Journal of Cranio-Maxillofacial Surgery (2009) 37, 235e238

Ó 2009 European Association for Cranio-Maxillofacial Surgery

doi:10.1016/j.jcms.2008.12.001, available online at http://www.sciencedirect.com

Penetrating injury of the maxilla by needlefish jaws

Yaniv EBNER, MD, BPharm1, Daniel GOLANI, PhD2, Dov OPHIR, MD1, Yehuda FINKELSTEIN, MD, MA1
1
Department of Otolaryngology - Head and Neck Surgery (Head: Professor Dr. D. Ophir), Meir Medical Centre, Kfar
Saba, Israel, affiliated to Sackler Faculty of Medicine, Tel Aviv University, Israel; 2 Department of Evolution, Systematics
and Ecology (Head: Professor R. Nathan), The Hebrew University of Jerusalem, Jerusalem, Israel

SUMMARY. Introduction: Needlefish penetrating injuries have become a worldwide problem, inflicting critical
morbidities and even mortalities. This is the first published case of needlefish injury in the Mediterranean
basin. Case report: A 29 year old man was admitted to Meir Medical Centre in Israel with a penetrating facial
wound caused by elongated needlefish jaws. The severity of the wound contrasted greatly with the expected in-
jury from collision with a fish inflicting a small penetration lesion. The rigid jaws penetrated the maxilla trans-
versely and obliquely from the left canine-fossae, through the nasal cavity, and to the right maxillary sinus, with
its tip reaching the right medial-inferior orbital wall. The needlefish jaws were completely removed using a com-
bined endoscopic and external approach. The course of surgery and hospitalization was uneventful and the pa-
tient was discharged with no complications. Conclusions: Fish inflicted critical facial injuries might be
dangerously underestimated prima facie. The impact might be energetic enough to penetrate deep facial and vital
cranial structures, hence thorough examination and imaging are recommended. Needlefish species are now com-
mon in the tropical and subtropical regions of all oceans and therefore this phenomenon is of interest to world-
wide trauma medical providers, fishermen, divers, and also to marine-biologists. Ó 2009 European Association
for Cranio-Maxillofacial Surgery

Keywords: maxillofacial injuries, endoscopic surgical procedure, sports injuries, needlefish, mediterranean sea

INTRODUCTION the impact, the needlefish’s jaws broke and detached

Facial penetrating injuries caused by marine creatures are
usually considered to be rare and exotic events. How-
ever, human injuries, particularly those caused by needle-
fish, are common in Oceania (Barss, 1982; Labbe et al.,
1995) and were also reported from Hawaii (McCabe
et al., 1978), India (Thakker and Usha, 2006), the Red
Sea (Bendet et al., 1995) and the American (Link et al.,
1999) and European (Kerkhoffs et al., 2003) coasts of
the Atlantic Ocean. Such injuries can be hazardous and
indeed at least 13 fatal cases have already been reported
(McCabe et al., 1978; Barss, 1982).
This is the first report of a needlefish injury in the
Mediterranean basin.
CASE REPORT
During the winter season, in the early hours of darkness,
two amateur divers were spear fishing off the shores of
Herzliya (10 km north of Tel Aviv, Israel). They were
equipped with underwater flashlights and spear guns.
The divers collected several specimens of needlefish (Be-
lonidae), which they observed in large numbers. They
met on the sea surface about 100 m off shore, where
the water depth is about 6 m. When they switched on
their head flashlights, an underwater commotion ensued
and several needlefish leaped out of the water, one of
them striking the patient’s face on his left side. Due to
from the fish and remained embedded in the patient’s
face. The patient felt extreme pain but did not lose con-
sciousness. He managed to swim ashore, albeit ex-
hausted. He was driven to Meir Medical Centre where
he arrived one and a half hours after the injury.
On admission to the emergency room, the 29 year
old male was haemodynamically stable and in good gen-
eral condition. He had a small penetration wound in the
left nasolabial fold, with the proximal end of the fish
jaws protruding and totally immobile. Even though the
wound was lateral to his left nostril, clotted blood was
observed coming out from both nostrils (Fig. 1). Unex-
pectedly, touching the proximal end of the jaws (protrud-
ing from the left side of the patient’s face) caused
him pain in the right (contralateral) side of the face.
There were no signs of injury to the eyes or orbits.
The divers brought with them the head of another nee-
dlefish, speared from the same school, so that the basic
structure of the embedded jaws could be comprehended
(Fig. 2, top).
The patient was prophylactically treated with Ciprox-
floxacin 500 mg Per Os, directed against gram-negative
marine bacteria species, mainly Vibrio species. Tetanus
immunization was also given.
Computerized tomography revealed the unexpected
extent of the internal injury. The elongated heavily cal-
cified jaws penetrated diagonally from the left canine-
fossae to the left nasal cavity and through the septum

235
236 Journal of Cranio-Maxillofacial Surgery
Fig. 1 e The needlefish’s jaws protruding from the penetration wound in
the area of the left nasolabial fold.
Fig. 2 e Top: Head of a needlefish specimen brought by the divers.
Bottom: the fragmented removed needlefish’s jaws.
to the right side and from there through the lateral nasal
wall to the right maxillary sinus. The sharp tip of the
jaws almost reached the medial-inferior orbital wall
(Fig. 3).
Under general anaesthesia, only a segment of one nee-
dlefish jaw that was fractured from the impact of the col-
lision could be carefully extracted from the patient’s
maxilla (Fig. 2 bottom). On endoscopic survey, the re-
maining fish jaws were found penetrating from the left
lateral nasal wall through the left inferior turbinate, cross-
ing the left nasal cavity, penetrating the nasal septum
(Fig. 4), and crossing the right nasal cavity and penetrat-
ing obliquely the right middle turbinate. Using the endo-
scopic nasal cutting forceps, the jaws that were firmly
embedded, were cut into fragments, which were pulled
out through the penetration wound. The sharp needle-
like fish teeth, which were scattered and impaled in the
nasal mucosa of the left inferior turbinate, septum, right
middle turbinate, and middle meatus, were meticulously
removed with debridement of the surrounding soft tissue.
Repeated irrigation reduced the risk of secondary infec-
tion or envenomation, which could result from gram-neg-
ative bacteria. The patient recovered quickly and was
discharged from hospital after two days, and has had
no short or long-term consequences.
DISCUSSION
The presented case emphasizes the important fact that
marine-related penetrating head injuries may be particu-
larly hazardous and can result in unpredicted internal in-
juries. The needlefish has elongated, sharp and rigid
jaws. The serial sections of the computed tomography
demonstrated their massive calcified structure and their
high penetrability even of a bony structure such as the
maxilla. The life of our patient may have been saved
by the casual and accidental turning of his head toward
his friend, preventing a frontal, possibly lethal injury.
Two other head injuries caused by needlefish have
been previously reported. One of them resulted in death
due to a carotid-cavernous fistula (McCabe et al., 1978).
The second report describes a retrobulbar trajectory that
caused a penetrating globe injury and damaged orbital
contents (Thakker and Usha, 2006).
Facial injuries from collisions with other kinds of ma-
rine animals have also been reported, including facial
nerve paralysis from compression by a fish jaw in the ret-
romandibular fossae (Morello et al., 1968; Zwisler and
Beigel, 1997).
Needlefish are carnivorous and their putrid sharp teeth
can cause severe marine pathogen infection (Link et al.,
1999). The possibility of needlefish being inoculated
with Vibrio species has been previously described (Cui
et al., 2000). In Israel, twelve to twenty-four new cases
of serious infection due to Vibrio vulnificus, including
mortality, are reported annually (Israel Ministry of
Health - Public Health Services, 2006). Although most
of these cases involve Tilapia fish, which are raised in
fresh water fishponds, Vibrio vulnificus is also found in
marine waters off the coast of Israel and was previously
isolated from Herzlya’s shore (i.e. the same shore as in
our reported case) (Ghinsberg et al., 1999). Wound infec-
tion by this bacterium can result in the rapid appearance
of severe pain, fever, oedema, vesicles, and subdermal
inflammation. In immunocompromised patients this in-
fection can cause sepsis and death (Bisharat et al.,
1999). Secondary infection due to needlefish injury has
been reported (Link et al., 1999) and prophylactic antibi-
otic treatment should be given as early as possible.
A Discrepancy between minor physical findings in pa-
tients with facial injuries and the actual scope of damage
was previously reported (Kloss et al., 2008). The small
diameter of the wound should not mislead the physician,
because the narrow needlefish beak is long enough to
cause significant damage to internal organs. As in our
case, the damage can be inflicted at some distance from
the entry point with an unexpected trajectory. Hence,
Emergency Room staff, Cranio-Maxillofacial surgeons,
Otolaryngologists and Ophthalmologists, should become
familiar with this type of penetrating injury. Arteriogra-
phy should be performed when a vascular injury is sus-
pected. The surgical treatment should include
meticulous exploration and debridement.
Identification of the injurious fish species was made
possible due to another specimen from the same school
that was brought by the divers and from the form and
length of the remains of the jaws removed from the
 Penetrating injury of the maxilla by needlefish jaws 237

Fig. 3 e Serial sections of computed tomography show the trajectory of the needlefish’s jaw lodged within the maxilla.

patient’s maxilla, as well as from comparative material

from the Hebrew University Fish Specimen Collection.
The fish was identified as 57e60 cm full length specimen
belonging to the genus Tylosorus of the Belonidae
(‘‘Needlefish’’) family, which consists of 32 species
worldwide. The Mediterranean Sea is occupied by only
two very similar species of Tylosorus (Golani and
Levy, 2005). The much more common Tylosorus acus
is most likely to have been the causal species.
Needlefish are sea-surface dwelling and have a very
elongated body, which is semi-cylindrical with a slightly
compressed abdomen. They have extremely long and
pointed jaws, almost beak-like, with many needle-like
teeth. This hydrodynamic shape and fin arrangement en-
able the needlefish to accelerate rapidly, thus when leap-
ing out of the water due to fright, the needlefish can reach
a speed of up to 60 km/h (Link et al., 1999). These leaps
have resulted in injury or even death to fishermen and Fig. 4 e Endoscopic view of the penetrating jaw within the left nasal
swimmers (McCabe et al., 1978; Barss, 1982). This be- cavity (The left inferior turbinate on the right, the nasal septum on the
haviour is not the result of intentional attack by the left).
238 Journal of Cranio-Maxillofacial Surgery
needlefish, but is rather their method of escaping danger
(Randall, 1995).
Previous case reports have traced the spread of hazard-
ous needlefish injuries from the endemic Oceania area to
the coasts of the Pacific and Atlantic oceans, including
the coasts of the United States and Europe. The present
case heralds the arrival in the Mediterranean basin of
this worldwide life-threatening hazard.
CONCLUSIONS
The observed needlefish behaviour near the sea-surface
and the increased popularity of scuba diving either for
fishing or for sport, mandate awareness and caution by
swimmers, fishermen and scuba divers when near water
surface in the vicinity of a school of needlefish, and
most especially when using flashlights at night.
The potential hazardous infection from marine patho-
gen, such as Vibrio vulnificus, should mandate the physi-
cian who encounters an injury from marine animals to
consider prophylactic antibiotic treatment.
We discovered that the severity of the internal injury
could not be predicted from the small superficial wound
and that the impact of collision of marine-creatures might
be much higher than expected. From this we conclude
that emergency room staff, even in the face of an ‘‘inno-
cent’’ story or primary physical findings, should not erro-
neously underestimate similar injuries.
CONFLICT OF INTEREST
None of the authors has any conflict of interest, financial
or otherwise.
ACKNOWLEDGMENTS
We thank Elli Bennatan, BSc, MA, for his writing and editing assis-
tance. We thank Yeella Ebner for her illustration editing assistance.
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Dr. Yaniv EBNER, MD, BPharm
Department of Otolaryngology - Head and Neck Surgery
Meir Medical Centre
Tchernichovsky 59
95847 Kfar Saba
Israel
Tel.: +972 9 747 2149
Fax: +972 9 747 1291
E-mail: yaniv.ebner@gmail.com
Paper received 28 June 2008
Accepted 17 December 2008