Infratemporal Fossa Foreign Body Using Computed Tomography
Needle-Wire Localization of an Larry J. Shemen, MD;
Lawrence S.
We report a case involving the localization and surgical removal of a traumatically introduced foreign body deep within the infratemporal fossa. Needle-hookwire placement with computed tomographic guidance allowed the precise localization and marking of the foreign body. Surgical removal under local anesthesia and without extensive exploration was, therefore, possible. The details of the localization and marking techniques are described. Needle\x=req-\ hookwire localization under computed tomographic guidance should be considered for deeply located foreign bodies in the head and neck area. (Arch Otolaryngol HeadNeck Surg. 1992;118:1337-1339) \s=b\
needle-hookwire localization of nonpalpable breast lesions using mammographie guidance has Preoperative and become
commonly employed well-accepted with procedure.13 Breast lesions haveInalso been localized computed tomography (CT).4-5 addition, CT has been a
used to localize
foreign
bodies in various locations
preoperatively.6,7 Exploratory dissection for the localization and removal of foreign bodies deep within the head and neck region can be a challenging and frustrating endeavor. The proximity of vital and delicate structures, the distortions due to the introducing injury, and the visibility of large incisions to permit wide access can present formidable problems. The retrieval of foreign bodies from the infratemporal fossa can be difficult owing to muscular and bony limitations. The zygomatic arch impedes a direct approach while the temporalis and pterygoid muscle bulk can easily conceal the sought object. Precise preoperative localization and marking of the foreign body prior to surgical removal have the potential to limit these difficulties. By affording direct and reliable access to the foreign body, the necessity for wide dissection is minimized. We present a case where CT-assisted needlehookwire techniques were used to preoperatively localize Accepted for publication June 24, 1992. From the Departments of Surgery (Drs Shemen and Godfrey) and Radiology (Dr Shemen), Booth Memorial Medical Center, Flushing, Queens, NY. Reprint requests to 233 E 69th St, New York, NY 10021 (Dr Shemen).
Schechter, MD; a
Norman
Godfrey,
MD
foreign body in the infratemporal fossa allowing for suc¬ surgical removal.
cessful
REPORT OF A CASE A 28-year-old man presented with marked trismus and pain on mastication. Two weeks before, he had been involved in an alter¬ cation at which time he was stabbed in the left infratemporal area with a pen. Anteroposterior and lateral views showed the metal nib of the pen (Fig 1). An attempt was made to remove the for¬ eign body at another institution; however, the foreign body was not recovered. On examination, there was a well-healed laceration just inferolateral to the eyebrow. The incision from the previous exploration was situated close to the entry laceration and was also well-healed. The patient had trismus to one finger breadth (1 cm), and there was fullness of the left infratemporal fossa. Plain roentgenograms demonstrated the mass deep to zygomatic arch, ad¬ jacent to the calvarium. Immediately before the repeated exploration, the patient was sent to the CT department, at which time needle-hookwire local¬ ization of the foreign body was performed. A Picker 1200 CT scanner (Picker International Ine, Highland Heights, Ohio) was employed. Contiguous 5-mm sections were obtained with the patient in the supine position. The foreign body was localized in the left infratemporal fossa abutting the skull (Fig 2, left). A Kopan's spring hook localizer needle system8 was employed. The wire was placed immediately above the zygomatic arch and advanced under CT guidance until the tip of the needle was
to the foreign body (Fig 2, right). The needle was withdrawn and the hookwire left in place. Plain roentgenograms were then obtained to confirm the position of the hookwire in relation to the pen tip (Fig 3). The patient was then sent to the operating room with the hookwire taped in place. At exploration, under local anesthesia with intravenous seda¬ tion, a vertical incision was made in the hair line above the zygoma. Sharp dissection was continued into and through the temporal muscle. The infratemporal crest was palpated and the wire identified in the upper fibers of the lateral pterygoid mus¬ cle. The wire was followed medially onto the lateral pterygoid plate at which time several large vessels were found. A blue foreign body was seen just anterior to the wire at a depth 3.5 cm from the skin surface; this foreign body was grasped with a nasal forceps. With considerable difficulty, the foreign body was released from the surrounding muscle fibers and extracted. It was the nib and a portion of the plastic, radiolucent shaft of a pen (Papermate) (Fig 4). Postoperatively, the patient's pain resolved immediately. The trismus abated, and he underwent physiotherapy to the temporomandibular joint to prevent any derangement in joint function.
adjacent
Downloaded From: http://archotol.jamanetwork.com/ by a University of Pennsylvania User on 06/15/2015
COMMENT
Analysis of the indications for the operative removal of foreign bodies in the head and neck region is beyond the scope of this article. In the present case, the patient suffered from symptoms that related more to the retained pen components than to the stab injury. In addition, the nature of the instrument made it likely that, in addition to the metal nib, there was a retained plastic reservoir with ink that would cause persistent and significant trismus and pain.
In the head and neck
region, the profusion of complex, localization by surgi¬ cal exploration alone undesirable. In particular, extensive dissection increases the risk of operative injury to vital delicate, and vital
structures makes
structures, promotes functional restriction due to postop¬ erative scar, requires more extensive anesthetic techniques, and results in greater disfigurement secondary to the larger incisions that are required. Clearly, the patient is best served when precise preoperative spatial localization permits direct and unerring access to the foreign body with only minimal dissection required to protect and avoid vi¬ tal structures. There are several methods for visualization of foreign bodies. The inherent limitations of translating fundamen¬ tally two-dimensional imaging to the operative field
sonography,9 CT,10 and stereotactic tech¬ nique.11·12 Needle localization was first employed for the identification and ultimate biopsy of nonpalpable breast oroscopy,
lesions found on mammography. Instead of using mammography, the CT scan or magnetic resonance image can be used to identify an area for biopsy.13 Needle localization with CT was employed to find a foreign body of the foot.14 In the present case, CT visualization with hookwire lo¬ calization proved invaluable and accurate, facilitating the removal of a foreign body embedded deep within the soft tissues of the infratemporal fossa. The advantages of CT over other radiologie modalities are that it provides the most information in two dimensions and, coupled with the thin sections, allows extrapolation in the third dimension. This was particularly useful in our case, where the foreign body itself was relatively small but surrounded by nu¬ merous complex and vital structures. There are several advantages for using a hookwire when exploring a mus¬ cle bed. It is the best means of transferring information from the radiology department to the operating room. In addition, it allows for precise dissection of the muscle to¬ ward the foreign body with a minimum of ensuing scar¬ ring. In most situations, CT should also give more detail of
operative removal of small foreign bodies a challenging undertaking. Imaging techniques include flumakes the
Fig 1.—Posteroanterior skull view showing metal pen nib (arrow) deep to
the zygomatic arch.
Fig 2.—Left, Transaxial computed tomographic scan illustrating metal foreign body against calvarium within muscle of the infratemporal fossa. Right, Transaxial computed tomographic scan demonstrating placement of hookwire needle immediately adjacent to the foreign body.
Fig 3.—Lateral skull view showing hookwire (arrow) immediately pos¬ terior to the metal pen nib.
Fig 4.—Photograph of specimen removed at surgery. At right, the metal
pen nib
shaft.
seen
roentgenographically. At left, the plastic, radiolucent pen
Downloaded From: http://archotol.jamanetwork.com/ by a University of Pennsylvania User on 06/15/2015
the foreign body, although it is surprising that, in our case, such was not forthcoming. The great precision and reliability of the preoperative CT imaging and needle-hookwire localization allowed opera¬ tive removal of a deep-seated foreign body from a complex anatomic site through a limited, direct surgical approach. As a result, the procedure was readily performed under local anesthesia on an ambulatory basis. Moreover, the patient enjoyed immediate relief of the pain and trismus with virtually no untoward results. References 1. Bigelow R, Smith R, Goodman PA, Wilson GS. Needle localization of nonpalpable breast masses. Arch Surg. 1985:120:565-569. 2. Meyer JE, Kopans DB, Stomper PC, Lindfors KK. Occult breast abnormalities: percutaneous pre-operative needle localization. Radiology. 1984; 150:335-337. 3. Homer MJ, Smith TJ, Marchant DJ. Outpatient needle localization and biopsy for nonpalpable breast lesions. JAMA. 1984;252:2452-2454. 4. Dixon GD. Pre-operative computed tomographic localization of breast calcifications. Radiology. 1983;146:836.
5. Jewel WR, Thomas JH, Chang CHJ. Computed tomographic mammography directed biopsy of the breast. Surg Gynecol Obstet. 1983;159:75-76. 6. Etherington RJ, Hourihan MD. Localization of intraocular and intraorbital foreign bodies using computed tomography. Clin Radiol. 1989;40:610\x=req-\
614. 7. Bissonnette RT, Connell DG,
Fitzpatrick DG. Pre-operative localization of low density foreign bodies under CT guidance. Can Assoc J Radiol. 1988; 39:286-287. 8. Kopans DB, Meyer JE. Versatile spring hookwire breast lesion localizer. AJR Am J Roentgenol. 1982;138:586-587. 9. Shiels WE, Babcock DS, Wilson JL, Burch RA. Localization and guided removal of soft tissue foreign bodies with sonography. AJR Am J Roentgenol. 1990:155:1277-1281. 10. Alford BR, Chenault DI, Danziger J. Detection of foreign bodies with computerized tomography. Arch Otolaryngol. 1979:105:203-204. 11. Hailing F, Merten HA, Dieckmann Luhr HG. Stereotactic removal of foreign bodies in the maxillofacial area. Dentomaxillofac Radiol. 1991: 20:100-104. 12. Horton CE, McFadden JT. Stereotactic localization of a facial foreign body. Plast Reconstr Surg. 1971:47:598-599. 13. Keidan RD, Solin LJ, Gatenby R, Weese JL. CT-guided needle localization for intraoperative biopsy of the head and neck. Laryngoscope. 1990:
G,
100:97-98. 14. Goldenberg RA, Goldenberg EM, Estersohn HS. Needle localization of foreign bodies using computed tomography: a case report. J Am Podiatr Med Assoc. 1988:78:629-631.
NEWS AND COMMENT ARO Midwinter Meeting.—The midwinter meeting of the Association for Re¬ search in Otolarynology (ARO) will be held at the Tradewinds Hotel, St Peters¬ burg Beach, Fla, from February 7 through 11,1993. A distingushed international panel will describe the most recent results on the functioning of sensory recep¬ tors of taste, smell, electrosense, and the auditory and vestibular systems. A fea¬ tured symposium/workshop will be held on the topic of communication with our various audiences. There is an acknowledged need for scientists to communicate their results to not only to colleagues but also to a broad audience ranging from school children to politicians. A group of experts affiliated with The Johns Hop¬ kins Center for Hearing and Balance will conduct seminars and workshops on various aspects of scientific communication. For further information, contact ARO Business Office, 431 E Locust St, Des Moines, 50309; (515) 243-1558; fax: (515) 243-2049.
Downloaded From: http://archotol.jamanetwork.com/ by a University of Pennsylvania User on 06/15/2015
Needle-Wire Localization of an Larry J. Shemen, MD;
Lawrence S.
We report a case involving the localization and surgical removal of a traumatically introduced foreign body deep within the infratemporal fossa. Needle-hookwire placement with computed tomographic guidance allowed the precise localization and marking of the foreign body. Surgical removal under local anesthesia and without extensive exploration was, therefore, possible. The details of the localization and marking techniques are described. Needle\x=req-\ hookwire localization under computed tomographic guidance should be considered for deeply located foreign bodies in the head and neck area. (Arch Otolaryngol HeadNeck Surg. 1992;118:1337-1339) \s=b\
needle-hookwire localization of nonpalpable breast lesions using mammographie guidance has Preoperative and become
commonly employed well-accepted with procedure.13 Breast lesions haveInalso been localized computed tomography (CT).4-5 addition, CT has been a
used to localize
foreign
bodies in various locations
preoperatively.6,7 Exploratory dissection for the localization and removal of foreign bodies deep within the head and neck region can be a challenging and frustrating endeavor. The proximity of vital and delicate structures, the distortions due to the introducing injury, and the visibility of large incisions to permit wide access can present formidable problems. The retrieval of foreign bodies from the infratemporal fossa can be difficult owing to muscular and bony limitations. The zygomatic arch impedes a direct approach while the temporalis and pterygoid muscle bulk can easily conceal the sought object. Precise preoperative localization and marking of the foreign body prior to surgical removal have the potential to limit these difficulties. By affording direct and reliable access to the foreign body, the necessity for wide dissection is minimized. We present a case where CT-assisted needlehookwire techniques were used to preoperatively localize Accepted for publication June 24, 1992. From the Departments of Surgery (Drs Shemen and Godfrey) and Radiology (Dr Shemen), Booth Memorial Medical Center, Flushing, Queens, NY. Reprint requests to 233 E 69th St, New York, NY 10021 (Dr Shemen).
Schechter, MD; a
Norman
Godfrey,
MD
foreign body in the infratemporal fossa allowing for suc¬ surgical removal.
cessful
REPORT OF A CASE A 28-year-old man presented with marked trismus and pain on mastication. Two weeks before, he had been involved in an alter¬ cation at which time he was stabbed in the left infratemporal area with a pen. Anteroposterior and lateral views showed the metal nib of the pen (Fig 1). An attempt was made to remove the for¬ eign body at another institution; however, the foreign body was not recovered. On examination, there was a well-healed laceration just inferolateral to the eyebrow. The incision from the previous exploration was situated close to the entry laceration and was also well-healed. The patient had trismus to one finger breadth (1 cm), and there was fullness of the left infratemporal fossa. Plain roentgenograms demonstrated the mass deep to zygomatic arch, ad¬ jacent to the calvarium. Immediately before the repeated exploration, the patient was sent to the CT department, at which time needle-hookwire local¬ ization of the foreign body was performed. A Picker 1200 CT scanner (Picker International Ine, Highland Heights, Ohio) was employed. Contiguous 5-mm sections were obtained with the patient in the supine position. The foreign body was localized in the left infratemporal fossa abutting the skull (Fig 2, left). A Kopan's spring hook localizer needle system8 was employed. The wire was placed immediately above the zygomatic arch and advanced under CT guidance until the tip of the needle was
to the foreign body (Fig 2, right). The needle was withdrawn and the hookwire left in place. Plain roentgenograms were then obtained to confirm the position of the hookwire in relation to the pen tip (Fig 3). The patient was then sent to the operating room with the hookwire taped in place. At exploration, under local anesthesia with intravenous seda¬ tion, a vertical incision was made in the hair line above the zygoma. Sharp dissection was continued into and through the temporal muscle. The infratemporal crest was palpated and the wire identified in the upper fibers of the lateral pterygoid mus¬ cle. The wire was followed medially onto the lateral pterygoid plate at which time several large vessels were found. A blue foreign body was seen just anterior to the wire at a depth 3.5 cm from the skin surface; this foreign body was grasped with a nasal forceps. With considerable difficulty, the foreign body was released from the surrounding muscle fibers and extracted. It was the nib and a portion of the plastic, radiolucent shaft of a pen (Papermate) (Fig 4). Postoperatively, the patient's pain resolved immediately. The trismus abated, and he underwent physiotherapy to the temporomandibular joint to prevent any derangement in joint function.
adjacent
Downloaded From: http://archotol.jamanetwork.com/ by a University of Pennsylvania User on 06/15/2015
COMMENT
Analysis of the indications for the operative removal of foreign bodies in the head and neck region is beyond the scope of this article. In the present case, the patient suffered from symptoms that related more to the retained pen components than to the stab injury. In addition, the nature of the instrument made it likely that, in addition to the metal nib, there was a retained plastic reservoir with ink that would cause persistent and significant trismus and pain.
In the head and neck
region, the profusion of complex, localization by surgi¬ cal exploration alone undesirable. In particular, extensive dissection increases the risk of operative injury to vital delicate, and vital
structures makes
structures, promotes functional restriction due to postop¬ erative scar, requires more extensive anesthetic techniques, and results in greater disfigurement secondary to the larger incisions that are required. Clearly, the patient is best served when precise preoperative spatial localization permits direct and unerring access to the foreign body with only minimal dissection required to protect and avoid vi¬ tal structures. There are several methods for visualization of foreign bodies. The inherent limitations of translating fundamen¬ tally two-dimensional imaging to the operative field
sonography,9 CT,10 and stereotactic tech¬ nique.11·12 Needle localization was first employed for the identification and ultimate biopsy of nonpalpable breast oroscopy,
lesions found on mammography. Instead of using mammography, the CT scan or magnetic resonance image can be used to identify an area for biopsy.13 Needle localization with CT was employed to find a foreign body of the foot.14 In the present case, CT visualization with hookwire lo¬ calization proved invaluable and accurate, facilitating the removal of a foreign body embedded deep within the soft tissues of the infratemporal fossa. The advantages of CT over other radiologie modalities are that it provides the most information in two dimensions and, coupled with the thin sections, allows extrapolation in the third dimension. This was particularly useful in our case, where the foreign body itself was relatively small but surrounded by nu¬ merous complex and vital structures. There are several advantages for using a hookwire when exploring a mus¬ cle bed. It is the best means of transferring information from the radiology department to the operating room. In addition, it allows for precise dissection of the muscle to¬ ward the foreign body with a minimum of ensuing scar¬ ring. In most situations, CT should also give more detail of
operative removal of small foreign bodies a challenging undertaking. Imaging techniques include flumakes the
Fig 1.—Posteroanterior skull view showing metal pen nib (arrow) deep to
the zygomatic arch.
Fig 2.—Left, Transaxial computed tomographic scan illustrating metal foreign body against calvarium within muscle of the infratemporal fossa. Right, Transaxial computed tomographic scan demonstrating placement of hookwire needle immediately adjacent to the foreign body.
Fig 3.—Lateral skull view showing hookwire (arrow) immediately pos¬ terior to the metal pen nib.
Fig 4.—Photograph of specimen removed at surgery. At right, the metal
pen nib
shaft.
seen
roentgenographically. At left, the plastic, radiolucent pen
Downloaded From: http://archotol.jamanetwork.com/ by a University of Pennsylvania User on 06/15/2015
the foreign body, although it is surprising that, in our case, such was not forthcoming. The great precision and reliability of the preoperative CT imaging and needle-hookwire localization allowed opera¬ tive removal of a deep-seated foreign body from a complex anatomic site through a limited, direct surgical approach. As a result, the procedure was readily performed under local anesthesia on an ambulatory basis. Moreover, the patient enjoyed immediate relief of the pain and trismus with virtually no untoward results. References 1. Bigelow R, Smith R, Goodman PA, Wilson GS. Needle localization of nonpalpable breast masses. Arch Surg. 1985:120:565-569. 2. Meyer JE, Kopans DB, Stomper PC, Lindfors KK. Occult breast abnormalities: percutaneous pre-operative needle localization. Radiology. 1984; 150:335-337. 3. Homer MJ, Smith TJ, Marchant DJ. Outpatient needle localization and biopsy for nonpalpable breast lesions. JAMA. 1984;252:2452-2454. 4. Dixon GD. Pre-operative computed tomographic localization of breast calcifications. Radiology. 1983;146:836.
5. Jewel WR, Thomas JH, Chang CHJ. Computed tomographic mammography directed biopsy of the breast. Surg Gynecol Obstet. 1983;159:75-76. 6. Etherington RJ, Hourihan MD. Localization of intraocular and intraorbital foreign bodies using computed tomography. Clin Radiol. 1989;40:610\x=req-\
614. 7. Bissonnette RT, Connell DG,
Fitzpatrick DG. Pre-operative localization of low density foreign bodies under CT guidance. Can Assoc J Radiol. 1988; 39:286-287. 8. Kopans DB, Meyer JE. Versatile spring hookwire breast lesion localizer. AJR Am J Roentgenol. 1982;138:586-587. 9. Shiels WE, Babcock DS, Wilson JL, Burch RA. Localization and guided removal of soft tissue foreign bodies with sonography. AJR Am J Roentgenol. 1990:155:1277-1281. 10. Alford BR, Chenault DI, Danziger J. Detection of foreign bodies with computerized tomography. Arch Otolaryngol. 1979:105:203-204. 11. Hailing F, Merten HA, Dieckmann Luhr HG. Stereotactic removal of foreign bodies in the maxillofacial area. Dentomaxillofac Radiol. 1991: 20:100-104. 12. Horton CE, McFadden JT. Stereotactic localization of a facial foreign body. Plast Reconstr Surg. 1971:47:598-599. 13. Keidan RD, Solin LJ, Gatenby R, Weese JL. CT-guided needle localization for intraoperative biopsy of the head and neck. Laryngoscope. 1990:
G,
100:97-98. 14. Goldenberg RA, Goldenberg EM, Estersohn HS. Needle localization of foreign bodies using computed tomography: a case report. J Am Podiatr Med Assoc. 1988:78:629-631.
NEWS AND COMMENT ARO Midwinter Meeting.—The midwinter meeting of the Association for Re¬ search in Otolarynology (ARO) will be held at the Tradewinds Hotel, St Peters¬ burg Beach, Fla, from February 7 through 11,1993. A distingushed international panel will describe the most recent results on the functioning of sensory recep¬ tors of taste, smell, electrosense, and the auditory and vestibular systems. A fea¬ tured symposium/workshop will be held on the topic of communication with our various audiences. There is an acknowledged need for scientists to communicate their results to not only to colleagues but also to a broad audience ranging from school children to politicians. A group of experts affiliated with The Johns Hop¬ kins Center for Hearing and Balance will conduct seminars and workshops on various aspects of scientific communication. For further information, contact ARO Business Office, 431 E Locust St, Des Moines, 50309; (515) 243-1558; fax: (515) 243-2049.
Downloaded From: http://archotol.jamanetwork.com/ by a University of Pennsylvania User on 06/15/2015
