2017-18 HSC Section 3 Green Book

Reprinted by permission of Am J Rhinol Allergy. 2017; 31(2):29-34.

Presentation, workup, and management of penetrating transorbital and transnasal injuries: A case report and systematic review

Saied Ghadersohi, M.D., 1 Elisabeth H. Ference, M.D., M.P.H., 2 Kara Detwiller, M.D., 1 and Robert C. Kern, M.D. 1

ABSTRACT Background: A foreign body (FB) penetrating intracranially after passing transorbitally or transnasally is a rare occurrence. However, otolaryngologists are increasingly being asked to participate in the care of these patients for both endoscopic removal of the object and repair of any skull base defects. Objective: To assess the presentation, workup, and management of transnasal or transorbital penetrating FB injury. Methods: Systematic review of the presentation, workup, and management of transnasal or transorbital penetrating FB injury; plus, a case report of a 53-year-old woman with a transorbital penetrating rose bush branch. We searched medical literature data bases, which resulted in 215 total titles, which were then narrowed based on inclusion and exclusion criteria. Results: Thirty-five cases of transorbital or transnasal low-velocity trauma that involved the paranasal sinuses were reviewed from 33 articles. The average age was 30 years, 40% of the objects were made of wood. Fifty-seven percent of the cases were transorbital, whereas 43% were transnasal. Forty-six percent of the surgical interventions were completed endoscopically or with endoscopic assistance. Complications of injury were common, with 66% of patients experiencing cerebrospinal fluid leaks; 23%, permanent blindness; 17%, meningitis; 14%, ophthalmoplegia; 9%, decreased visual acuity; and 3%, brain abscess. Our patient presented with a traumatic cerebrospinal fluid leak, and recovered well after transorbital and endoscopic removal of the branch, skull base repair, and a prolonged course of antibiotics and antifungal medications. Conclusions: Transnasal and transorbital penetrating FB injuries are a relatively uncommon occurrence but when they do occur require rapid workup and interdisciplinary management to prevent acute and delayed complications.

(Am J Rhinol Allergy 31, e29–e34, 2017; doi: 10.2500/ajra.2017.31.4421)

T ransorbital and transnasal injuries are relatively common; how- ever, < 1% of these injuries can lead to intracranial penetration and trauma. 1 These injuries are most commonly due to falls, assault, and motor vehicle collisions (MVC). 1 The direction and the velocity of the penetrating foreign body (FB) will determine its trajectory and extent of injury. 2 The velocities of the penetrating FB are grouped into missiles (velocity of > 100 m/s) and nonmissiles, with the caveat that missile injuries will not only have injury related to the actual object but also from kinetic and thermal energies that are dissipated into the surrounding tissues. 2 The normal “cone” shape of the orbit can direct penetrating objects and temporal lobe. However, if an FB penetrates the orbit or the nose in the appropriate velocity and direction, it can penetrate the sinuses and intracranial cavity. There have been several reports of these injuries in the neurosurgery and ophthalmology literature. Until 10–15 years ago, many of these injuries required extensive craniotomy procedures for removal of the FB; however, there has been a move toward “minimally invasive” endoscopic techniques for visualization during removal of these FBs. There have been few reports and, to our knowledge, no systematic review in the otolaryngology literature,

despite otolaryngologists being recruited for endoscopic assistance with these cases. We reported a case of a 53-year-old woman who presented with a transorbital penetrating rose bush branch injury that traversed the ethmoid sinuses and skull base. We also performed a systematic review of the available literature that assessed the presen- tation, workup, and management of transorbital and transnasal pen- etrating injuries with sinus involvement. CASE REPORT A 53-year-old woman presented to an outside hospital emergency department 1 hour after a fall from a chair located on a porch onto a rose bush into the yard below, with a branch that penetrated her right eye. She reported headache and right eye pain but denied vision changes, nausea, or vomiting. Results of her initial examination were remarkable for a ~ 3-cm avulsion of the right upper eyelid and eye- brow, with a visible 0.8-cm-diameter branch and pooled clear fluid seen in the wound (Fig. 1). She had intact vision, full extraocular movements, with an otherwise unremarkable neurologic examina- tion. Intraocular pressure was 14 mm Hg. Computed tomography (CT) of the orbits showed a 4.3-cm, straight, radiolucent FB that penetrated the right medial orbit past an intact globe, which con- tinued through the lamina papyracea, ethmoid air cells, and then fractured and displaced the fovea ethmoidalis into the intracranial cavity, with a small contusion of the frontal lobe (Fig. 2 A – C ). A CT The patient was transferred to Northwestern Memorial Hospital for escalation of care, where neurosurgery, otolaryngology, and oph- thalmology services were consulted. A lumbar drain was placed. The patient was started on prophylactic Levetiracetam and antibi- otic prophylaxis with vancomycin and ceftazidime. A plan was made to take the patient to the operating room urgently, with a combined endoscopic and transorbital approach for removal of the FB. A septoplasty and right endoscopic sinus surgery, including maxillary antrostomy, total ethmoidectomy, sphenoidotomy, and frontal sinusotomy, was performed, which revealed the noted defect and FB in the ethmoid roof (Fig. 3). The orbital contents and angiography showed no vascular injury.

From the 1 Department of Otolaryngology—Head and Neck Surgery, Northwestern

University Feinberg School of Medicine, Chicago, Illinois, and 2 Department of Otolar- yngology—Head and Neck Surgery, University of California Los Angeles School of Medicine, Los Angeles, California No external funding sources reported The authors have no conflicts of interest to declare pertaining to this article Poster presentation, American Rhinologic Society Annual meeting, September 16–17, 2016, San Diego, California Address correspondence to Robert C. Kern, M.D., Department of Otolaryngology— Head and Neck Surgery, Northwestern University Feinberg School of Medicine, 676 N

Saint Clair Suite 1325, Chicago IL 60611 E-mail address: r-kern@northwestern.edu Copyright © 2017, OceanSide Publications, Inc., U.S.A.

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