A 58-year-old Iranian man presented to our emergency department after an air gun shot injury. On admission, a penetrating wound in the left lateral region of zone II of his neck was detected. His vital signs were normal. His only complaint was slight odynophagia. No bleeding, hematoma, dysphonia or subcutaneous emphysema was noticeable. On further investigation, anteroposterior and lateral X-rays showed a hyperdense pellet in the left latera region of his neck (Figure ). A computed tomography scan confirmed the presence of the pellet at the level of the thyroid cartilage (Figure ).\nOur patient underwent a neck exploration using a hockey stick incision. After the primary incision of the skin and platysma, the carotid sheath was explored with no findings of note. An intraoperative X-ray of his neck, using control needle markers, revealed a tiny orifice of about 1.5mm on the left superior part of the thyroid cartilage. Extending the orifice to 1.5cm showed a pellet between the cartilage and the lining mucosa (Figure ). The pellet was removed. After complete repair of the cartilage and placing a drain, the subcutaneous tissue and skin were repaired.\nOur patient was discharged after drain removal with good general health. On a two-year follow-up he did not report any problem or complication and his physical examination remained normal.
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.