BACKGROUND: Hemodynamically stable penetrating neck trauma with retained deep foreign bodies can conceal functionally significant neural injury despite absence of major vascular findings on computed tomography angiography. In selected cases, early laryngoscopy may provide decisive functional evidence and help identify occult recurrent laryngeal nerve injury requiring timely surgical exploration.

CASE REPORT: A 45-year-old woman presented with penetrating neck trauma caused by multiple glass fragments, with Zone II entry wounds and a deep transcervical trajectory across zones. She was hemodynamically stable, without airway compromise. Computed tomography angiography demonstrated multiple retained glass foreign bodies in deep cervical compartments, without contrast extravasation, pseudoaneurysm, or hematoma. Flexible laryngoscopy demonstrated left vocal fold paralysis. Given the deep retained foreign bodies, proximity to critical structures, and laryngoscopy-confirmed vocal fold immobility, selective exploratory cervicotomy was performed. Forty glass fragments were removed. Intraoperatively, left recurrent laryngeal nerve transection was identified within the tracheoesophageal groove. After debridement of nonviable nerve ends, primary repair was not feasible; direct reinnervation was performed using the superior root of the ansa cervicalis under 3× surgical loupe magnification. The postoperative course was uneventful; the patient was discharged on postoperative day 5. At the 12-month follow-up, she demonstrated sustained functional voice recovery, with improvements in maximum phonation time, acoustic parameters, and videolaryngostroboscopic findings.

CONCLUSIONS: In selected stable penetrating neck trauma cases, hard sign absence does not exclude functionally important occult neural injury. Deep wound trajectories associated with retained foreign bodies may warrant early laryngoscopy with computed tomography angiography—this assessment can guide selective exploration and enable timely nerve reconstruction when technically feasible.

Keywords: Microsurgery, Neck Injuries, Recurrent Laryngeal Nerve, Tomography, X-Ray Computed, Vocal Cord Paralysis