Carpenter Shoots Himself in the Neck with Nail Gun

According to Boston News, in early December 2011, a carpenter accidentally discharged a nail gun and embedded a 3.5 inch nail in the bottom of his neck. Based on the CT scan included here, it appears the nail entered the neck dead center given the clear appearance of the windpipe.

Based on the location, the anatomic sequence of nail piercing is as follows:

Skin --> Thyroid Gland --> Trachea --> Esophagus Back Wall --> Cervical Vertebral Body

The damage to skin, thyroid, and trachea is not a big deal... In fact, one can consider this a mini-tracheostomy. Minimal bleeding would be expected.

However, the hole between the trachea and esophagus is another matter which may heal well... or not. The esophagus is the swallow tube which transports food from the mouth to the stomach. A hole in the esophagus to the trachea (tracheo-esophageal fistula) would allow swallowed food/liquid to pass from the esophagus over to the trachea and into the lungs leading to pneumonia and bronchitis. This uncontrollable aspiration can potentially be life threatening as the hole could also allow food to pass BETWEEN the trachea and esophagus right down to the heart leading to possible mediastinitis (inflammation/infection of the heart lining).

Treatment initially would be placement of a feeding tube and a long course of IV antibiotics. If the hole does not spontaneously close, it would require surgical closure, typically with a flap of some kind.

The easiest test to perform to determine whether the hole has closed up or not is a swallow study using gastrografin or barium. Watch a video of how this test is performed.



As the news story mentioned, he was VERY lucky the nail went in where it did. If it went in a little further to the right or left, it could have punctured his carotid or jugular vein and he would have bled to death.

Reference:
Carpenter Shoots Himself In Neck With Nail Gun. WCVB Boston News

A Crime For Doctors to Ask About Guns?

When I saw this report on ABC about a Florida politician wanting to make it a crime if a physician asks about guns in the home or else face 5 years in jail and up to $5 million fine, I could not believe it.

Who cares that more children die of accidents than of diseases.

It is standard practice for pediatricians to provide guidance on a variety of unintentional injury-prevention counseling for infants, preschool-aged children, school-aged children, and adolescents as well as their parents. These include:

• Traffic safety
• Burn prevention
• Fall prevention
• Choking prevention
• Drowning prevention/water safety
• Safe sleep environment
• Cardiopulmonary resuscitation
• Poison prevention
• Firearm safety
• Sports safety

According to the American Academy of Pediatrics, gunshot wounds account for one in 25 admissions to pediatric trauma centers in the United States. Furthermore, a gun in the home is 43 times more likely to be used to kill a friend or family member than a burglar or other criminal.

As the trite but true saying goes, an ounce of prevention is worth a pound of cure.

And in this day where healthcare costs are spiraling, how precious and common-sense it is to ask and provide guidance on firearm safety and security at a cost of one physician visit rather than a child accidentally getting shot and using up hundreds of thousands of dollars worth of surgeries, hospitalizations, studies, physician visits, etc.

Read the ABC report here.

Why as an ENT am I even bothered about this? It's because I often have to ask similar but what some people may consider very private questions akin to asking about guns (ie, oral sex).

Reference:
Office-based counseling for unintentional injury prevention. Pediatrics 2007 Jan;119(1):202-6.

Machine Gun Sneezing

ABC News on November 11, 2009 aired a story about a 12 year old girl with an unfortunate condition called "machine gun sneezing". Apparently, she sneezes up to 16 times a minute all day except while sleeping and started after recovering from a mild cold.

To be frank, it's a condition I've never seen before.

Per an allergist interviewed for this story, the condition is extremely rare and "can be triggered by hundreds of causes, including allergies, sinus problems, or growths in the nasal passage."

Read more here. A video of the report can also be found at the link.

This girl was eventually found to have a diagnosis called PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus)! Read more here.