case report Étude de cas - canadian journal of...

Aseemingly benign traumaticinjury may be potentially life-threatening as demonstrated

in this case report of an unsuspectedmaxillo-orbitocranial foreign body.The unusual method of injury, thecritical position of a foreign body, thesimple surgical extraction and the ab-sence of any neurologic deficitsprompted us to describe this case.

CASE REPORT

A 37-year-old man presented to theemergency department of a 28-bedhospital, claiming that a tree branchhad struck him in the face. Two hoursearlier, he was adjusting his chain sawwith a metallic file. The chain saw was

supported by the base of a large treethat he had just cut down. Nearby, an-other worker was cutting down a tree,a portion of which landed on the tip ofthe tree supporting the chain saw. Thebase of that tree was lifted into the airand, according to the patient, struckhim on the right aspect of hismandible. He did not lose conscious-ness and was ambulatory. Initially, hereported no changes in his vision;however, his right eye was painful andswollen. He returned home and ap-plied ice to the painful area before pre-senting at the hospital.The patient’s medical history was

significant only for an amputation of theleft index finger from a chain-saw acci-dent. He was alert, oriented and com-

fortable on arrival in the emergency de-partment. Inspection of the head re-vealed marked right-sided periorbitaledema and a small abrasion above thebody of the mandible (Fig. 1). Thewound did not extend into the oral cav-ity. Pupils were equal, round and reac-tive bilaterally. Visual acuity and fun-doscopy were normal bilaterally. Thepatient had double vision with right lat-eral and upward gaze. Retraction of theright superior palpebra revealed amarked exophthalmos. There was noevidence of cervical tenderness, andneurologic examination demonstratedno motor or sensory deficits except foranesthesia of the maxillary division of the right trigeminal nerve. There was no cerebrospinal fluid rhinorrhea.

Case ReportÉtude de cas

UNSUSPECTED PENETRATING MAXILLO-ORBITOCRANIALINJURY: A CASE REPORT

Kashif Irshad, MD CM;* David McAuley, MD;† Khalil Khalaf, MD;‡ Daniel Ricard, MD§

*First year resident in general surgery, McGill University, Montreal, Que.

†Emergency Services, Gatineau Memorial Hospital, Gatineau, Que.

‡Department of Neurosurgery, Centre Hospitalier Regional de l’Outaouais, Hull, Que.

§Department of Oral and Maxillofacial Surgery, Centre Hospitalier Regional de l’Outaouais, Hull, Que.

Accepted for publication Sept. 17, 1997

Correspondence to: Dr. Kashif Irshad, Room L9.416, Montreal General Hospital, 1650 Cedar Ave., Montreal, QC H3G 1A4

© 1998 Canadian Medical Association (text and abstract/résumé)

A healthy 37-year-old man presented to the emergency room, complaining of blunt trauma to his mandiblefrom a tree branch. Plain radiographs and computed tomography demonstrated a penetrating orbitocranialforeign body with the maxillary sinus as the entry site. The foreign body was a chain-saw file. It was ex-tracted successfully through the oral cavity. The patient’s recovery was uncomplicated and he suffered noneurologic or opthalmic sequelae.

Un homme âgé de 37 ans et en bonne santé se présente à l’urgence et se plaint d’un traumatisme conton-dant causé par une branche d’arbre qui l’a frappé au mandibule. Des radiographies ordinaires et une tomo-graphie assistée par ordinateur révèlent qu’un corps étranger a pénétré dans la région orbitocranienne parle sinus maxillaire. Le corps étranger était une lime de scie à chaîne, que l’on a réussi à extraire par la cavitébuccale. Le patient s’est rétabli sans complication et n’a eu aucune séquelle neurologique ou ophtalmique.

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Radiographs of the facial bones(Figs. 2 and 3) demonstrated a hy-perdense foreign body in the anteriorsegment of the right maxillary sinus,projecting through the medial aspectof the right orbit and penetratinginto the anterior cranial fossa. Re-examination of the right cheek revealeda wound 4 mm in diameter, consis-tent with an entry wound caused bya penetrating object. The patient wastransferred to the regional level 3trauma centre in Hull, where his con-dition was re-evaluated. He wasstarted on cefuroxime, and sent foran emergency computed tomographyof the cranium, which demonstrateda cylindrical, metallic foreign bodypenetrating the lateral wall and roofof the maxillary sinus immediatelyadjacent to the infraorbital nerve.The object extended through the

floor of the orbit immediately pos-teromedial to the right globe (Fig. 4)and finally through the roof of theorbit into the frontal lobe of thebrain (Fig. 5). There were no in-tracranial or intraorbital hematomas.The status of the optic nerve couldnot be assessed. The patient wasstarted on a broad spectrum antibi-otic regimen, which included van-comycin, metronidazole and cef-tazidime, and the foreign body wasremoved by a maxillofacial surgeonand a neurosurgeon.An incision was made in the

vestibule of the right upper maxillaand the Caldwell–Luc approach wasused, revealing a round insertion holethrough the lateral wall of the maxil-lary sinus (Fig. 6). The metal objectwas easily visible and was withdrawnwith a Kelly clamp without difficulty.

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FIG. 1. View at the time of presentation showing periorbital edema, superior palpebral hematomaand a small abrasion of the right cheek.

FIG. 2. Anteroposterior view of the facial bones shows the presence of ametallic object.

FIG. 3. Lateral view of the facial bones confirms the presence of the foreign body within the paranasal sinuses and cranium.

There was no evidence of a cere-brospinal fluid leak or hemorrhage.The foreign body (Fig. 7) was a 9-cmlong cylindrical piece of metal, likely abroken chain-saw file. Cultures fromthe specimen were negative.

Six months postoperatively therewere no neurologic or ophthalmicdeficits. There was never evidence ofcerebrospinal fluid rhinorrhea andconsequently no fascial repair of thefrontal bone was required.

DISCUSSION

The patient’s presentation was con-sistent with trauma from the impact ofthe tree. The swiftness with which theobject penetrated the cheek, the max-

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FIG. 4. Computed tomography scan of the head demonstrating a cylindricalforeign body within the orbit posteromedial to the right globe.

FIG. 5. CT scan of the cranium shows penetration of the foreign body intothe right frontal lobe.

FIG. 6. Operative view of the oral cavity demonstrates a penetrating injurythrough the floor of the maxillary sinus.

FIG. 7. The foreign body after extraction. The patient identified it as thebroken tip of his chain-saw file.

illary sinus, the orbit and cranium mis-led the patient into giving a historysuggesting blunt trauma with perior-bital hematoma and possible facialbone fractures. However, plain radi-ographs of the facial bones revealed apenetrating orbitocranial foreign body.This type of injury is unusual; we areunaware of any previous report of trans -orbital intracranial penetration withthe maxillary sinus as the entry site.This type of injury is potentially life-

threatening. Studies of penetrating in-juries during the Second World Wardemonstrated a 12% death rate, twicethe rate of penetrating cranial injuriesnot affecting the orbit.1 The orbitalroof, which consists of the frontal boneand its sinus and the lesser sphenoidbone, represents a relatively weak andthin bony structure. Foreign bodiescan penetrate through the orbital roofinto the anterior cranial fossa with lit-tle force. In the elderly, this barrier canoften be reabsorbed leaving the duraas the only barrier between the orbitalcontents and the frontal lobe.2 In thispatient, the foreign body penetratedthe lateral aspect of the roof of themaxillary sinus.Sequelae from orbitocranial foreign

bodies include intracerebral hematomas,extraocular muscle dysfunction, cra-nial nerve palsies and optic neu-ropathies. However, more seriousrepercussions include cerebral hernia-tion, pneumocephalus, subarachnoidhemorrhage and cerebrospinal leakageleading to meningitis and possible or-bital or brain abscesses.3 Brain abscessis the most frequent complication andthe major cause of death. Miller,Brodkey and Colombi4 reported thata brain abscess developed in half of 42patients with intracranial injury result-ing from periorbital wounds; Staphy-lococcus aureus was the pathogen mostcommonly implicated. Organismspresent on the foreign object, or skinand sinus bacteria contaminating it

during the impact provide the sourceof abscess formation. Additionally, themetallic file provided a communica-tion between the maxillary sinus andthe cranial contents. Due to the prox-imity of the paranasal sinuses, intracra-nial infection is more common withtransorbital lesions than with pene-trating cranial wounds at other sites.5

Also, the nature of the foreign bodyinfluences the risk of infection. Theporous texture of wood provides adangerous reservoir for bacteria, re-sulting in a 12.5% to 25% death ratesecondary to intracranial infection.4

Wood is also difficult to detect bymost radiographic modalities. There-fore prompt surgical exploration maybe necessary if retained fragments ofwood are suspected. Metallic objectsare less likely to be contaminated andmuch easier to detect with CT.Axial CT of the head and orbits is

not always sufficient and may miss asignificant orbital fracture. The planeof the orbital floor and roof are runparallel to the axial scanning beam;consequently only a small part of thesestructures is present on any axial cut.Coronal views should therefore be ob-tained to detect orbital roof or floorfractures.6

Once a roof fracture has been de-tected the need for surgical interven-tion must be assessed. If there is noconcomitant dural laceration, the pa-tient may be managed conservatively.Surgery should be performed if an oc-ular motility disorder develops. How-ever, if there is a roof fracture with adural laceration resulting in a cere-brospinal fluid leak, the presence ofpneumocephalus, or both, the man-agement should follow a differentcourse.6 Patients with a dural lacera-tion run a higher risk of brain abscessformation or meningitis.7 They shouldbe observed carefully for any changesin neurologic status and for the devel-opment of a fever. The dura does not

need to be repaired urgently because80% of these lacerations seal sponta-neously within the first 72 hours afterthe insult. A temporary drain to re-duce the cerebrospinal fluid pressuremay be helpful in promoting healingof the laceration. However, if the leakpersists, the roof fracture and the lac-eration should be repaired.6

In our case no sequelae were de-tected on CT and access to the foreignbody was easiest through a Cald-well–Luc approach. A neurosurgeonwas available for an emergency cran-iotomy in the event of uncontrollablehemorrhage from the brain when theobject was withdrawn.Another complication that may de-

velop perioperatively is epilepsy. Thisoccurs in 30% or more of patients withpenetrating brain wounds, so anticon-vulsant therapy is recommended. Car-bamazepine, phenytoin and pheno-barbital are all acceptable.8

The remarkable ability of the eye-ball to escape injury depends on 3 fac-tors: the location and size of the tran-sorbital penetration, and the velocityof the penetration. In relatively low-velocity stabs, as in our case, the eye-ball has the ability to move into thespace provided by the abundant orbitalfatty tissue that surrounds the eye.9

The initially benign appearance ofthis injury serves as a reminder thatseemingly trivial wounds of the facecan have serious concurrent orbitaland intracranial lesions requiring im-mediate surgical treatment. CT is thebest radiologic modality for evaluatingpenetrating injuries to the soft tissues;however, it is limited in its capacity todetect objects with densities similar tothe surrounding tissues.10 ImmediateCT and prompt surgical interven tionled to effective treatment and symptom-free survival in our patient.

Thanks to Dr. Irving Tiong for his editorial as-sistance.

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References

1. Webster JE, Schneider RC, LofstromJE. Observations upon management oforbitocranial wounds. J Neurosurg1946;3:229.

2. Wolff E. The bony orbit and paranasalsinuses. In Warwick R, editor. Anatomyof the eye and orbit. Philadelphia, W.B.Saunders; 1976. p. 710.

3. Wesley RE, Anderson SR, Weiss MR,Smith HP. Management of orbital-cranial trauma. Adv Ophthalmic PlastReconstr Surg 1988;7:3-26.

4. Miller CF, Brodkey JS, Colombi BJ.The danger of intracranial wood. SurgNeurol 1977;7(2):95-103.

5. De Villiers JC, Sevel D. Intracranialcomplications of transorbital stabwounds. Br J Ophthalmol 1975;59(1):52-6.

6. Solomon KD, Pearson PA, Tetz MR,Baker RS. Cranial injury from unsus-pected penetrating orbital trauma: a re-view of five cases. J Trauma 1993;34(2):285-9.

7. Raskind R. Cerebrospinal fluid rhinor-rhea and otorrhea. Diagnosis and treat-

ment in 35 cases. J Int Coll Surg1965;43:141-54.

8. Rosenwasser RH, Andrews DW,Jimenez DF. Penetrating craniocere-bral trauma [review]. Surg Clin NorthAm 1991;71(2):305-16.

9. Verbiest H. Penetrating transorbitalinjuries. Ned T Geneesk 1954;98:529.

10. Lydiatt DD, Hollins RR, Moyer DJ,Davis LF. Problems in evaluation ofpenetrating foreign bodies with com-puted tomography scans: report ofcases. J Oral Maxillofac Surg 1987;45(11):965-8.

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SESAP Critique / Critique SESAP

ITEM 262Because laparoscopic cholecystectomy is now the preferred operative therapy for cholelithiasis, decisions about pa-tients who require operative cholecystectomy become less familiar to the surgeon. Patients undergoing laparoscopiccholecystectomy who are found to have stones in the common bile duct (CBD) that cannot be removed shouldhave ERCP and sphincterotomy in the immediate postoperative period. However, the decision would not be thesame for patients who are having an open procedure.Surgical exploration of the CBD is indicated especially when an open procedure is being performed. Sphinc -

teroplasty is indicated if one or more stones are impacted in the ampulla, multiple CBD stones are present, or for re-current stones with a CBD diameter less than 15 mm. Choledochojejunostomy offers no advantage for this patientbecause it requires two anastomoses and a large CBD to facilitate the anastomosis.Chemical dissolution of gallstones has limited clinical applicability. Choledochoduodenostomy is another option.

C

References262/1. Anderson TM, Pitt HA, Longmire WP Jr: Experience with sphincteroplasty and sphincterotomy in pancre-atobiliary surgery. Ann Surg 201:399-406, 1985262/2. Fink AS: Current dilemmas in management of common duct stones. Surg Endosc 7:285-291, 1993262/3. Leitman IM, Fisher ML, McKinley MJ, et al: The evaluation and management of known or suspectedstones of the common bile duct in the era of minimal access surgery. Surg Gynecol Obstet 176:527-533, 1993262/4. NIH Consensus Conference: Gallstones and laparoscopic cholecystectomy. JAMA 269:1018-1024, 1993262/5. Schwab G, Pointner R, Wetscher G, et al: Treatment of calculi of the common bile duct. Surg GynecolObstet 175:115-120, 1992

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