a case report - Canadian Journal of Surgery

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Case Report
Étude de cas
UNSUSPECTED PENETRATING MAXILLO-ORBITOCRANIAL
INJURY: A CASE REPORT
Kashif Irshad, MD CM;* David McAuley, MD;† Khalil Khalaf, MD;‡ Daniel Ricard, MD§
A healthy 37-year-old man presented to the emergency room, complaining of blunt trauma to his mandible
from a tree branch. Plain radiographs and computed tomography demonstrated a penetrating orbitocranial
foreign body with the maxillary sinus as the entry site. The foreign body was a chain-saw file. It was extracted successfully through the oral cavity. The patient’s recovery was uncomplicated and he suffered no
neurologic or opthalmic sequelae.
Un homme âgé de 37 ans et en bonne santé se présente à l’urgence et se plaint d’un traumatisme contondant causé par une branche d’arbre qui l’a frappé au mandibule. Des radiographies ordinaires et une tomographie assistée par ordinateur révèlent qu’un corps étranger a pénétré dans la région orbitocranienne par
le sinus maxillaire. Le corps étranger était une lime de scie à chaîne, que l’on a réussi à extraire par la cavité
buccale. Le patient s’est rétabli sans complication et n’a eu aucune séquelle neurologique ou ophtalmique.
A
seemingly benign traumatic
injury may be potentially lifethreatening as demonstrated
in this case report of an unsuspected
maxillo-orbitocranial foreign body.
The unusual method of injury, the
critical position of a foreign body, the
simple surgical extraction and the absence of any neurologic deficits
prompted us to describe this case.
CASE REPORT
A 37-year-old man presented to the
emergency department of a 28-bed
hospital, claiming that a tree branch
had struck him in the face. Two hours
earlier, he was adjusting his chain saw
with a metallic file. The chain saw was
supported by the base of a large tree
that he had just cut down. Nearby, another worker was cutting down a tree,
a portion of which landed on the tip of
the tree supporting the chain saw. The
base of that tree was lifted into the air
and, according to the patient, struck
him on the right aspect of his
mandible. He did not lose consciousness and was ambulatory. Initially, he
reported no changes in his vision;
however, his right eye was painful and
swollen. He returned home and applied ice to the painful area before presenting at the hospital.
The patient’s medical history was
significant only for an amputation of the
left index finger from a chain-saw accident. He was alert, oriented and com-
fortable on arrival in the emergency department. Inspection of the head revealed marked right-sided periorbital
edema and a small abrasion above the
body of the mandible (Fig. 1). The
wound did not extend into the oral cavity. Pupils were equal, round and reactive bilaterally. Visual acuity and fundoscopy were normal bilaterally. The
patient had double vision with right lateral and upward gaze. Retraction of the
right superior palpebra revealed a
marked exophthalmos. There was no
evidence of cervical tenderness, and
neurologic examination demonstrated
no motor or sensory deficits except for
anesthesia of the maxillary division
of the right trigeminal nerve. There
was no cerebrospinal fluid rhinorrhea.
*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)
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IRSHAD ET AL
FIG. 1. View at the time of presentation showing
periorbital edema, superior palpebral hematoma
and a small abrasion of the right cheek.
Radiographs of the facial bones
(Figs. 2 and 3) demonstrated a hyperdense foreign body in the anterior
segment of the right maxillary sinus,
projecting through the medial aspect
of the right orbit and penetrating
into the anterior cranial fossa. Reexamination of the right cheek revealed
a wound 4 mm in diameter, consistent with an entry wound caused by
a penetrating object. The patient was
transferred to the regional level 3
trauma centre in Hull, where his condition was re-evaluated. He was
started on cefuroxime, and sent for
an emergency computed tomography
of the cranium, which demonstrated
a cylindrical, metallic foreign body
penetrating the lateral wall and roof
of the maxillary sinus immediately
adjacent to the infraorbital nerve.
The object extended through the
FIG. 2. Anteroposterior view of the facial bones shows the presence of a
metallic object.
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JCC, Vol. 41, No 5, octobre 1998
floor of the orbit immediately posteromedial to the right globe (Fig. 4)
and finally through the roof of the
orbit into the frontal lobe of the
brain (Fig. 5). There were no intracranial or intraorbital hematomas.
The status of the optic nerve could
not be assessed. The patient was
started on a broad spectrum antibiotic regimen, which included vancomycin, metronidazole and ceftazidime, and the foreign body was
removed by a maxillofacial surgeon
and a neurosurgeon.
An incision was made in the
vestibule of the right upper maxilla
and the Caldwell–Luc approach was
used, revealing a round insertion hole
through the lateral wall of the maxillary sinus (Fig. 6). The metal object
was easily visible and was withdrawn
with a Kelly clamp without difficulty.
FIG. 3. Lateral view of the facial bones confirms the presence of the
foreign body within the paranasal sinuses and cranium.
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PENETRATING MAXILLO-ORBITOCRANIAL INJURY
There was no evidence of a cerebrospinal fluid leak or hemorrhage.
The foreign body (Fig. 7) was a 9-cm
long cylindrical piece of metal, likely a
broken chain-saw file. Cultures from
the specimen were negative.
Six months postoperatively there
were no neurologic or ophthalmic
deficits. There was never evidence of
cerebrospinal fluid rhinorrhea and
consequently no fascial repair of the
frontal bone was required.
DISCUSSION
The patient’s presentation was consistent with trauma from the impact of
the tree. The swiftness with which the
object penetrated the cheek, the max-
FIG. 4. Computed tomography scan of the head demonstrating a cylindrical
foreign body within the orbit posteromedial to the right globe.
FIG. 5. CT scan of the cranium shows penetration of the foreign body into
the right frontal lobe.
FIG. 6. Operative view of the oral cavity demonstrates a penetrating injury
through the floor of the maxillary sinus.
FIG. 7. The foreign body after extraction. The patient identified it as the
broken tip of his chain-saw file.
CJS, Vol. 41, No. 5, October 1998
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IRSHAD ET AL
illary sinus, the orbit and cranium misled the patient into giving a history
suggesting blunt trauma with periorbital hematoma and possible facial
bone fractures. However, plain radiographs of the facial bones revealed a
penetrating orbitocranial foreign body.
This type of injury is unusual; we are
unaware of any previous report of transorbital intracranial penetration with
the maxillary sinus as the entry site.
This type of injury is potentially lifethreatening. Studies of penetrating injuries during the Second World War
demonstrated a 12% death rate, twice
the rate of penetrating cranial injuries
not affecting the orbit.1 The orbital
roof, which consists of the frontal bone
and its sinus and the lesser sphenoid
bone, represents a relatively weak and
thin bony structure. Foreign bodies
can penetrate through the orbital roof
into the anterior cranial fossa with little force. In the elderly, this barrier can
often be reabsorbed leaving the dura
as the only barrier between the orbital
contents and the frontal lobe.2 In this
patient, the foreign body penetrated
the lateral aspect of the roof of the
maxillary sinus.
Sequelae from orbitocranial foreign
bodies include intracerebral hematomas,
extraocular muscle dysfunction, cranial nerve palsies and optic neuropathies. However, more serious
repercussions include cerebral herniation, pneumocephalus, subarachnoid
hemorrhage and cerebrospinal leakage
leading to meningitis and possible orbital or brain abscesses.3 Brain abscess
is the most frequent complication and
the major cause of death. Miller,
Brodkey and Colombi4 reported that
a brain abscess developed in half of 42
patients with intracranial injury resulting from periorbital wounds; Staphylococcus aureus was the pathogen most
commonly implicated. Organisms
present on the foreign object, or skin
and sinus bacteria contaminating it
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during the impact provide the source
of abscess formation. Additionally, the
metallic file provided a communication between the maxillary sinus and
the cranial contents. Due to the proximity of the paranasal sinuses, intracranial infection is more common with
transorbital lesions than with penetrating cranial wounds at other sites.5
Also, the nature of the foreign body
influences the risk of infection. The
porous texture of wood provides a
dangerous reservoir for bacteria, resulting in a 12.5% to 25% death rate
secondary to intracranial infection.4
Wood is also difficult to detect by
most radiographic modalities. Therefore prompt surgical exploration may
be necessary if retained fragments of
wood are suspected. Metallic objects
are less likely to be contaminated and
much easier to detect with CT.
Axial CT of the head and orbits is
not always sufficient and may miss a
significant orbital fracture. The plane
of the orbital floor and roof are run
parallel to the axial scanning beam;
consequently only a small part of these
structures is present on any axial cut.
Coronal views should therefore be obtained to detect orbital roof or floor
fractures.6
Once a roof fracture has been detected the need for surgical intervention must be assessed. If there is no
concomitant dural laceration, the patient may be managed conservatively.
Surgery should be performed if an ocular motility disorder develops. However, if there is a roof fracture with a
dural laceration resulting in a cerebrospinal fluid leak, the presence of
pneumocephalus, or both, the management should follow a different
course.6 Patients with a dural laceration run a higher risk of brain abscess
formation or meningitis.7 They should
be observed carefully for any changes
in neurologic status and for the development of a fever. The dura does not
need to be repaired urgently because
80% of these lacerations seal spontaneously within the first 72 hours after
the insult. A temporary drain to reduce the cerebrospinal fluid pressure
may be helpful in promoting healing
of the laceration. However, if the leak
persists, the roof fracture and the laceration should be repaired.6
In our case no sequelae were detected on CT and access to the foreign
body was easiest through a Caldwell–Luc approach. A neurosurgeon
was available for an emergency craniotomy in the event of uncontrollable
hemorrhage from the brain when the
object was withdrawn.
Another complication that may develop perioperatively is epilepsy. This
occurs in 30% or more of patients with
penetrating brain wounds, so anticonvulsant therapy is recommended. Carbamazepine, phenytoin and phenobarbital are all acceptable.8
The remarkable ability of the eyeball to escape injury depends on 3 factors: the location and size of the transorbital penetration, and the velocity
of the penetration. In relatively lowvelocity stabs, as in our case, the eyeball has the ability to move into the
space provided by the abundant orbital
fatty tissue that surrounds the eye.9
The initially benign appearance of
this injury serves as a reminder that
seemingly trivial wounds of the face
can have serious concurrent orbital
and intracranial lesions requiring immediate surgical treatment. CT is the
best radiologic modality for evaluating
penetrating injuries to the soft tissues;
however, it is limited in its capacity to
detect objects with densities similar to
the surrounding tissues.10 Immediate
CT and prompt surgical intervention
led to effective treatment and symptomfree survival in our patient.
Thanks to Dr. Irving Tiong for his editorial assistance.
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Docket: 1-5529
Customer: CJS Oct /98
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PENETRATING MAXILLO-ORBITOCRANIAL INJURY
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SESAP Critique / Critique SESAP
ITEM 262
Because laparoscopic cholecystectomy is now the preferred operative therapy for cholelithiasis, decisions about patients who require operative cholecystectomy become less familiar to the surgeon. Patients undergoing laparoscopic
cholecystectomy who are found to have stones in the common bile duct (CBD) that cannot be removed should
have ERCP and sphincterotomy in the immediate postoperative period. However, the decision would not be the
same for patients who are having an open procedure.
Surgical exploration of the CBD is indicated especially when an open procedure is being performed. Sphincteroplasty is indicated if one or more stones are impacted in the ampulla, multiple CBD stones are present, or for recurrent stones with a CBD diameter less than 15 mm. Choledochojejunostomy offers no advantage for this patient
because 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
References
262/1. Anderson TM, Pitt HA, Longmire WP Jr: Experience with sphincteroplasty and sphincterotomy in pancreatobiliary surgery. Ann Surg 201:399-406, 1985
262/2. Fink AS: Current dilemmas in management of common duct stones. Surg Endosc 7:285-291, 1993
262/3. Leitman IM, Fisher ML, McKinley MJ, et al: The evaluation and management of known or suspected
stones of the common bile duct in the era of minimal access surgery. Surg Gynecol Obstet 176:527-533, 1993
262/4. NIH Consensus Conference: Gallstones and laparoscopic cholecystectomy. JAMA 269:1018-1024, 1993
262/5. Schwab G, Pointner R, Wetscher G, et al: Treatment of calculi of the common bile duct. Surg Gynecol
Obstet 175:115-120, 1992
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