2017-18 HSC Section 3 Green Book

Figure 6. A summary of systematic re- view findings.

logic examination if there is orbital involvement, and nasal endoscopy to assess the extent of injury and CSF leak. A high index of suspicion for penetrating FB must be maintained with patients who present with only benign-appearing eyelid lacerations. Two cases were noted in which the patients had recurrent clear rhinorrhea and meningitis of unclear etiology for 3 years, and, subsequently, proper imaging showed the offending FBs. 8,11 A noncontrast CT of the maxillofacial skeleton should be obtained in all patients to reveal an underlying FB and to show the trajectory of the penetrating FB. It is important to note that, often on CT, wooden FBs are seen as a radiolucency, as in our case, versus metal objects that may appear radiopaque with artifacts or plastic objects, which may go entirely un- detected. 11 This was noted in a case by Davis et al. , 11 in which a pen inserted transorbitally showed a tract on CT identified with bony frac- tures; however, no FB was noted, a later magnetic resonance image (MRI) was obtained and showed a large, 6-cm pen in this tract 3 years after the original incident. Therefore, an MRI should be obtained as complementary imaging to identify plastic FBs and also to better identify cerebral contusion and brain parenchymal injury. 6,11 It is also important to note that, if a metal object is suspected, then an MRI should be avoided. CT angiography, magnetic resonance angiography, or formal angiogram should be performed if, on the CT, a hematoma is noted or if there is suspicion for vascular injury due to the trajectory of the FB, especially in cases of middle cranial fossa or sphenoid sinus involve- ment, which can have a high risk of carotid injury. 2

There is a vast assortment of FBs that can be implicated in transnasal and transorbital injury (Table 1). Identification of the FB, even if removed at the site where the injury occurred, is important because it may have implications for infection risk, in addition to imaging choice, as dis- cussed above. For example, wooden FBs have been shown to have a higher risk of infection. 6 Therefore, medical management of these inju- ries consists of initiation of broad spectrum central nervous system penetrating antibiotics on admission. Our review showed that 31 of 35 patients (89%) were treated with antibiotics; for the other four patients, antibiotic usage was not reported but was likely. Cultures of the rose bush branch extracted from our patient grew coagulase negative Staph- ylococcus and Paraconiothyrium species fungus. She received prolonged courses of intravenous antimicrobials to prevent any infectious compli- cations. It, therefore, is important to maintain a high level of suspicion for both bacterial and fungal infections from these FBs. More than 94% of patients received some form of surgical manage- ment, whether an open procedure or an endoscopic procedure, for removal of the FB; in fact, 83% of the patients had surgical manage- ment within 24 hours of presentation. There are two cases in which the patients were managed conservatively, with observation. 3,7 Bhatji- wale et al. 3 reported a case in which a 7-year-old patient presented with nausea, vomiting, headache, and a single generalized seizure after a fragment of metal wire broke, entered the nose, and lodged in the frontal lobe. The patient’s symptoms improved, so the fragment was left in place, and he was treated with months of anticonvulsants

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