“Cold Steel”: A Unique Approach to a Pediatric Penetrating Facial and Skull Base Blowdart Injury

PROGRAM DESCRIPTION: In the practice of otolaryngology, how do you prepare for the unexpected? With respect to the management of penetrating trauma of the head and neck, there is no standard algorithm as each injury presents a unique challenge in urgent surgical treatment. As is often the case in pediatric patients, penetrating trauma to the face is usually the result of accidentally injury from a toy or projectile. In many instances, penetrating injuries from projectiles can be deep in the craniofacial skeleton, presenting a particular challenge for approach when the superficial injury may be minor or not as extensive. In these cases, when applicable, we turn to the endoscopic endonasal approach and principles of sinus and skull base surgery

In this surgical video presentation, we present a highly unique and dangerous case of a penetrating injury in a pediatric patient who suffered a blowdart injury to the face. The blowdart entered the nasal cavity through a small laceration in the nasal ala and penetrated the base of skull at the craniocervical junction. With close proximity to major neurovascular structures, quick action was needed to devise a plan on removal and management of multiple potential complications, through a combined effort of rhinologists, pediatric otolaryngologists, and neurosurgeons. Using established endoscopic endonasal techniques in sinus and skull base surgery, a purely endonasal approach was utilized to approach and manage skull base reconstruction following removal of the projectile. This minimally invasive technique avoided any external incisions to approach the penetrating trauma and demonstrates the utility of using established endoscopic techniques applied to the management of a unique traumatic injury.