T. Ambro, M.D., M.S.1
1Dept. Otolaryngology – Head and Neck Surgery, University of Maryland School of Medicine, Baltimore, MD,
2 Department of Otolaryngology Head & Neck Surgery, Walter Reed National Military Medical Center, Washington, DC
CONTACT
Bryan T. Ambro, M.D., M.S.,
Assistant Professor
University of Maryland School of Medicine
Department of Otorhinolaryngology,
Head and Neck Surgery
Email: bambro@smail.umaryland.edu
Phone:410.328.3223
Fax: 410.328.5690
INTRODUCTION
Case Report
Penetrating facial trauma with a retained foreign body presents a
diagnostic and management dilemma, due to the variety and complexity
of potential injuries that may occur during removal, some of which may
be life-threatening. We present an unusual case of the removal of a
retained crossbow bolt from the maxillofacial region. While removal
was clearly indicated, the presence of a rigid, retained foreign body
passing in close proximity to multiple neurovascular structures, and
ultimately penetrating the airway, posed a unique management
challenge. A brief review of the literature is also included.
Operative removal of foreign body
-Awake tracheostomy was performed to secure
airway. Right neck exploration performed for
access to external carotid in the event of
uncontrolled bleeding on bolt removal.
Case Report
- Left neck apron incision with midline lip split
was performed, tooth #22 was extracted, a
parasymphyseal mandibulotomy was performed
at tooth extraction site and left mandible was
retracted laterally to expose tip of crossbow bolt
in retromolar trigone.
DISCUSSION
Case Report
Operative removal of foreign body (continued)
-Bolt was observed in choanae/nasopharynx with an endoscope, and
superior blade was retracted endoscopically. Arrowhead was advanced
forward and removed through left oropharynx. No neurovascular injury
occurred. A palate laceration from the arrowhead and the floor of mouth
were closed primarily, mandible was plated and neck incisions closed
with bilateral drains. Nasopharyngeal stents were placed to prevent scar
contracture/stenosis.
-Post operative course was uneventful: decannulated post-op day 5,
discharged without complications post-op day 8, and1 month follow up
showed no further neurologic deficit.
.
Initial evaluation
-Healthy 31-year-old Caucasian shot twice to head with crossbow bolts,
entry wounds to midforehead and right temple.
Figure 1. Computed tomography reconstruction.
Figure 2. Unused bolt
.
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- Several systems exist for classifying craniofacial injuries, like the Le Fort scheme, yet our patients
injuries did not fit well into any one classification. Most focus on bony trauma, but do not incorporate
soft tissue, neurovascular, or airway injuries which were significant here. Donat et al classify facial
fractures on skeletal supports, but do not include soft tissue injuries.3 Lee et al.’s MCFONTZL score
incorporates facial soft tissue trauma, but leaves out intraoral lesions which were significant here.4
We do not propose a new classification scheme, but perhaps a more comprehensive system
incorporating soft tissue, neurovascular and airway trauma should be investigated in future research.
- Since imaging revealed injury with a broad tip bow, retrograde removal in our patient was excluded
due to the risk of neurovascular injury and possible separation of bolt tip.
- Transbuccal approach would have risked injury to the facial nerve and parotid duct.
- Le Fort I osteotomy may have provided exposure, but not adequate access for safe removal. Thus,
extended lip-split midline mandibulotomy selected.
- The crossbow’s growing popularity poses a potential public health concern. Many authors express
concern that crossbows are easily obtainable by mail, require no license in the US, and can be shot
easily and silently from afar.4, 5, 6, 7, 8, 9, 10 A 2004 collection of crossbow injury cases included four
fatalities.4 If a corresponding increase in crossbow injuries is seen, discussion on greater regulation
on ownership may be necessary.
Figure 1. Pre-operative photo
Figure 2. Right neck exploration
Figure 3. Extracted bolt.
REFERENCES
1. Chen AY, Stewart MG, Raup G. Penetrating injuries of the face. Otolaryngol Head Neck Surg. 1996 Nov; 115(5):464-70.
2. Pereira KD, Wang BS, Webb BD. Impalement injuries of the pediatric craniofacial skeleton with retained foreign bodies. Arch Otolaryngol Head Neck Surg. 2005 Feb;
131(2):158-62.
3. Donat TL, Endress C, Mathog RH. Facial fracture classification according to skeletal support mechanisms. Arch Otolaryngol Head Neck Surg. 1998 Dec;124(12):1306-14.
4. Lee RH, Gamble WB, Robertson B, Manson PN.The MCFONTZL classification system for soft-tissue injuries to the face. Plast Reconstr Surg. 1999 Apr;103(4):1150-7.
5. Grellner W, Buhmann D, Giese A, Gehrke G, Koops E, Püschel K. Fatal and non-fatal injuries caused by crossbows. Forensic Sci Int. 2004 May 28; 142(1):17-23.
6. Chang WK, Hsee LC, Crossbow injury in a developed country. Injury, Int. J Care Injured 41 (2010) 1090-1092
7. Kaye K, Kilgore KP, Grorud C. Transoral crossbow injury: an unusual case of central nervous system foreign body. J Trauma. 2004 Sep; 57(3):653-5.
8. Franklin GA, Lukan JK. Self-inflicted crossbow injury to the head. J Trauma. 2002 May; 52(5):1009.
9.Osborne SF, Papchenko T, de Souza CF, Polkinghorne PJ, Hart R. Orbital crossbow injury. Clin Experiment Ophthalmol. 2009 Jul; 37(5):527-9.
-Unused crossbow bolts were inspected to understand the nature of the
foreign body.
-Retrograde extraction was deemed unsafe due to deployment of
cutting blades. Midfacial degloving with Lefort I osteotomy was
considered, but due to difficulty mobilizing foreign body, and need for
vascular control of external carotid arteries bilaterally, a mandibular
swing approach was favored.
- CT scans should be obtained rapidly, or proceed with plain radiographs for metallic or radio-opaque
objects, MRI’s for suspected soft tissue injury, and CT angiogram for suspected vascular injury.2
-Two types of bolts are common with differing injury patterns. A ‘broad tip’ is typically used for hunting
and includes backward angled cutting blades around the shaft to prevent backward retraction. These
tips can separate to cause further damage. A conical-shaped ‘field tip’ is used for target shooting. Tip
knowledge is crucial for determining extraction techniques.
-Oral examination showed tooth #16 laterally displaced by the tip of a
crossbow bolt. Fiberoptic exam revealed metallic foreign body in
posterior nasal cavity and nasopharynx with no active bleeding.
Remaining exam unremarkable.
Preoperative consideration
-Due to location of foreign object in nasopharynx removal was deemed
necessary. There was a concern for possible internal maxillary
artery/sphenopalatine artery injury with the foreign body tamponading
hemorrhage, and that removal might precipitate significant bleeding
which would be difficult to control. As a precaution, interventional
radiology team was held on standby for possible embolization.
- The Ben Taub General Hospital Algorithm for penetrating facial trauma suggests initial stabilization
followed by imaging and appropriate consultation with neurosurgery or ophthalmology if needed.1
- The rarity of crossbow trauma adds to the challenge for the otolaryngologist. Bolts fire with an
energy of 90-165 Joules and can penetrate soft tissue and pierce the osteocranium from only a few
meters.5 Furthermore, although long and rigid, bolts have been seen to deviate in direction during
passage through the body as much as 90 degrees.5
-Vital signs normal, neurologic exam revealed immobility of right
frontalis muscle, hypesthesia in distribution of right infraorbital nerve
(V2).
-CT findings: 8.5cm by 1.91cm crossbow bolt extending from right
infratemporal fossa through right pterygopalatine fossa and posterior
maxillary sinus traversing the nasopharynx and through the left
posterior soft palate with the tip ending anterior to the left mandibular
ramus. “Blades” of arrow tip were in ‘open’ position in retromaxillary
space and nasopharynx. CT angiogram was negative for internal
maxillary or sphenopalatine artery injury. CT also revealed a left frontal
bone fracture immediately superior to the frontal sinus and a minimal
amount of pneumocephalus in the anterior cranial vault.
- While retained crossbow bolt injuries to the head and neck are uncommon, retained foreign bodies
from penetrating injuries in the maxillofacial region, are often encountered by otolaryngologists.
10. Shadid O, Simpson Michael, Sizer J. Penetrating injury of the maxillofacial region with an arrow: an unsuccessful attempt of suicide. Br J Oral Maxillofac Surg. 2008;
46:244-6.
Figure 4. Midline lip Split.
Figure 5. Removal of bolt
Figure 6. 2 Week Post-Op