The Journal of Craniofacial Surgery • Volume 25, Number 4, July 2014
FIGURE 1. The photograph before (left, A and C) and 7 days after (right, B and D) porous polyethylene implantation and orbital zygomatic fracture reduction.
cases of traumatic enophthalmos. This often needs screw fixation to ensure the accurate position and to avoid implant displacement or protrusion. In mild enophthalmos cases, a single layer of porous polyethylene implantation with or without screw fixation is sufficient. In severe enophthalmos cases, individually customized multiple layers of porous polyethylene implantation with screw fixation are used (Fig. 2). Sometimes, it might seem necessary to place one of the screws on the internal orbital wall to get stronger fixation; this method is used in the clinic and is reported.4,5 In this case, the first mircoscrew was placed on the rim. To get a biomechanically stronger fixation, the second mircoscrew was placed on the medial anterolateral wall where it was supposed to be firm enough to hold it. However, the mircoscrew entered into the maxillary sinus
FIGURE 2. Individually customized multiple layers of porous polyethylene implant with screw fixation for traumatic enophthalmos. A–C, Multiple layers of porous polyethylene implant designed to elevate the eyeball in both vertical and sagittal directions. D–E, Multiple layers of porous polyethylene implant placed behind the axis of the eyeball to elevate it in vertical direction. A, Three layers of porous polyethylene implant are fixed together with sutures. B, The implant is fixed with 3 microscrews on the orbital rim. C, Sagittal view of the implant. D, The implant is fixed with 2 microplates and 4 microscrews. E, Sagittal view of the implant.
Brief Clinical Studies
during fixation. The possible causes of this incident are, first, the mircoscrew was placed just 3 mm away from the border of the inferior wall defect and, second, it was tried to be fixed without predrilling because microscrews are self-tapping. Thus, here, we present several points to avoid iatrogenic damage during rigid fixation of the porous polyethylene implant in enophthalmos correction. First, the orbital rim is the safest zone to lay the screw. The internal orbital wall is very fragile, it is especially brittle in those cases because of the existent orbital wall fracture. We could easily cause the orbital wall fracture if a screw is placed on it without caution. Second, if the screw placement on the internal orbital wall cannot be avoided, we should locate the screw away from the wall defect and as anterior as possible at the anterior third of the wall for it is thicker. Third, a pilot hole should be drilled even for the self-tapping screw. Because we have to put extra pressure on the self-tapping screw without predrilling, it would increase the risk of the damage of internal orbital wall. Fourth, the length of the microscrew located in the internal orbital wall should be 3 mm to catch the bone without entering the sinus. Fifth, A microdrill guide should be used regularly for a new hand to avoid an oversized hole. Similar situation also exists in other maxillofacial surgeries. There is a report about accident entry of the screw into the sphenoid sinus during paranasal augmentation.6 In fact, we have to avoid placing the screw on all the thin bones such as the internal orbital wall, frontal sinus, and anterior maxillary wall if possible. When the internal fixation of those areas is aimed, microscrew and microplate with predrilling for the self-tapping screw by meticulous manipulation are recommended.
REFERENCES 1. Lang W. Traumatic enophthalmos with retention of perfect acuity of vision. Trans Ophthalmol Soc UK 1889;9:41–45 2. Manson PN, Clifford CM, Su CT, et al. Mechanisms of global support and post-traumatic enophthalmos: I. the anatomy of the ligament sling and its relation to intramuscular cone orbital fat. Plast Reconstr Surg 1985;77:193–202 3. Clauser L, Galiè M, Pagliaro F, et al. Posttraumatic enophthalmos: etiology, principles of reconstruction, and correction. J Craniofac Surg 2008;19:351–359 4. Glassman RD, Manson PN, Vanderkolk CA, et al. Rigid fixation of internal orbital fractures. Plast Reconstr Surg 1990;86:1103–1109; discussion 1110–1111. 5. Burm JS. Internal fixation in trapdoor-type orbital blowout fracture. Plast Reconstr Surg 2005;116:962–970 6. Tang XJ, Zhang ZY, Shi L, et al. Accident entry of titanium screw into the sphenoid sinus during paranasal augmentation with porous polyethylene implant. J Craniofac Surg 2012;23:e394–e396
Removal of Orbital-Maxillary Sinus-Pterygopalatine Fossa Foreign Body With External and Endoscopic Combined Approach Xiaoshan Wu, MD, DDS,* Aifang Li, DDS,* Jia Tan, MD, PhD,† Xinrong Ou, MD, DDS* Abstract: Craniofacial trauma involving the pterygopalatine fossa region is reported to be rare. We present a case of a foreign body involving
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
1547
The Journal of Craniofacial Surgery • Volume 25, Number 4, July 2014
Brief Clinical Studies
the orbit, maxillary sinus, and pterygopalatine fossa in a 4-year-old boy. The object was a reed shaft. Three-dimensional computed tomographic scans and magnetic resonance imaging were done to make a correct diagnosis and to apply the best surgical treatment. The Caldwell-Luc approach combined with endoscopic approach was applied to remove all the fragments of the foreign body, which had been decayed in the human body. One month later, the patient showed satisfactory aesthetic and functional results. Key Words: Pterygopalatine fossa, foreign body, endoscopic
F
oreign bodies of the maxillary sinus sometimes can be seen in dental surgeries. Dental implants or tooth roots can migrate into the sinus during the operation.1–3 However, a foreign body extending from the orbit-sinus into the pterygopalatine fossa is reported to be rare and few reports exist in the English literature. The foreign bodies in the orbit-sinus and nearby regions can cause severe complications such as partially purulent infection, sinusitis, and blindness.4–6 The Caldwell-Luc (C-L) approach or the lateral window approach, or endoscopic surgery has been reported to remove the foreign bodies in the maxillary sinus.1–3 However, for the foreign body in the pterygopalatine fossa region, the surgery has to overcome the anatomic problems related to the difficulty of access. Inappropriate removal may cause severe hemorrhage.7 In this clinical case, we successfully removed an orbital-maxillary sinus-pterygopalatine fossa foreign body using the C-L approach combined with the endoscopic approach.8
CLINICAL REPORT A 4-year-old boy presented to the oral and maxillofacial department because of infraorbital region swelling and suppuration of 8 days in duration after a reed shaft plunged into his orbit. Immediately after the trauma, he was sent to the nearby local hospital and the surgeons extracted the outside part of the stick. A few days after the surgery, however, the wound did not heal but turned swollen and suppurated. After computed tomographic (CT) examination, the retained (inside) part of the stick was found. To get a better treatment, his family turned to us and the boy was hospitalized. The clinical examination showed a discharging wound in the right palpebra inferior and periorbital swelling. There was no limitation of ocular motility as well as no obvious displacement of the left eye and of the orbital soft tissues. The remainder of the physical examination was unremarkable. The patient’s vital signs were as follows: blood pressure, 86/59 mm Hg; heart rate, 90 beats per minute; and temperature, 37.2°C. The white blood cell count was 18.4 109/L, the neutrophile granulocyte was 14.9 109/L, and the creatine kinase was 1330.2 U/L. The sagittal and transverse plain views of CT showed that the left part of the hollow reed shaft went almost beyond the orbit, penetrated through the superior maxillary sinus, and extended into the pterygopalatine fossa (Figs. 1A, B). After the three-dimensional From the Departments of *Oral and Maxillofacial Surgery, and †Ophthalmology, Xiangya Hospital, Central South University, Hunan, China. Received January 14, 2014. Accepted for publication February 1, 2014. Address correspondence and reprint requests to Xingrong Ou, MD, DDS, Department of Oral and Maxillofacial Surgery, Xiangya Hospital, Central South University Changsha, Xiangya Road #87, Hunan 410008, China; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000848
1548
FIGURE 1. A, Presurgical sagittal CT scan. B, Presurgical transverse CT scan. C, Presurgical three-dimensional reconstruction of the orbit from CT scans; the yellow arrow points to the elevated inferior orbit wall. D, Presurgical sagittal MRI.
reconstruction, we found that it was the inferior orbital fissure where the shaft penetrated and that the inferior orbit wall was elevated (Fig. 1C). The sagittal magnetic resonance imaging (MRI) showed the contour more clearly (Fig. 1D). A combined approach, image-guided endoscopic and C-L operation, was used to remove the foreign body. The endoscope was inserted directly into the wound tunnel. In the meantime, the C-L operation was done, which included sublabial antrostomy opening as well as radical removal of all antral mucosa and an inferior meatal window. A forcep was inserted into the window, clamped the pieces of the foreign body in the superior maxillary sinus, and pulled them toward into the orbit. With the combined approach, almost all the pieces of the foreign body were found and took out (Fig. 2). The postsurgical examination after 1 month showed satisfactory aesthetic and functional results (Fig. 3).
DISCUSSION Orbital-sinus foreign bodies were sometimes reported previously.4–6 However, the pterygopalatine fossa foreign body can hardly be found in the English literature. Most of these injury cases have a history of facial trauma. However, history alone is not sufficient to rule out a retained foreign body. Early MRI or CT scan is necessary for the evaluation of the extent of injury.4 In this case, the first attempt to extract the foreign body was done right after the trauma. However, both the parents and the local physicians did not realize that what they
FIGURE 2. Pieces of the foreign body.
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 25, Number 4, July 2014
FIGURE 3. Postsurgical frontal view after 1 month.
Brief Clinical Studies
Surgical Therapy of a Vertebral Artery Aneurysm With Saccular and Fusiform Segments Tevfik Yilmaz, MD, Yahya Turan, MD, Adnan Ceviz, MD
extracted was only a part of the foreign body, not the whole. The retained part was not found until the CT scan and MRI were done. In the presurgical evaluation, the nature of the foreign body plays an important role. A different nature of the foreign body requires different imaging equipments. Mostly, CT scan can satisfy most cases. However, CT scan hardly identifies wooden or herbaceous objects when the object has penetrated the face. Compared with CT scans, MRI allows to better study the foreign objects with low density such as wooden bodies.6 In this case, the reed shaft showed a very low signal in CT scan but showed a clear contour in MRI. On the other hand, a soft or crisp foreign body increases the difficulty of the surgery. After a certain time that they are retained in a human body, the foreign bodies may decay and disintegrate. It requires good visualization and access to the deep bottom of the tunnel in the surgery. In this case, what we took out in the surgery were actually the fragments of the decayed reed shaft. Because these foreign bodies may cause severe orbital infection and threaten the patient’s vision, surgical removal is necessary. It is often difficult to do surgeries in the pterygomaxillary region because of a limited surgical access and nearby critical vascular and neurologic structures. Traditionally, the lateral or inferolateral approach, in which the parotid gland, facial nerve, and zygomatic arch are all involved, is often selected to gain the access.7 For the surgery of taking out a foreign body, these methods seem inefficient and macrotraumatic. In this case, we selected external and endoscopic combined approach. Endoscopic surgery provided good visualization and access. It ensured that all the fragments could be taken out in visual range. The C-L operation in this case helped to locate and remove the foreign body, and all antral mucosa was removed because of the maxillary sinusitis.8 This combined approach proves to be safe and effective for extraction of the foreign bodies that extend deeply into the maxillary sinus and pterygopalatine fossa.
REFERENCES 1. Ramotar H, Jaberoo MC, Koo Ng NK, et al. Image-guided, endoscopic removal of migrated titanium dental implants from maxillary sinus: two cases. J Laryngol Otol 2010;124:433–436 2. Costa F, Robiony M, Toro C, et al. Endoscopically assisted procedure for removal of a foreign body from the maxillary sinus and contemporary endodontic surgical treatment of the tooth. Head Face Med 2006;2:37 3. Sohn DS, Jung HS, Kim KH, et al. Removal of displaced foreign body from the maxillary sinus using replaceable bony windows and saline irrigation, followed by suctioning of the foreign body. Implant Dent 2011;20:112–127 4. Kwiatkowski TJ, Magardino TM, Austin M. Management of orbital-sinus foreign bodies. J Craniomaxillofac Trauma 1998;4:24–29 5. Samaha M, Manoukian JJ, Arthurs B. Sino-orbital foreign body in a child. Int J Pediatr Otorhinolaryngol 2000;52:189–192 6. Gasparini G, Brunelli A, Rivaroli A, et al. Maxillofacial traumas. J Craniofac Surg 2002;13:645–649 7. Jian XC, Wang CX, Jiang CH. Surgical management of primary and secondary tumors in the pterygopalatine fossa. Otolaryngol Head Neck Surg 2005;132:90–94 8. Ikeda K, Hirano K, Oshima T, et al. Comparison of complications between endoscopic sinus surgery and Caldwell-Luc operation. Tohoku J Exp Med 1996;180:27–31
Abstract: Vertebral artery aneurysms form a group of aneurysms having high rates of rebleeding, morbidity, and mortality, poor treatment outcomes, as well as low rate of surgical treatment. Examinations for subarachnoid bleeding revealed a vertebral artery aneurysm with a diameter of 12 mm in a 67-year-old man who presented with headache. The vertebral artery aneurysm with saccular and fusiform segments was shrunk and clipped via lateral left suboccipital approach. No neurologic deficit was present at the postoperative period. Control digital subtraction angiography showed complete shrinkage of aneurysm with continued blood flow and no residue. Clinical findings, treatments, and surgical approaches of VA aneurysms are different from anterior and posterior circulation aneurysms. Microneurosurgical clipping is the most effective treatment of vertebral artery aneurysms in suitable cases. Although endovascular intervention is commonly applied as therapeutic modality for patients with vertebral artery aneurysm, researchers have also emphasized that saccular vertebral aneurysms with fusiform extension can also be surgically treated in suitable cases. Key Words: Subarachnoid hemorrhage, vertebral artery, saccular fusiform cranial aneurysm
P
osterior circulation aneurysms (PCAs) are risky vascular pathologies with high rebleeding rate and poor treatment outcomes.1 This region has a more complex anatomy compared with other brain regions. Their rare occurrence and low rate of surgical treatment increase the complexity of these lesions. Aneurysms of the vertebrobasilar system account for approximately 3.8% to 15% of all intracranial aneurysms.1 Among them, basilar bifurcation aneurysms are the most common subtype, making up almost half of such aneurysms. It is followed by aneurysms originating from vertebral artery (VA), posterior inferior cerebellar artery (PICA), superior cerebellar artery and anterior inferior cerebellar artery origin, posterior cerebral artery, and vertebrobasilar junction.2,3 Vertebral artery aneuryms in PCA are rarer but have a high morbidity and mortality (21.7% and 8.7%, respectively).1 Sudden loss of consciousness is invariably present in PCAs, and headache is localized to the occipital region. Focal deficits such as monoparesia, lower extremity dysesthesia, oculomotor dysfunction, abducent nerve paralysis, and dysarthria are observed at a rate of 35% to 50%.4 Posterior circulation aneurysms have a mortality rate of 90% within From the Department of Neurosurgery, Faculty of Medicine, Dicle University, Diyarbakir, Turkey. Received January 4, 2014. Accepted for publication February 1, 2014. Address correspondence and reprint requests to Tevfik Yilmaz, MD, Department of Neurosurgery, Faculty of Medicine, Dicle University, Yeniþehir 21280 Diyarbakir, Turkey; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000854
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
1549
FIGURE 1. The photograph before (left, A and C) and 7 days after (right, B and D) porous polyethylene implantation and orbital zygomatic fracture reduction.
cases of traumatic enophthalmos. This often needs screw fixation to ensure the accurate position and to avoid implant displacement or protrusion. In mild enophthalmos cases, a single layer of porous polyethylene implantation with or without screw fixation is sufficient. In severe enophthalmos cases, individually customized multiple layers of porous polyethylene implantation with screw fixation are used (Fig. 2). Sometimes, it might seem necessary to place one of the screws on the internal orbital wall to get stronger fixation; this method is used in the clinic and is reported.4,5 In this case, the first mircoscrew was placed on the rim. To get a biomechanically stronger fixation, the second mircoscrew was placed on the medial anterolateral wall where it was supposed to be firm enough to hold it. However, the mircoscrew entered into the maxillary sinus
FIGURE 2. Individually customized multiple layers of porous polyethylene implant with screw fixation for traumatic enophthalmos. A–C, Multiple layers of porous polyethylene implant designed to elevate the eyeball in both vertical and sagittal directions. D–E, Multiple layers of porous polyethylene implant placed behind the axis of the eyeball to elevate it in vertical direction. A, Three layers of porous polyethylene implant are fixed together with sutures. B, The implant is fixed with 3 microscrews on the orbital rim. C, Sagittal view of the implant. D, The implant is fixed with 2 microplates and 4 microscrews. E, Sagittal view of the implant.
Brief Clinical Studies
during fixation. The possible causes of this incident are, first, the mircoscrew was placed just 3 mm away from the border of the inferior wall defect and, second, it was tried to be fixed without predrilling because microscrews are self-tapping. Thus, here, we present several points to avoid iatrogenic damage during rigid fixation of the porous polyethylene implant in enophthalmos correction. First, the orbital rim is the safest zone to lay the screw. The internal orbital wall is very fragile, it is especially brittle in those cases because of the existent orbital wall fracture. We could easily cause the orbital wall fracture if a screw is placed on it without caution. Second, if the screw placement on the internal orbital wall cannot be avoided, we should locate the screw away from the wall defect and as anterior as possible at the anterior third of the wall for it is thicker. Third, a pilot hole should be drilled even for the self-tapping screw. Because we have to put extra pressure on the self-tapping screw without predrilling, it would increase the risk of the damage of internal orbital wall. Fourth, the length of the microscrew located in the internal orbital wall should be 3 mm to catch the bone without entering the sinus. Fifth, A microdrill guide should be used regularly for a new hand to avoid an oversized hole. Similar situation also exists in other maxillofacial surgeries. There is a report about accident entry of the screw into the sphenoid sinus during paranasal augmentation.6 In fact, we have to avoid placing the screw on all the thin bones such as the internal orbital wall, frontal sinus, and anterior maxillary wall if possible. When the internal fixation of those areas is aimed, microscrew and microplate with predrilling for the self-tapping screw by meticulous manipulation are recommended.
REFERENCES 1. Lang W. Traumatic enophthalmos with retention of perfect acuity of vision. Trans Ophthalmol Soc UK 1889;9:41–45 2. Manson PN, Clifford CM, Su CT, et al. Mechanisms of global support and post-traumatic enophthalmos: I. the anatomy of the ligament sling and its relation to intramuscular cone orbital fat. Plast Reconstr Surg 1985;77:193–202 3. Clauser L, Galiè M, Pagliaro F, et al. Posttraumatic enophthalmos: etiology, principles of reconstruction, and correction. J Craniofac Surg 2008;19:351–359 4. Glassman RD, Manson PN, Vanderkolk CA, et al. Rigid fixation of internal orbital fractures. Plast Reconstr Surg 1990;86:1103–1109; discussion 1110–1111. 5. Burm JS. Internal fixation in trapdoor-type orbital blowout fracture. Plast Reconstr Surg 2005;116:962–970 6. Tang XJ, Zhang ZY, Shi L, et al. Accident entry of titanium screw into the sphenoid sinus during paranasal augmentation with porous polyethylene implant. J Craniofac Surg 2012;23:e394–e396
Removal of Orbital-Maxillary Sinus-Pterygopalatine Fossa Foreign Body With External and Endoscopic Combined Approach Xiaoshan Wu, MD, DDS,* Aifang Li, DDS,* Jia Tan, MD, PhD,† Xinrong Ou, MD, DDS* Abstract: Craniofacial trauma involving the pterygopalatine fossa region is reported to be rare. We present a case of a foreign body involving
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
1547
The Journal of Craniofacial Surgery • Volume 25, Number 4, July 2014
Brief Clinical Studies
the orbit, maxillary sinus, and pterygopalatine fossa in a 4-year-old boy. The object was a reed shaft. Three-dimensional computed tomographic scans and magnetic resonance imaging were done to make a correct diagnosis and to apply the best surgical treatment. The Caldwell-Luc approach combined with endoscopic approach was applied to remove all the fragments of the foreign body, which had been decayed in the human body. One month later, the patient showed satisfactory aesthetic and functional results. Key Words: Pterygopalatine fossa, foreign body, endoscopic
F
oreign bodies of the maxillary sinus sometimes can be seen in dental surgeries. Dental implants or tooth roots can migrate into the sinus during the operation.1–3 However, a foreign body extending from the orbit-sinus into the pterygopalatine fossa is reported to be rare and few reports exist in the English literature. The foreign bodies in the orbit-sinus and nearby regions can cause severe complications such as partially purulent infection, sinusitis, and blindness.4–6 The Caldwell-Luc (C-L) approach or the lateral window approach, or endoscopic surgery has been reported to remove the foreign bodies in the maxillary sinus.1–3 However, for the foreign body in the pterygopalatine fossa region, the surgery has to overcome the anatomic problems related to the difficulty of access. Inappropriate removal may cause severe hemorrhage.7 In this clinical case, we successfully removed an orbital-maxillary sinus-pterygopalatine fossa foreign body using the C-L approach combined with the endoscopic approach.8
CLINICAL REPORT A 4-year-old boy presented to the oral and maxillofacial department because of infraorbital region swelling and suppuration of 8 days in duration after a reed shaft plunged into his orbit. Immediately after the trauma, he was sent to the nearby local hospital and the surgeons extracted the outside part of the stick. A few days after the surgery, however, the wound did not heal but turned swollen and suppurated. After computed tomographic (CT) examination, the retained (inside) part of the stick was found. To get a better treatment, his family turned to us and the boy was hospitalized. The clinical examination showed a discharging wound in the right palpebra inferior and periorbital swelling. There was no limitation of ocular motility as well as no obvious displacement of the left eye and of the orbital soft tissues. The remainder of the physical examination was unremarkable. The patient’s vital signs were as follows: blood pressure, 86/59 mm Hg; heart rate, 90 beats per minute; and temperature, 37.2°C. The white blood cell count was 18.4 109/L, the neutrophile granulocyte was 14.9 109/L, and the creatine kinase was 1330.2 U/L. The sagittal and transverse plain views of CT showed that the left part of the hollow reed shaft went almost beyond the orbit, penetrated through the superior maxillary sinus, and extended into the pterygopalatine fossa (Figs. 1A, B). After the three-dimensional From the Departments of *Oral and Maxillofacial Surgery, and †Ophthalmology, Xiangya Hospital, Central South University, Hunan, China. Received January 14, 2014. Accepted for publication February 1, 2014. Address correspondence and reprint requests to Xingrong Ou, MD, DDS, Department of Oral and Maxillofacial Surgery, Xiangya Hospital, Central South University Changsha, Xiangya Road #87, Hunan 410008, China; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000848
1548
FIGURE 1. A, Presurgical sagittal CT scan. B, Presurgical transverse CT scan. C, Presurgical three-dimensional reconstruction of the orbit from CT scans; the yellow arrow points to the elevated inferior orbit wall. D, Presurgical sagittal MRI.
reconstruction, we found that it was the inferior orbital fissure where the shaft penetrated and that the inferior orbit wall was elevated (Fig. 1C). The sagittal magnetic resonance imaging (MRI) showed the contour more clearly (Fig. 1D). A combined approach, image-guided endoscopic and C-L operation, was used to remove the foreign body. The endoscope was inserted directly into the wound tunnel. In the meantime, the C-L operation was done, which included sublabial antrostomy opening as well as radical removal of all antral mucosa and an inferior meatal window. A forcep was inserted into the window, clamped the pieces of the foreign body in the superior maxillary sinus, and pulled them toward into the orbit. With the combined approach, almost all the pieces of the foreign body were found and took out (Fig. 2). The postsurgical examination after 1 month showed satisfactory aesthetic and functional results (Fig. 3).
DISCUSSION Orbital-sinus foreign bodies were sometimes reported previously.4–6 However, the pterygopalatine fossa foreign body can hardly be found in the English literature. Most of these injury cases have a history of facial trauma. However, history alone is not sufficient to rule out a retained foreign body. Early MRI or CT scan is necessary for the evaluation of the extent of injury.4 In this case, the first attempt to extract the foreign body was done right after the trauma. However, both the parents and the local physicians did not realize that what they
FIGURE 2. Pieces of the foreign body.
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 25, Number 4, July 2014
FIGURE 3. Postsurgical frontal view after 1 month.
Brief Clinical Studies
Surgical Therapy of a Vertebral Artery Aneurysm With Saccular and Fusiform Segments Tevfik Yilmaz, MD, Yahya Turan, MD, Adnan Ceviz, MD
extracted was only a part of the foreign body, not the whole. The retained part was not found until the CT scan and MRI were done. In the presurgical evaluation, the nature of the foreign body plays an important role. A different nature of the foreign body requires different imaging equipments. Mostly, CT scan can satisfy most cases. However, CT scan hardly identifies wooden or herbaceous objects when the object has penetrated the face. Compared with CT scans, MRI allows to better study the foreign objects with low density such as wooden bodies.6 In this case, the reed shaft showed a very low signal in CT scan but showed a clear contour in MRI. On the other hand, a soft or crisp foreign body increases the difficulty of the surgery. After a certain time that they are retained in a human body, the foreign bodies may decay and disintegrate. It requires good visualization and access to the deep bottom of the tunnel in the surgery. In this case, what we took out in the surgery were actually the fragments of the decayed reed shaft. Because these foreign bodies may cause severe orbital infection and threaten the patient’s vision, surgical removal is necessary. It is often difficult to do surgeries in the pterygomaxillary region because of a limited surgical access and nearby critical vascular and neurologic structures. Traditionally, the lateral or inferolateral approach, in which the parotid gland, facial nerve, and zygomatic arch are all involved, is often selected to gain the access.7 For the surgery of taking out a foreign body, these methods seem inefficient and macrotraumatic. In this case, we selected external and endoscopic combined approach. Endoscopic surgery provided good visualization and access. It ensured that all the fragments could be taken out in visual range. The C-L operation in this case helped to locate and remove the foreign body, and all antral mucosa was removed because of the maxillary sinusitis.8 This combined approach proves to be safe and effective for extraction of the foreign bodies that extend deeply into the maxillary sinus and pterygopalatine fossa.
REFERENCES 1. Ramotar H, Jaberoo MC, Koo Ng NK, et al. Image-guided, endoscopic removal of migrated titanium dental implants from maxillary sinus: two cases. J Laryngol Otol 2010;124:433–436 2. Costa F, Robiony M, Toro C, et al. Endoscopically assisted procedure for removal of a foreign body from the maxillary sinus and contemporary endodontic surgical treatment of the tooth. Head Face Med 2006;2:37 3. Sohn DS, Jung HS, Kim KH, et al. Removal of displaced foreign body from the maxillary sinus using replaceable bony windows and saline irrigation, followed by suctioning of the foreign body. Implant Dent 2011;20:112–127 4. Kwiatkowski TJ, Magardino TM, Austin M. Management of orbital-sinus foreign bodies. J Craniomaxillofac Trauma 1998;4:24–29 5. Samaha M, Manoukian JJ, Arthurs B. Sino-orbital foreign body in a child. Int J Pediatr Otorhinolaryngol 2000;52:189–192 6. Gasparini G, Brunelli A, Rivaroli A, et al. Maxillofacial traumas. J Craniofac Surg 2002;13:645–649 7. Jian XC, Wang CX, Jiang CH. Surgical management of primary and secondary tumors in the pterygopalatine fossa. Otolaryngol Head Neck Surg 2005;132:90–94 8. Ikeda K, Hirano K, Oshima T, et al. Comparison of complications between endoscopic sinus surgery and Caldwell-Luc operation. Tohoku J Exp Med 1996;180:27–31
Abstract: Vertebral artery aneurysms form a group of aneurysms having high rates of rebleeding, morbidity, and mortality, poor treatment outcomes, as well as low rate of surgical treatment. Examinations for subarachnoid bleeding revealed a vertebral artery aneurysm with a diameter of 12 mm in a 67-year-old man who presented with headache. The vertebral artery aneurysm with saccular and fusiform segments was shrunk and clipped via lateral left suboccipital approach. No neurologic deficit was present at the postoperative period. Control digital subtraction angiography showed complete shrinkage of aneurysm with continued blood flow and no residue. Clinical findings, treatments, and surgical approaches of VA aneurysms are different from anterior and posterior circulation aneurysms. Microneurosurgical clipping is the most effective treatment of vertebral artery aneurysms in suitable cases. Although endovascular intervention is commonly applied as therapeutic modality for patients with vertebral artery aneurysm, researchers have also emphasized that saccular vertebral aneurysms with fusiform extension can also be surgically treated in suitable cases. Key Words: Subarachnoid hemorrhage, vertebral artery, saccular fusiform cranial aneurysm
P
osterior circulation aneurysms (PCAs) are risky vascular pathologies with high rebleeding rate and poor treatment outcomes.1 This region has a more complex anatomy compared with other brain regions. Their rare occurrence and low rate of surgical treatment increase the complexity of these lesions. Aneurysms of the vertebrobasilar system account for approximately 3.8% to 15% of all intracranial aneurysms.1 Among them, basilar bifurcation aneurysms are the most common subtype, making up almost half of such aneurysms. It is followed by aneurysms originating from vertebral artery (VA), posterior inferior cerebellar artery (PICA), superior cerebellar artery and anterior inferior cerebellar artery origin, posterior cerebral artery, and vertebrobasilar junction.2,3 Vertebral artery aneuryms in PCA are rarer but have a high morbidity and mortality (21.7% and 8.7%, respectively).1 Sudden loss of consciousness is invariably present in PCAs, and headache is localized to the occipital region. Focal deficits such as monoparesia, lower extremity dysesthesia, oculomotor dysfunction, abducent nerve paralysis, and dysarthria are observed at a rate of 35% to 50%.4 Posterior circulation aneurysms have a mortality rate of 90% within From the Department of Neurosurgery, Faculty of Medicine, Dicle University, Diyarbakir, Turkey. Received January 4, 2014. Accepted for publication February 1, 2014. Address correspondence and reprint requests to Tevfik Yilmaz, MD, Department of Neurosurgery, Faculty of Medicine, Dicle University, Yeniþehir 21280 Diyarbakir, Turkey; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000854
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
1549
