Foreign body of the skull base due to transorbital penetrating trauma RON D. GOnLIEB, MD. LAWRENCE Z. MEITELES, MD, ARIE L. L1EBESKIND, MD, and CHARLES P. KIMMELMAN, MD, FACS, New York, New York
Penetrating wounds of the orbit have several outcomes. The orbital contents can be severely injured, with resulting blindness. The trajectory of the stab wound is often through the orbital apex and into the brain. Less frequently, the path of penetration may be
From the Departments of Otolaryngology-Head and Neck Surgery (Drs. Gottlieb, Kimmelman, and Meiteles) and Radiology (Dr. Llebeskind). The New York Eye and Ear Infirmary, New York Medical College. Received for publication Feb. 14, 1992; revision received Aug. 18. 1992; accepted aug. 24, 1992. Reprint requests: Charles P. Kimmelman, MD. 210 East 64th s., New York. NY 10021.
23/4/42506
inferior to the base of skull. Further complications may arise if the penetrating object becomes fragmented, because the result may be infection, foreign body granuloma, or migration of the object. We report an unusual case of a pencil stab wound through the orbit, with retention of fragments in the pterygopalatine fossa at the base of skull. The pencil fragments were retrieved by means of a transantral approach to the pterygopalatine fossa. CASE REPORT A 27-year-old man was stabbed in the left lower eyelid with a pencil-during an altercation. The patient was evaluated at the local hospital by both ophthalmology and neurosurgery services and subsequently admitted. Intravenous cephapirin and tetanus immunization were administered. The patient was
Fig. 1. Computed tomograph shows pencil fragments In left floor of orbit (straight arrow) and pterygopalatine fossa (cuNed arrow). The wood Isthe lucent area surrounding the graphite (opaque) core.
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Volume 107 Number 6 Part1 December 1992
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Fig. 3. Radlodenslly of air. graphite. tissue. wood. and bone measured In Hounsfleld units.
then transferred to The New York Eye and Ear Infirmary for further treatment. On physical examination, the patient was afebrile, alert, and oriented. There was a stellate wound of the left lower eyelid, with surrounding edema and a palpable foreign body. Visual acuity testing revealed 20/20 vision bilaterally. Extraocular muscles were intact. The pupils were
equally round and reactive to light. The conjunctiva. cornea, and anterior chambers were normal bilaterally. Ophthalmoscopy was within normal limits. The patient reported had left maxillary cutaneous anesthesia. All other cranial nerves were intact. The patient was admitted to the ophthalmology service and
OtolaryngologyHead and Neck Surgery
802 Case Reports
administered intravenous cefazolin. Computed tomography (CT) of the head revealed a foreign body in the inferior left orbit and the pterygopalatine fossa (Fig. 1). The pencil appeared to have traversed the inferior orbital fissure. No intracranial pathology was noted. The ophthalmology service brought the patient to the operating room, explored the orbit, and removed a 4.0 em fragment of pencil from the floor of the orbit. It was noted that the distal end of the pencil was severed. Otolaryngology consultation was obtained. A magnetic resonance imaging (MRI) scan revealed an area of hypodensity in the pterygopalatine fossa. Because of the possibility of infection resulting from a contaminated wound, the patient underwent a transantral ex, ploration of the left pterygopalatine fossa. Numerous pencil fragments were visualized in the fossa (Fig. 2) and removed. Bacterial culture and sensitivity of the fragments and wound were obtained. After an inferior meatal antrostomy, the patient was returned to the recovery room. The postoperative course was without complications. Bacterial cultures revealed coagulase negative Staphylococcus aureus sensitive to cephalothin. The patient was discharged after administration of intravenous cefazolin for 16 days. At 1 month postoperatively, there were no sequelae, excluding persistent anesthesia of the left cheek. The patient has since been lost to followup.
DISCUSSION Transorbital penetrating stab wounds involving the base of the skull have been reported, 1·6 and intracranial occult foreign bodies must be considered. Objects entering the orbit are directed to the apex because of its funnel-like shape. The thin, orbital roof, which becomes accessible when the head is thrown back reflexively, can also be the point of egress." In such injuries, it is not unusual for only the superficial wound to be recognized. Only when the neurologic status deteriorates is there a search for an occult foreign body, such as the tip of an arrow, umbrella, antenna, or pencil.v" Internal carotid artery injuries have also resulted from transorbital penetrating wounds; accordingly, angiography should be considered in the initial evaluation. 10.11 CT is a useful modality in diagnosis of retained pencil fragments, as illustrated in this case. In Fig. I, the lucency around the opacified foreign body is, in fact, the wood that surrounds the graphite core. Figure 3 illustrates the radiodensities of various structures im-: aged by the Siemens Somatom CR CT scanner. The measured density of the air in the right maxillary sinus was -1022 Hounsfield units (HU). In contrast, the lucent area around the graphite core-was - 539 HU. The dense graphite core measured + 235 HU. As illustrated by this case, wood can be confused with free air. However, the difference in radiodensities confirms the diagnosis of wood, rather than free air, retained as a foreign body.
MR! has been used to detect intraorbital wood. 13 In this case, the pencil fragments were not delineated by MR!. MRI is contraindicated when a metallic foreign body is suspected within the orbit. The magnetic fields generated can induce motion of a ferromagnetic object, which may result in injury to intraocular contents. 14 The strong possibility of infection resulting from the retained pencil fragments was paramount in the decision to retrieve the foreign body. Wood, with its organic and porous nature, provides a nidus for bacterial infections. Orbitocranial wounds with retained wooden fragments have been shown to result in significant infectious morbidity. IS Bursick et aI. 7 reviewed the literature dating back to 1848 and found 21 cases of intracranial injuries from pencils. In 77% of the cases from the antibiotic era, infectious complications developed, despite the use of antibiotics. These cases illustrate the need for removal of the retained pencil fragments, as well as the administration of intravenous antibiotics. Tetanus immunization is imperative in these types of injuries. REFERENCES
I. Hanis AM, Wood RE, Nortje CI, Grotepass F. Deliberately
2. 3. 4. 5.
6. 7. 8. 9. 10. 11. 12. 13. 14. 15.
inflected, penetrating injuriesof the maxillofacial region (Jael's syndrome). I Craniomaxillofac Surg 1988;16:60-3. Hickman OM. Benignsequelaeof a transorbital stab wound: an unusual case report. Ann Plast Surg 1984;12:279-83. van Dellen JR, Lipschitz R. Stab wounds of the skull. Surg Neurol 1978;10:110-4. Sykes PI. An unusual penetrating injury of the cheek: a case report. Injury 1973;4:347-9. Lydiatt DO, Hollins RR, Moyer 01, Oavis LF. Problems in evaluation of penetrating foreign bodies with computed tomography scans: report of cases. I Oral Maxillofac Surg 1987;45: 965-8. MezueWC, SaddeqiN, Ude A. Barbedspear injury to the skull base; case report. Neurosurgery 1991;28:428-30. BursickOM, SellerRG. Intracranial pencilinjuries.Surg Neurol 1981;16:427-31. IrwinGE, TilelliJ. Unrecognized penetrating intracranial foreign body. Am J Emerg Med 1986;4:412-3. Sebag J, Shillito J, Robb R. Transorbital penetrating injuries to the frontal lobe. Ophthalmic Surg 1986;17:631-4. Carothers A. Orbitofacial wounds and cerebral artery injuries caused by umbrellatips. JAMA 1978;239:1151-2. Vander JF, NelsonCC. Penetrating orbitalinjurywithcavernous sinus involvement. Ophthalmic Surg 1988;19:328·30. Hansen JE, Gudeman SK, Holgate RC, Saunders RA. Penetrating intracranial wood wounds: clinical limitations of computerized tomography. J Neurosurg 1988;68:752-6. Green BF, Kraft SP, Carter KO, Buncic JR, Nerad JA, Armstrong O. Intraorbital wood: detection by magnetic resonance imaging. Ophthalmology 1990;97:608·1 I. Kelly WM, Paglen PO, Pearson JA, San Diego AG, Soloman MA. Ferromagnetism of intraocular foreignbody causes unilateral blindness after MR study. AJNR 1986;7:243-5. Miller CF, BrodkeyJS, ColombiBJ. The dangerof intracranial wood. Surg Neurol 1977;7:95-103. .
Penetrating wounds of the orbit have several outcomes. The orbital contents can be severely injured, with resulting blindness. The trajectory of the stab wound is often through the orbital apex and into the brain. Less frequently, the path of penetration may be
From the Departments of Otolaryngology-Head and Neck Surgery (Drs. Gottlieb, Kimmelman, and Meiteles) and Radiology (Dr. Llebeskind). The New York Eye and Ear Infirmary, New York Medical College. Received for publication Feb. 14, 1992; revision received Aug. 18. 1992; accepted aug. 24, 1992. Reprint requests: Charles P. Kimmelman, MD. 210 East 64th s., New York. NY 10021.
23/4/42506
inferior to the base of skull. Further complications may arise if the penetrating object becomes fragmented, because the result may be infection, foreign body granuloma, or migration of the object. We report an unusual case of a pencil stab wound through the orbit, with retention of fragments in the pterygopalatine fossa at the base of skull. The pencil fragments were retrieved by means of a transantral approach to the pterygopalatine fossa. CASE REPORT A 27-year-old man was stabbed in the left lower eyelid with a pencil-during an altercation. The patient was evaluated at the local hospital by both ophthalmology and neurosurgery services and subsequently admitted. Intravenous cephapirin and tetanus immunization were administered. The patient was
Fig. 1. Computed tomograph shows pencil fragments In left floor of orbit (straight arrow) and pterygopalatine fossa (cuNed arrow). The wood Isthe lucent area surrounding the graphite (opaque) core.
800
Volume 107 Number 6 Part1 December 1992
Case Reports 801
Fig. 3. Radlodenslly of air. graphite. tissue. wood. and bone measured In Hounsfleld units.
then transferred to The New York Eye and Ear Infirmary for further treatment. On physical examination, the patient was afebrile, alert, and oriented. There was a stellate wound of the left lower eyelid, with surrounding edema and a palpable foreign body. Visual acuity testing revealed 20/20 vision bilaterally. Extraocular muscles were intact. The pupils were
equally round and reactive to light. The conjunctiva. cornea, and anterior chambers were normal bilaterally. Ophthalmoscopy was within normal limits. The patient reported had left maxillary cutaneous anesthesia. All other cranial nerves were intact. The patient was admitted to the ophthalmology service and
OtolaryngologyHead and Neck Surgery
802 Case Reports
administered intravenous cefazolin. Computed tomography (CT) of the head revealed a foreign body in the inferior left orbit and the pterygopalatine fossa (Fig. 1). The pencil appeared to have traversed the inferior orbital fissure. No intracranial pathology was noted. The ophthalmology service brought the patient to the operating room, explored the orbit, and removed a 4.0 em fragment of pencil from the floor of the orbit. It was noted that the distal end of the pencil was severed. Otolaryngology consultation was obtained. A magnetic resonance imaging (MRI) scan revealed an area of hypodensity in the pterygopalatine fossa. Because of the possibility of infection resulting from a contaminated wound, the patient underwent a transantral ex, ploration of the left pterygopalatine fossa. Numerous pencil fragments were visualized in the fossa (Fig. 2) and removed. Bacterial culture and sensitivity of the fragments and wound were obtained. After an inferior meatal antrostomy, the patient was returned to the recovery room. The postoperative course was without complications. Bacterial cultures revealed coagulase negative Staphylococcus aureus sensitive to cephalothin. The patient was discharged after administration of intravenous cefazolin for 16 days. At 1 month postoperatively, there were no sequelae, excluding persistent anesthesia of the left cheek. The patient has since been lost to followup.
DISCUSSION Transorbital penetrating stab wounds involving the base of the skull have been reported, 1·6 and intracranial occult foreign bodies must be considered. Objects entering the orbit are directed to the apex because of its funnel-like shape. The thin, orbital roof, which becomes accessible when the head is thrown back reflexively, can also be the point of egress." In such injuries, it is not unusual for only the superficial wound to be recognized. Only when the neurologic status deteriorates is there a search for an occult foreign body, such as the tip of an arrow, umbrella, antenna, or pencil.v" Internal carotid artery injuries have also resulted from transorbital penetrating wounds; accordingly, angiography should be considered in the initial evaluation. 10.11 CT is a useful modality in diagnosis of retained pencil fragments, as illustrated in this case. In Fig. I, the lucency around the opacified foreign body is, in fact, the wood that surrounds the graphite core. Figure 3 illustrates the radiodensities of various structures im-: aged by the Siemens Somatom CR CT scanner. The measured density of the air in the right maxillary sinus was -1022 Hounsfield units (HU). In contrast, the lucent area around the graphite core-was - 539 HU. The dense graphite core measured + 235 HU. As illustrated by this case, wood can be confused with free air. However, the difference in radiodensities confirms the diagnosis of wood, rather than free air, retained as a foreign body.
MR! has been used to detect intraorbital wood. 13 In this case, the pencil fragments were not delineated by MR!. MRI is contraindicated when a metallic foreign body is suspected within the orbit. The magnetic fields generated can induce motion of a ferromagnetic object, which may result in injury to intraocular contents. 14 The strong possibility of infection resulting from the retained pencil fragments was paramount in the decision to retrieve the foreign body. Wood, with its organic and porous nature, provides a nidus for bacterial infections. Orbitocranial wounds with retained wooden fragments have been shown to result in significant infectious morbidity. IS Bursick et aI. 7 reviewed the literature dating back to 1848 and found 21 cases of intracranial injuries from pencils. In 77% of the cases from the antibiotic era, infectious complications developed, despite the use of antibiotics. These cases illustrate the need for removal of the retained pencil fragments, as well as the administration of intravenous antibiotics. Tetanus immunization is imperative in these types of injuries. REFERENCES
I. Hanis AM, Wood RE, Nortje CI, Grotepass F. Deliberately
2. 3. 4. 5.
6. 7. 8. 9. 10. 11. 12. 13. 14. 15.
inflected, penetrating injuriesof the maxillofacial region (Jael's syndrome). I Craniomaxillofac Surg 1988;16:60-3. Hickman OM. Benignsequelaeof a transorbital stab wound: an unusual case report. Ann Plast Surg 1984;12:279-83. van Dellen JR, Lipschitz R. Stab wounds of the skull. Surg Neurol 1978;10:110-4. Sykes PI. An unusual penetrating injury of the cheek: a case report. Injury 1973;4:347-9. Lydiatt DO, Hollins RR, Moyer 01, Oavis LF. Problems in evaluation of penetrating foreign bodies with computed tomography scans: report of cases. I Oral Maxillofac Surg 1987;45: 965-8. MezueWC, SaddeqiN, Ude A. Barbedspear injury to the skull base; case report. Neurosurgery 1991;28:428-30. BursickOM, SellerRG. Intracranial pencilinjuries.Surg Neurol 1981;16:427-31. IrwinGE, TilelliJ. Unrecognized penetrating intracranial foreign body. Am J Emerg Med 1986;4:412-3. Sebag J, Shillito J, Robb R. Transorbital penetrating injuries to the frontal lobe. Ophthalmic Surg 1986;17:631-4. Carothers A. Orbitofacial wounds and cerebral artery injuries caused by umbrellatips. JAMA 1978;239:1151-2. Vander JF, NelsonCC. Penetrating orbitalinjurywithcavernous sinus involvement. Ophthalmic Surg 1988;19:328·30. Hansen JE, Gudeman SK, Holgate RC, Saunders RA. Penetrating intracranial wood wounds: clinical limitations of computerized tomography. J Neurosurg 1988;68:752-6. Green BF, Kraft SP, Carter KO, Buncic JR, Nerad JA, Armstrong O. Intraorbital wood: detection by magnetic resonance imaging. Ophthalmology 1990;97:608·1 I. Kelly WM, Paglen PO, Pearson JA, San Diego AG, Soloman MA. Ferromagnetism of intraocular foreignbody causes unilateral blindness after MR study. AJNR 1986;7:243-5. Miller CF, BrodkeyJS, ColombiBJ. The dangerof intracranial wood. Surg Neurol 1977;7:95-103. .
