Ballistic head and neck injuries: management rationale and outcomes in a case series.

Introduction: Penetrating head and neck injuries with retained foreign bodies pose significant management challenges due to the anatomical density of vital structures. The optimal therapeutic strategy - ranging from surgical extraction to conservative observation - remains guided by individual patient and injury characteristics. Methods: This case series retrospectively reviews four distinct presentations of retained metallic foreign bodies in the head and neck region. Diagnostic evaluation utilized advanced computed tomography (CT) for precise localization. Management strategies were individualized, including functional endoscopic sinus surgery, open surgical exploration via parotid and cervical approaches, and active observation. Results: CT imaging was critical for preoperative planning in all symptomatic cases, accurately defining the relationship of fragments to neurovascular structures. Endoscopic retrieval was successful for a fragment within an Onodi cell. Open approaches were required for fragments embedded in the parotid region and deep neck, with one patient developing Frey syndrome postoperatively. In an asymptomatic patient with no structural compromise, observation was safely elected. Delayed complications, including chronic pain and infection, manifested years after the initial injury in two cases. Conclusions: Management of penetrating head and neck foreign bodies requires a tailored, multidisciplinary approach. Advanced imaging is indispensable for risk assessment and planning. Treatment should be individualized, with minimally invasive techniques preferred when feasible, while observation is a valid option in select asymptomatic patients. Long-term follow-up is essential due to the potential for delayed sequelae.