A 20-year old male presented to the Emergency Department having been accidentally shot in the neck, by a friend using a 0.22 calibre air rifle, at a distance of approximately three metres. He complained of neck stiffness and pain on swallowing. Examination revealed an entry wound 1 cm below the level of the thyroid notch to the left of the midline, figure . A tense, non-pulsatile haematoma was evident deep to the entry wound. No bleeding or surgical emphysema were present. His voice was hoarse, although flexible endoscopic examination showed no pharyngeal or laryngeal abnormality. Cervical spine radiographs demonstrated an airgun pellet antero-lateral to the transverse process of C6, with a surrounding 6 cm diameter radiopacity consistent with haematoma and no deviation of the trachea, figure .\nPrimary resuscitation was uneventful, and the patient was taken to theatre within four hours for exploration of the wound and evacuation of the haematoma. Upon evacuation of the haematoma extensive haemorrhage developed from a defect in the anterior wall of the external carotid artery, which required rapid access and surgical repair. The airgun pellet was localised using image intensification and successfully retrieved from the paraspinous muscles, figure .\nThe pellet tract traversed the left lobe of the thyroid gland and the carotid sheath, impacting on the antero-medial aspect of the external carotid artery, just above the bifurcation, figure . It further traversed the paraspinous muscles and embedded immediately anterior to the transverse process of the sixth cervical vertebrae, at a depth of 8 cm from the skin entry wound.\nInitial recovery was uneventful, however at follow-up it was clear that the patient had Horner's syndrome from injury to the left cervical sympathetic chain and carotid arteries.
A 45-year-old male presented to the emergency department with alleged history of getting hit over the left side of neck by some air-borne object while standing on the roadside. This was followed up with severe, piercing pain in the neck region associated with bleeding from the wound site. He also gave history of transient loss of consciousness but had no neurological sequelae thereafter. There was no history of difficulty in breathing, change in voice, or swelling over the neck or face. On examination, his vitals were stable. There was no respiratory distress. There was a 2 cm × 1 cm linear lacerated wound on the left side of neck at the junction of upper 1/3rd and lower 2/3rd of the sternomastoid muscle on its anterior border. There was no active bleed or crepitus at the time of examination. No foreign body was visible or palpable in the neck. Indirect laryngoscopic examination was normal. An X-ray of the cervical region showed a radio-opaque foreign body in the left side of neck suggestive of a pellet (). A CT scan was ordered before taking up the patient for an exploration and removal of the foreign body. The scan confirmed the position of the pellet as being medial to the sternomastoid around the level of the glottis (Figures and ).\nThe neck was explored under general anaesthesia. On going medial to the sternomastoid, a thrill was palpable over the carotid sheath proximal to the foreign body. The pellet was identified within the carotid sheath partially piercing the internal jugular vein such that a part of it was outside the vessel and half of it was within the lumen. The pellet was carefully removed. The bleed was controlled with local pressure, and the vein was ligated and transfixed both proximal and distal to the site of injury.\nThe postoperative period was uneventful, and the patient is asymptomatic in his follow-up visits.