Cervical impalement injury by a firework whistle: a rare case of airway obstruction, facial nerve paralysis, and extensive subcutaneous emphysema induced by thermal and combustion effects

• Firework whistle-related injuries are exceptionally rare. • Thermal and gas-related damage can occur after firework-related injuries. • Chemical reactions generating carbon dioxide can cause emphysematous changes. Firework-related burn injuries are common worldwide and vary widely in mechanism and severity. Airway injuries caused by intraoral ignition are well documented. In contrast, impaling firework injuries with ongoing subcutaneous combustion and extensive emphysema in the absence of any obvious mucosal damage are extremely rare. We present the case of a patient with an extremely rare burn injury caused by a subsidiary firework whistle. The device impaled the neck through the left submental region and continued to burn the left cervical area, leading to a constellation of complications, including a marginal mandibular branch facial nerve palsy, upper airway obstruction secondary to arytenoid edema, and extensive subcutaneous emphysema. Tracheal intubation was successfully avoided by prompt fiberoptic laryngoscopic examination after the patient experienced worsening hoarseness, and early administration of intravenous corticosteroids. Subsequent microsurgical repair of the facial nerve yielded favorable functional outcomes. The widespread subcutaneous emphysema was potentially associated with sustained combustion of the entrapped firework, which generated carbon dioxide through ongoing chemical reactions. This case underscores the importance of not only recognizing thermal injuries when firework-related injuries occur, but also the possibility of gas-related tissue complications that can arise from the chemical properties of fireworks. Clinicians managing firework-associated burns should maintain a high level of suspicion for emphysematous changes induced by these reactions, particularly after impaling injuries with retained combustive elements.