Speargun injuries of the head and neck are extremely rare but potentially devastating because of the high density of vital structures in this region. Most available data derive from isolated case reports, and guidance specific to oral and maxillofacial surgeons remains limited. We report three patients with craniofacial speargun injuries managed in a maxillofacial surgery setting, illustrating three distinct scenarios with increasing complexity: an isolated sinonasal trajectory confined to the midface, an anterior cranial fossa trajectory following a submental/oral entry, and a transoral posterior fossa trajectory associated with diffuse haemorrhage and delayed neurological deterioration. Review of the literature confirms recurrent patterns in entry sites, trajectories, complications and outcomes, and supports several key principles: early airway control, systematic cross-sectional and vascular imaging, multidisciplinary planning, and anatomically driven choice between retrograde and anterograde extraction with watertight skull-base reconstruction. These concepts are crucial for maxillofacial surgeons facing these rare but high-risk injuries.
Supplementary Information: The online version contains supplementary material available at 10.1007/s10006-026-01534-8.
Keywords: Case series; Craniofacial trauma; Maxillofacial surgery; Penetrating head injury; Skull base reconstruction; Speargun injury.