Translaryngeal puncture in a collegiate fencer☆☆☆★

Translaryngeal puncture in a collegiate fencer JEFFREYP. CAMPBELL, MD, RICHARD E. BROWNLEE, MD, MARK C. WEISSLER,MD, and STANLEY J. MARTINKOSKY, PhD,Lexington, Kentucky,Gainesville, Florida, and Chapel Hill, North Carolina

P e n e t r a t i n g injury to the neck represents a relatively common clinical problem to the otolaryngologist-head and neck surgeon. Gunshot and knife wounds to the neck received during personal assaults and motor vehicle accidents remain the most common causes of this type of neck injury. Traditionally, these injuries are explored if the wound penetrates the platysma muscular layer. In this article we describe a specific type of unusual injury resulting from a subtle fault in protective equipment in a collegiate fencer. The patient reported received an apparently superficial penetrating injury to the neck with his opponent's foil. The foil, after fracture of its protective tip during a lunge, penetrated the protective garment made of Kevlar. The foil produced a midline translaryngeal puncture wound in the supraglottic region. This injury was successfully managed without surgery with no adverse sequelae. Fencers and all users of Kevlar protective equipment should routinely inspect and replace equipment that appears worn or frayed (even if this fraying occurs at the edges of the garment). Otolaryngologist-head and neck surgeons should be diligent in fully investigating such foil injuries because they may appear superficial but penetrate deeply because of a combination of the large force generated by the lunge and the minute area of the foil tip. Management of these injuries should be based on the history, physical examination (including fiberoptic

From the Division of Otolaryngology-Headand Neck Surgery (Dr. Campbell), University of Kentucky Chandler Medical Center, Lexington; the Division of Otolaryngology-Head and Neck Surgery (Dr. Brownlee), University of Florida, Gainesville; the Division of Otolaryngology-Head and Neck Surgery (Drs. Weissler and Martinkosky), University of North Carolina, Chapel Hill. Reprint requests: JeffreyR Campbell, MD, Director, Section on Facial Plastic and Reconstructive Surgery, Division of OtolaryngologyHead and Neck Surgery, University of Kentucky Chandler Medical Center, 800 Rose St., Room C236, Lexington,KY 40536. Otolaryngol Head Neck Surg 1997;116:120-2. Copyright © 1997 by the American Academy of OtolaryngologyHead and Neck Surgery Foundation, Inc. 0194-5998/97/$5.00 + 0 23•4•72279

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nasopharyngoscopy), and radiographic studies (e.g., plain films and angiography if indicated). CASE REPORT

A 21-year-old male collegiate fencer went to the emergency department of the University of North Carolina Hospitals after a penetrating injury to the neck suffered during an 6p6e fencing match. The patient's opponent lunged with the foil directed at the neck. According to spectators, the protective tip of the opponent's foil fractured, and the proximal tip penetrated the patient's Kevlar neck shield. This resulted in a puncture wound to the patient's neck. The patient was asymptomatic after the injury, except for some minor pain, but went to the emergency department on the request of his coach. The patient was afebrile and had normal vital signs on arrival to the emergency department. The otolaryngology-head and neck service was consulted, although the emergency physician thought the wound was superficial on examination. Examination of the patient revealed a young man in no acute distress with a very small puncture wound to the midline anterior neck approximately midway between the superior border of the thyroid cartilage and the inferior border of the hyoid bone (Fig. 1). The remainder of his general physical examination was unremarkable. Indirect mirror laryngoscopy revealed a small amount of blood superior to the level of the vocal cords. Fiberoptic nasopharyngoscopy revealed mucosal puncture wounds in the region of the epiglottic petiole and the adjacent posterior pharyngeal wall (Figs. 2, 3, and 4). Cervical spine series and soft tissue plain radiographs of the neck were unremarkable. Speech pathology testing of phonation was within normal limits. The patient was admitted to the otolaryngology-head and neck service for observation and a brief course of intravenous antibiotics (ampicillin sodiurrdsulbactam sodium 3.0 gm intravenously every 6 hours). He remained afebrile, and his pain gradually diminished. He was discharged from the hospital after 1 day and took cephalexin 250 mg orally four times daily for 1 week. The patient recovered well and was seen both 3 days and 2 weeks after the injury, at which time repeat nasopharyngoscopy revealed a normal, well-healed supraglottic larynx.

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Fig. 1. Entrance wound in the anterior neck created by the foil. By palpation, this entry wound was approximately midway between the superior border of the thyroid cartilage and the inferior border of the hyoid bone.

Fig. 3. Posterior laryngeal wall puncture wound in closeup view.

Fig. 2. Foil puncture wound on the posterior wall of the supraglottic larynx as seen through fiberoptic nasopharyngoscopy.

Fig. 4. Foil puncture wound in the region of the epigloffic petiole in closeup view.

DISCUSSION

attached Keviar neck piece apparently because of a frayed edge of the fabric adjacent to the penetration site (Fig. 5). Although the fraying of the protective fabric appears minor, this fraying allows loosening of the woven Kevlar yarn and therefore penetration by weapons with small surface areas. Interestingly, the common denominator in reported fencing deaths and injuries all involve fracture of the foil with penetration

Because of the great forces generated by the lunge and the minute surface area of the foil, the risk of penetrating puncture injuries is high in the sport of fencing. Protective equipment consists of a wire mesh facial shield, with the remainder of the body being protected by Kevlar fabric. In this case, the foil penetrated the

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Fig. 5. Puncture site created by the foil in the Kevlar protective garment. In addition, fraying of the Kevlar fabric is seen along the lower edge of this garment below the region of the puncture site.

of the proximal tip, as in this case, and the only reported case of death caused by a fencing injury in the English literature involved a through-and-through neck injury with penetration of the common carotid artery and trachea. 1,2 This suggests that prevention of penetrating fencing injuries lies in development of materials other than steel for manufacture of the foil. Although other materials have been tried experimentally, it has been maintained that they unacceptably alter the nature of the sport. This is apparently an underrecognized mechanism of possible injury among fencers and possibly other users of Kevlar protection. Penetrating injuries to the neck are traditionally surgically explored if the wound penetrates the platysma layer.3-7 Furthermore, penetrating injuries have traditionally been subdivided into zone 1 (low), zone 2 (medium), and zone 3 (high) injuries depending on the penetrating entrance wound. Zone 1 injuries occur

below the lower border of the cricoid cartilage. Zone 2 injuries occur between the angle of the mandible and the lower border of the cricoid cartilage. Zone 3 injuries occur above the angle of the mandible. In general, zone 1 and zone 3 injuries tend to require angiographic evaluation more often than zone 2 injuries, in which vascular injuries may be surgically addressed with relative ease because of the improved exposure in this zone. 8 Additionally, esophagoscopy, bronchoscopy, and laryngoscopy may be indicated, depending on the location of the penetrating injury. 3-9 More recently, reports of selective management of penetrating neck injuries have arisen and reflect the trend toward observation of neck penetrating injuries that do not involve major neurovascular structures.S, 9 Bronchoscopy, esophagoscopy, and/or laryngoscopy may be performed as an extension of the physical examination, if these structures are suspected of injury. Diagnostic cervical angiography is performed in those stable patients with questionable vascular injuries.a, 9 Otherwise, a significant subset of patients with no significant bleeding or neurologic deficits may be safely observed with antibiotic therapy.S,9 Our case is unusual in that physical examination (including fiberoptic nasopharyngoscopy) confirmed the path of the weapon to be strictly midline, with its deepest level of penetration being the cervical prevertebral region. The integrity of the bony cervical spine was confirmed by simple radiographic studies. No further angiographic or endoscopic studies were required. The patient was therefore spared an exploratory operation. Otolaryngologists-head and neck surgeons must be vigilant in assessing penetrating neck injuries with superficial wounds. REFERENCES

1. Crawfurd AR. Death of a fencer. Br J Sports Med 1984;18(3):220-2. 2. Clery R. Apropos d'un accident. L'Escrime 1983;45:14-9. 3. Mannel A. The management of knife wounds of the neck. Injury 1978;10(1):56-65. 4. Thai ER, Meyer DM. Penetrating neck trauma. Curt Probl Surg 1992;Jan:t -56. 5. Fitchett VH, Pomerantz M, Butsch DW, et al. Penetrating wounds of the neck: a military and civilian experience. Arch Surg 1969;99:307-14. 6. SheelyCH II, Mattox KL, Reul GJ Jr, et al. Current concepts in the management of penetrating neck trauma. J Trauma 1975;15:895-900. 7. Roon AJ, Christensen N. Evaluation and treatment of penetrating cervical injuries. J Trauma 1979;19:391-7. 8. Mansours MA, Moore EE, Moore FA, et al. Validating the selective management of penetrating neck wounds. Am J Surg 1991;162:517-21. 9. McConnell DB, Trunkey DD. Management of penetrating trauma to the neck. Adv Surg 1994;27:97-127.