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Int J Surg Case Rep
Int J Surg Case Rep
International Journal of Surgery Case Reports
2210-2612
Elsevier

S2210-2612(24)00951-9
10.1016/j.ijscr.2024.110170
110170
Case Report
An unusual penetrating cervical wound involving a disc grinder: A case report
Meherzi Samia meherzisamia9@gmail.com
⁎
Jerbi Leila
Koury Ahmed
Zahmoul Asma
ENT department, Sidi Bouzid Hospital, Tunisia
University of Sousse, Faculty of Medicine of Sousse, Tunisia
⁎ Corresponding author at: ENT Department, Sidi Bouzid Hospital, 9117, Tunisia. meherzisamia9@gmail.com
16 8 2024
10 2024
16 8 2024
123 11017013 6 2024
8 8 2024
10 8 2024
© 2024 Published by Elsevier Ltd on behalf of IJS Publishing Group Limited.
2024

https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction

Penetrating neck injuries pose a unique challenge due to the limited space for controlling bleeding and performing repairs. This often leads to high mortality rates when major blood vessels are severed, and can also result in neurological damage.

Case presentation

We present a case of a penetrating injury to the internal jugular vein caused by a dislodged angle grinder disc, a rare mechanism of injury with potentially fatal consequences. The patient underwent emergency surgery to explore the wound and ligate the injured veins. After the operation, the patient fully recovered with no neurological deficits and did not require further treatment.

Discussion

Angle grinders are well-known for causing severe penetrating neck injuries due to their high-speed operation. Venous vascular wounds can be controlled with ligation and have a good prognosis. Nerve injuries are common. Protective measures should be taken in these patients.

Conclusion

This case highlights the significant risk of injury associated with disc grinders, and the importance of seeking prompt specialized medical attention.

Highlights

• Cervical injuries by angle grinders are rare but serious.

• Venous vascular wounds are common and have a good prognosis.

• Traumas to the vagus nerve can manifest as dysphonia.

Keywords

Angle grinder
Accident
Vascular injuries
Prevention
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pmc1 Introduction

The neck is a highly intricate anatomical area, and the penetration of a high-speed foreign object can result in deadly harm [1]. Zones II and III of the neck encompass the broadest and most vulnerable cervical region. This area includes critical structures such as the common carotid arteries, internal and external jugular veins, multiple cranial nerves, larynx, hypopharynx, and cervical esophagus [2]. Neck wounds caused by angle grinders are serious and can be life-threatening because they are most often associated with major vascular injuries [3].

In this case, we describe a lateral penetrating cervical injury resulting from a disc grinder. The disc has deeply penetrated, creating an open wound that extends from the cricoid cartilage to the nape of the neck on the same side, severing the sternocleidomastoid muscle and affecting nearby important structures. This work has been reported in line with the SCARE criteria [4].

1.1 Case report

A 30-year-old industrial worker was brought to the emergency room with a penetrating neck wound and ongoing bleeding after a workplace incident with a disc grinder while shredding plastic. The disc, still intact, dislodged from the paper shredding machine and struck the patient's neck before falling to the floor. On-site, the wound was packed due to increasing bleeding. In the emergency room, the patient remained conscious, with stable hemodynamic and respiratory parameters except for tachycardia. Approximately 250 mL of blood loss was recorded by paramedics. Initial blood tests revealed a hemoglobin level of 13.5 g/L. There was no sensory motor loss observed.

Examination of the injury site confirmed a zone II penetrating lesion of the neck with adjacent subcutaneous crepitus distant from upper aerodigestive tract and anterior neck region. Dysphonia was reported during the examination, with no other upper airway dysfunction signs (i.e. stridor dyspnoea dysphagia hemoptysis nor upper airway oedema), airway injury was further ruled out upon examination of the oropharynx (no bulging of the lateral nor posterior wall) thus a decision was made to proceed directly with a computed tomographic angiography CT-A.

The cervical scan showed sectioning of the swollen sternocleidomastoid muscle, emphysematous infiltration of the para- and retro-pharyngeal deep cervical spaces, edematous and hemorrhagic infiltration of the deep left cervical spaces extending to the superior mediastinal orifice, compression of the left internal jugular vein at the C6 level up to its termination at the innominate vein trunk, with no contrast extravasation observed on various acquisition phases, left recurrent laryngeal nerve palsy, as evidenced by ipsilateral vocal cord medialization to the right (Fig. 1).Fig. 1 Cervical CT scan with contrast, axial sections (A + B): section of the sternocleidomastoid muscle (red arrow), emphysematous infiltration of the para- and retro-pharyngeal deep cervical spaces (black arrow), ipsilateral vocal cord medialization to the right (yellow arrows). Angiography (C): Sudden cessation of opacification of the internal jugular vein at C6. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 1

During surgical exploration of the left-sided wound, the following findings were noted: a linear lateral-cervical wound with active bleeding; lateral sectioning of the sternocleidomastoid muscle; sectioning of the internal and external jugular vein at the level of the thyrolinguofacial trunk; an elongated vagus nerve suggestive of traction of the nerve but with maintained continuity of the connective nerve tissue (Fig. 2). The carotid artery and its branches were intact, except for a localized lateralized thinning of the common trunk. Treatment involved ligation of the venous wounds (external and internal jugular left veins), insertion of a drain, and layered closure. Postoperatively, the patient recovered completely (Fig. 3), with a drop in hemoglobin levels to 12.7 (from an initial 13.5) and a persistent hoarseness of voice. An isolated Left vocal cord paresis was noted during nasofibroscopy in accordance with CT-A findings. The rest of the supraglottic and glottic areas were undamaged, with intact mucosal lining and no detected edema, laceration, hematoma or constriction in laryngeal lumen. The patient received a course of Amoxicillin and clavulanic acid for 10 days post-surgery, along with anti-tetanus serum. A follow-up examination after the first month showed no particular issues, and a noticeable improvement in voice which is no longer breathy nor hoarse, further confirmed by nasofibroscopic exam showing mobile vocal cords with no abnormalities of the pharyngolaryngeal tract.Fig. 2 Perioperative view: Intact internal carotid artery (yellow arrow), ligated Jugular vein, Vagus nerve: identified and preserved (white arrow). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 2

Fig. 3 Postoperative appearance of cervical injury.

Fig. 3

2 Discussion

Incidents of penetrating trauma caused by angle grinders often involve a shattering of the disc and the explosive projection of debris (rather than the disc itself) onto individuals, causing cranio-facial injuries. Cervical injuries are less frequent but also occur [1,2].

The incidence of significant vascular damage from penetrating cervical trauma can be as high as 50 %, with injuries to the carotid sheath potentially leading to fatal hemorrhaging [5,6]. Patient history, injury mechanism, and thorough exams are crucial.

Research indicates a strong correlation between patient outcomes and their clinical condition during the initial emergency room assessment: 98 % survival for normotensive, 67 % for shock, 0 % for moribund patients [2]. Past experiences with a large number of cervicothoracic vascular trauma cases underscore key clinical insights, with our current observations reaffirming these findings: These injuries carry a high risk of death from severe bleeding, particularly following penetrating trauma, Isolated venous injuries on the other hand were not associated with mortality nor major complications as was the case for our patient [5].

A methodical approach for neck injuries is vital, starting with clinical evaluation, identifying ‘hard signs’ necessitating urgent exploration, and determining the neck zone (I, II, or III) to guide management choice (surgical exploration being the standard procedure for zone II injuries).

Controlled bleeding along with a stable respiratory state and hemodynamics in our patient, allowed for further analysis with the help of CT-A, deviating from the conventional zone approach.

The management approach for such ‘stable’ symptomatic patients has slowly shifted from the zone based approach to a CT-A based approach reducing negative exploration rates and enhancing lesion assessment accuracy (level 2A evidence) [7]. As for the case of suspected vascular injuries: a meta analysis established by Morales-Uribe Et al. demonstrated a sensitivity and specificity higher than 97 % for detecting vascular injuries in the neck, comparable to conventional angiography [8].

Optimal management for penetrating neck injuries patients potentially affected by such vascular trauma includes efficient prehospital resuscitation, prompt transfer to a trauma center, vigilant monitoring for associated neurological and aerodigestive injuries, and timely technical interventions, with a willingness to perform sternotomy or thoracotomy as needed for vascular control [5,6]. Neurological structures are threatened, in these cases either through cerebral blood flow reduction or direct involvement of cranial nerves and the brachial plexus. Dysphonia was the only neurological sequelae presented by our subject, following a post traumatic stretch and wear of the vagus nerve.

The worker in our case study and those in a recent survey, indicated a lack of understanding regarding disc selection and proper fitting, as well as the significance of a protective guard for the machine and personal protective equipment for those operating it [1,9]. This incident could have been easily avoided if the worker had worn suitable gear and received proper posture, work positioning, and technique training.

3 Conclusion

Work-related incidents arising from angle grinders are notorious for causing high-speed penetrating neck injuries. These cases pose a significant challenge due to the multiple critical structures in the neck that are frequently harmed simultaneously. Regardless of the zone of injury, radiographic study (CT-A) in combination with standard trauma physical examination is effective in evaluating stable symptomatic patients and guiding management.

Informed consent declaration

Written consent for the publication of this case report and its accompanying images has been acquired from the patient. No information in the submitted manuscript can be used to identify the patient.

Ethical approval

This case report has been reviewed and approved by the Medical Ethics Committee of our institution (Ethics No. 202407).

Funding

The authors received no financial support for the preparation, research, authorship, and/or publication of this manuscript.

Author contribution

Samia Meherzi: study concept, data collection, writing the paper.

Leila Jerbi: data collection, writing the paper.

Ahmed Koury: data collection.

Asma Zahmoul: study concept.

Guarantor

Samia Meherzi.

Research registration number

N/A.

Conflict of interest statement

The authors do not have any potential conflicts of interest concerning this manuscript.

Acknowledgments

None.
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