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| CASE REPORT |
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| Year : 2022 | Volume
: 5
| Issue : 1 | Page : 50-53 |
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Arrow injury through the floor of the mouth – How to proceed
Pavan Kumar Dammalapati, Chaitali Sen Dasgupta, Soumi Das
Department of Cardio Thoracic Vascular Anaesthesiology, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
| Date of Submission | 24-Oct-2021 |
| Date of Acceptance | 23-Jan-2022 |
| Date of Web Publication | 11-Mar-2022 |
Correspondence Address:
Dr. Pavan Kumar Dammalapati
Flat 4A, Griham Regency, 357/1/14, Prince Anwar Shah Road, Kolkata - 700 068, West Bengal
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/arwy.arwy_60_21
Although traditional arrow injuries are relatively rare nowadays, we occasionally come across such injuries being reported from remote areas. With the increase in recreational activities with modern arrows in the contemporary era, we should expect arrow injuries even in the urban population. Arrow injuries are managed in a similar manner to other penetrating injuries. Although arrow injuries in different parts of the body have been reported, arrow injury through the floor of the mouth is relatively rare. We describe a case of arrow injury where the arrow entered the floor of the mouth and emerged through the side of the neck posing difficulty in positioning, ventilation and intubation. Proximity to important structures in the neck also contributed to the rarity of this presentation.
Keywords: Arrow injury, difficult airway, two-table position technique
How to cite this article:
Dammalapati PK, Dasgupta CS, Das S. Arrow injury through the floor of the mouth – How to proceed. Airway 2022;5:50-3 |
| Introduction | |  |
Arrows are one of the oldest weapons invented in ancient civilisation. Arrow injury is relatively rare in the modern world due to advances in weapons, but arrows are still used in remote places. There is also a recent increase in the usage of arrows in the western world due to the increase in recreational activities such as archery. There are a few cases reported of arrow injuries to different parts of the body including head, neck, chest and abdomen. We report a case of an arrow entering through the floor of the mouth, passing through the neck and exiting at the base of nape causing major vasculature injury. We have reviewed different modalities available for securing an airway, including special positioning of the patient as well as use of airway adjuncts.
| Case Report | | |
An 18-year-old male was referred to the department of Cardiothoracic and Vascular Surgery of our hospital following homicidal arrow injury through the floor of the mouth while he was asleep. The patient travelled overnight to reach our hospital, suffering significant blood loss enroute.
On examination, the arrow was found entering at the right corner of the mouth through the vestibule behind the lower lip. It traversed the floor of the mouth jutting out one inch caudal and lateral to the angle of mandible on the side of the neck. The arrow re-entered the side of the neck at the medial border of the sternocleidomastoid muscle in proximity to the great vessels to finally exit at the base of the nape.
The patient remained in the right lateral position all along as he could not lie on his back and was not comfortable even in the left lateral position [Figure 1] and [Figure 2]. Routine blood investigations such as complete blood/urine examination, renal/liver function tests, serology, blood grouping and typing, X-ray neck anteroposterior/lateral view [Figure 3] and computerised tomography (CT) neck were done. The CT findings suggested that the arrow was passing through the internal jugular vein and abutting the carotid artery. As the arrow entered through the floor of the mouth below the mandible, there was swelling in the submental region but no intraoral haemorrhage. The arrow was traversing the side of the neck and exiting at the base of the nape on the right side, creating difficulty in positioning the patient supine for laryngoscopy. Adequate blood was arranged as the major vessels were injured and significant blood loss was anticipated. | Figure 3: X-ray head and neck, anteroposterior and lateral views showing the trajectory of the arrow
Click here to view |
It was decided to place the patient on two operating tables with the legs and trunk up to the thorax on one operating table and the head on the other operating table placed perpendicular to the first table to allow the anaesthesiologist unhindered access to the head end. The second table was placed at the head end to support the patient's head in such a way that the portion of the arrow that was jutting out was accommodated between the two operating tables, avoiding displacement and inadvertent worsening of the injury. A flexible bronchoscope and Ambu® aScope 3 SlimTM were kept ready. The surgical team was on stand-by in case of a cannot ventilate/cannot intubate situation to perform an emergency tracheostomy. We also discussed the possibility of removing the arrow under local anaesthesia but this plan was abandoned in view of proximity of the arrow to the major vessels in the neck. We did not attempt an awake intubation as the patient was not cooperative and effective topicalisation was logistically difficult. In view of major vascular injury, adequate blood products were kept ready.
After initiating standard monitoring with electrocardiogram, noninvasive blood pressure and pulse oximetry, we secured with two large-bore peripheral venous canulae. We anticipated difficulty in laryngoscopy in view of the submental swelling. To overcome the difficulty in ventilation, we placed a mop at the right corner of the mouth in line with the entry of the arrow to achieve a tight seal. Cutting the arrow at the entry point was not considered as the arrow was close to the great vessels in the neck, and it would also lead to patient discomfort. The patient was preloaded with crystalloids before taking up for surgery. As the haemoglobin was 11 g/dL, blood was reserved in anticipation of intraoperative blood loss. With the surgical team in readiness, the patient was induced with intravenous medications including midazolam 2 mg, glycopyrollate 0.2 mg, fentanyl 50 μg, ketamine 100 mg and propofol 100 mg titrated to achieve adequate depth of anaesthesia. The plan was to attempt visualisation of the laryngeal inlet under deep sedation without neck extension. Should this fail, we were ready with other airway equipment including laryngeal mask airway and Ambu® aScope 3 SlimTM. Fortunately, visualisation of the vocal cords was achieved with neck stabilisation by an assistant and the airway was secured using a bougie-assisted technique.
The patient was later repositioned in the left lateral position to facilitate surgical access and the incision was made on the neck along the track created by the arrow [Figure 4]. The neck was dissected layer-by-layer following the path created by the arrow. The entry path of the arrow was identified and the track carefully dissected till the arrow was seen. Once the arrow was reached, it was gently pulled out from the floor of the oral cavity. The internal jugular vein was severed, and the arrow was sealing the rent. After temporarily controlling the bleeding using a vascular clamp, the severed ends of the internal jugular vein were anastomosed [Figure 5]. Finally, the oral cavity was inspected; the entry, exit wounds were thoroughly cleaned and packed with sterile gauze. The patient made an uneventful recovery and was discharged on the 5th postoperative day [Figure 6]. | Figure 4: Arrow entering at the right corner of the mouth jutting out below the mandible to re-enter again in the side of the neck behind the medial border of sternocleidomastoid muscle, finally exiting at the right base of nape
Click here to view |
 | Figure 5: Intraoperative picture showing repair of the internal jugular vein
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| Discussion | | |
Our patient highlights the importance of planning in cases of unusual circumstances causing difficult intubation. Our approach of using two operating tables simultaneously is especially useful in patients with injuries where a penetrating foreign body exits from the body surface in a manner such that positioning the patient supine on the operating table would be otherwise impossible. Placing two tables adjacent and parallel to each other for accommodating morbidly obese patients has been well documented in literature.[1] Similarly, a modification of having the head 'overhang' the edge of the operating table in case of a giant occipital encephalocele has also been reported.[2]
A series of patients with arrow injuries over a period of 5 years has been categorised and presented according to the region of the body affected.[3] The treatment of 22% of patients with head, neck and limb injuries has been outlined site wise. Intubation strategies in patients with penetrating arrow injuries cannot be generalised because of innumerable combinations of entry and exit points. Adam and Ngamdu reported two patients with arrow injury from Nigeria, one in the posterior triangle of neck and the other in the infra-auricular region.[4] Both these cases did not involve the airway. Another patient with an arrow entering on the left side of the front of neck and exiting on the back with the tip visible was intubated in right lateral position as the right side was completely spared.[5] We also considered intubation in the lateral position but as the base of the mouth was involved as also the neck, we thought it would be difficult. In another case of penetrating injury by an iron rod following road traffic accident, the rod entered from the submental region through the floor of the mouth and extruded out of the oral cavity. As there was no possibility of direct laryngoscopy, blind nasal intubation was done in this patient.[6]
As exemplified by our case as well as similar reports in literature, there is no single technique that can effectively manage all forms of penetrating airway trauma. Each scenario needs to be evaluated and an individualised plan developed depending on the airway equipment available at that medical facility. The experience of the surgical and anaesthesiology team also needs to be factored into the airway management strategy.
Acknowledgements
I thank Dr Chaitali Sen Dasgupta, Professor and Head of Cardio Thoracic Vascular Anaesthesiology for guiding me through the process of writing the case report. I also thank Dr Soumi Das, Associate Professor, for co-opting me as a team member and enriching my clinical experience in case management.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 2. | Singh H, Singh D, Sharma D, Tandon MS, Ganjoo P. Perioperative challenges in patients with giant occipital encephalocele with microcephaly and micrognathia. J Neurosci Rural Pract 2012;3:68-70. [ PUBMED] [Full text] |
| 3. | Yadav R, Singh S, Mathur RK, Moses S, Maheshwari A. Arrow injuries – In current scenarios. J Med Sci Clin Res 2018;6:653-7. |
| 4. | Adamu A, Ngamdu YB. Management of penetrating arrow neck injury: A report of two cases. MAMC J Med Sci 2020;6:63-7. [Full text] |
| 5. | Nepal A, Joshi RR, Bhandary S, Mathur NN, Roka YB, Yadav R. Penetrating neck injury by an arrow: A paradigm of age old assault. Nepal Med Coll J 2010;12:58-60. |
| 6. | Tiwari T, Singh A, Rawat J, Chaudhary J. Difficult airway caused by retained rod penetrating through floor of mouth and base of tongue following road traffic accident: A case report. Airway 2019;2:96-9. [Full text] |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
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