Ballistic injury to the neck in a soldier injured in the war in Ukraine: a case report

Clinical discussion: A CT scan revealed a foreign body in the neck on the right side, between the mastoid process and the right jaw angle. A CT scan with contrast revealed a foreign body in the neck – a bullet – and helped with observing relations to surrounding tissues and following the bullet’s trajectory. The multidisciplinary team performed surgery for foreign body removal. As a first step, carotid arteries and the internal jugular vein were dissected and looped to control potential bleeding. The bullet was 7.62 caliber. The patient recovered well with minimal postoperative complications, including hypoglossal and facial nerve neuropathy, which resolved in two weeks.


Introduction
Penetrating neck injuries (gunshots in particular) are associated with high mortality (up to 10%) and morbidity due to numerous adjacent vital structures located in the neck, without adequate musculoskeletal protection [1]. Gunshot wounds to the head and neck result in significant bone and soft tissue loss [1]. Injuries of major vessels, airways, spinal cord, major nerves, and esophagus lead to dramatic sequela; such cases require a multidisciplinary approach [2]. Here we present a case of a soldier shot into the oral cavity that resulted in unexpectedly moderate tissue injury and that required a multidisciplinary surgical approach because of the proximity of the foreign body to the neck vascular and nerve structures.

Case presentation
A 33-year-old male patient was shot in the mouth by AKM Kalashnikov's Automatic Rifle Modernized (AKM) assault rifle during close contact combat while defending his position on the south front of the Ukrainian-Russian war. The incident happened on January 3, 2023. A 7.62 caliber bullet, shot into the oral cavity, destroyed the first and second premolars of the left upper jaw, traversed the palate (Figure 1), and got lodged in soft tissues of the neck in zone III on the right side close to the internal jugular vein, and both internal and external right carotid arteries.

Patient information
The patient's general condition on admission was stable. His medical history, vital signs, and general physical examination were normal. The patient complained of neck and jaw pain on the right.

Clinical findings
On focused examination, we noted mild bleeding from the oral cavity. The 1 st and 2 nd left premolar of the upper jaw were destroyed and extracted. We detected mild edema of the gingival. The neck was slightly tender on the right side, just below the angle of the jaw. We detected no edema on the neck. Carotid pulsation was satisfactory. Neither bruit nor thrill was auscultated over the carotid vessels on the affected side. We did not detect a neurological deficit.

Diagnostic assessment
Basic blood tests were normal. A CT scan revealed a foreign body in the neck on the right side, between the mastoid process and the right jaw angle (Figure 2, panels A and B).
Retraction of damaged teeth was performed under local anesthesia. CT scan with contrast revealed a 27.5 by 6.9 mm metal foreign body above the bifurcation of the common carotid artery 2 mm away from the right internal jugular vein (Figure 2, panels C and D).

Therapeutic intervention
Initial management included pain control with dexketoprofen 50 mg IM TDS, mouthwash with chlorhexidine, and Ceftriaxone 1 gr IV BID. We analyzed the missile's path in detail and planned the foreign body removal surgery. We obtained the patient's informed consend for the procedure.
Due to the proximity to the internal carotid artery and suspected injury to the vessel wall, during preoperative planning, we decided to reveal and display the common carotid artery, external carotid artery, and internal carotid artery prior to attempting to remove the foreign body. The potential necessity to operate on the distal portion of the internal carotid artery in the narrowed space (between the jaw and cervical vertebrae) and anticipated challenges required the involvement of a maxillo-facial surgeon to perform subluxation of the right temporomandibular joint. Also, the anticipated difficulties in tissue dissection close to the neural roots of the cervical spine required the expertise of the neurosurgeon.  exposed and gently retracted. Further, cephalad dissection revealed a cavity. The cavity was opened and 2 ccs of pus were drained. On inspection, the metal piece (7.62 caliber bullet) was detected and gently retrieved (Figure 3). No hemorrhage was observed. The cavity was washed with saline and povidone-iodine, and a corrugated drain was placed.
No other abnormalities were detected. The wound was sutured and covered with sterile gauze.

Follow-up and outcomes
Postoperatively, the patient developed deviation of the tongue to the right and mild asymmetry of the face as a consequence of hypoglossal and fascial nerve neuropathy. There were no postoperative wound complications. The drain was removed after two days. The patient was discharged on the third postoperative day. Face asymmetry and tongue deviation resolved within two weeks.

Discussion
The immediate and long-term consequences of injury to the neck can be significant because of the close relationship of important anatomical structures in a confined space.
Delayed recognition of major injury and inadequate treatment results in high morbidity and mortality [3,4]. Major neck vessels, if injured, may lead to fast, massive bleeding and death at the scene if not arrested, either by forming hematoma or medical assistance.
Injury to the airways may cause immediate or delayed asphyxia [5]. Injuries to the spinal cord, neural roots, and vertebrae are associated with significant neurological deficits.
Perforation of the esophagus, if left untreated, leads to neck abscess, and mediastinitis and eventually may become lethal. Computed tomography angiography of the neck has been shown to be a sensitive, specific, and safe technique in screening for vascular injuries [1].
Management of gunshot neck injuries depends on a clear understanding of the anatomy of the neck. The radiologist can contribute substantially to the successful treatment of a patient with a gunshot wound. The important analysis includes the assessment of the missile path in emergency conditions by using plain film and computed tomography [6,7]. Surgical dissection can cause iatrogenic injuries to the nerves with serious adverse outcomes. The multidisciplinary approach is essential for repairing all injured organs and covering all possible intraoperative scenarios [2].