The “William Tell” sign: difficult airway resulting from cranial transfixion by an arrow

Excerpt

A 53-yr-old man was admitted to our trauma center with a self-inflicted transfixing head injury from an arrow fired from a compressed-air harpoon gun during a suicide attempt. The patient provided written consent for this report. On arrival, the patient was conscious, with a Glasgow coma score of 15. He could hardly speak, however, as the arrow had transfixed both the pharyngeal and oral tissues to the surrounding bony structures (Figure, left panel). A computed tomography scan of the cranium showed the course of the arrow through the head and neck (Figure, centre panel). The penetration point was slightly lateral (right) and just above the cricoid cartilage. The arrow’s pathway continued through the posterior tongue muscles and the soft palate, crossing into the right nasal turbinate (Figure, right panel) and perforating the sphenoid sinus before transiting through the intracranial space. It exited medial to the vertex. There was no vascular injury. Urgent neurosurgical removal of the arrow was planned and required securing the airway before general anesthesia could be induced.

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