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6. Cetinkaya EA, Okan C, and Pelin K. Transnasal, intracranial penetrating injury treated endoscopically. J Laryngol Otol 120:325–326, 2006. 7. Chan SK, Pang KY, and Wong CK. Transnasal penetrating intracra- nial injury with a chopstick. Hong Kong Med J 20:67–69, 2014. 8. de Tribolet W, Guignard G, and Zander E. Brain abscess after transnasal intracranial penetration of a paint-brush. Surg Neurol 11:187–189, 1979. 9. Sharif S, Roberts G, and Phillips J. Transnasal penetrating brain injury with a ball-pen. Br J Neurosurg 14:159–160, 2000. 10. Fallon MJ, Plante DM, and Brown LW. Wooden transnasal intracranial penetration: An unusual presentation. J Emerg Med 10:439–443, 1992. 11. Davis GA, Holmes AD, and Klug GL. Delayed presentation of tran- sorbital intracranial pen. J Clin Neurosci 7:545–548, 2000. 12. Dehgani Mobaraki P, Longari F, Lapenna R, et al. Combined exter- nal-endoscopic endonasal assisted removal of a nail gun. J Craniofac Surg 27:986–987, 2016. 13. Lee DH, Seo BR, and Lim SC. Endoscopic treatment of transnasal intracranial penetrating foreign body. J Craniofac Surg 22:1800–1801, 2011. 14. Liebelt BD, Boghani Z, Haider AS, and Takashima M. Endoscopic repair technique for traumatic penetrating injuries of the clivus. J Clin Neurosci 28:152–156, 2016. 15. Thomas S, Daudia A, and Jones NS. Endoscopic removal of foreign body from the anterior cranial fossa. J Laryngol Otol 121:794–795, 2007. 16. Perakis H, and Woodard TD. Endoscopic management of transnasal intracranial penetrating foreign bodies. Laryngoscope 120(suppl. 4): S242, 2010. 17. Kawamura S, Hadeishi H, Sasaguchi N, et al. Penetrating head injury caused by chopstick—Case report. Neurol Med Chir (Tokyo) 37:332– 335, 1997. 18. Verret DJ, Defatta R, and Ducic Y. Transorbital penetration of the skull base with an occult foreign body. Am J Emerg Med 23:901–902, 2005. 19. Cackett P, and Stebbing J. Transorbital brain injuries. Emerg Med J 22:299, 2005. 20. Scarfo GB, Mariottini A, and Palma L. Oculocerebral perforating trauma by foreign objects: Diagnosis and surgery. J Neurosurg Sci 34:111–116, 1990. 21. Mori S, Fujieda S, Tanaka T, and Saito H. Numerous transorbital wooden foreign bodies in the sphenoid sinus. ORL J Otorhinolaryn- gol Relat Spec 61:165–168, 1999. 22. Zweckberger K, Jung C, Unterberg A, and Schick U. Transorbital penetrating skull-base injuries: Two severe cases with wooden branches and review of the literature. Cent Eur Neurosurg 72:201– 205, 2011. 23. Damm A, Lauritsen AO, Klemp K, and Nielsen RV. Transorbital impalement by a wooden stick in a 3-year-old child. BMJ Case Rep 2015: pii: bcr2015211885, 2015. 24. Dekker AP, El-Sawy AH, and Rejali DS. An unusual transorbital penetrating injury and principles of management. Craniomaxillofac Trauma Reconstr 7:310–312, 2014. 25. Hickman DM. Benign sequelae of a transorbital stab wound: An unusual case report. Ann Plastic Surg 12:279–283, 1984. 26. Kitajiri S, Tabuchi K, and Hiraumi H. Transnasal bamboo foreign body lodged in the sphenoid sinus. Auris Nasus Larynx 28:365–367, 2001. 27. Rawlinson JN, Russell T, Coakham HB, and Byrnes DP. Transnasal hypophysectomy—An unusual sporting injury. Surg Neurol 30:311– 315, 1988. 28. Santoro R, Mannella VK, Freni F, and Galletti F. Penetrating foreign body in the nasal floor through nasolacrimal duct. BMJ Case Rep 2014: pii: bcr2013203270, 2014. 29. Seex K, Koppel D, Fitzpatrick M, and Pyott A. Trans-orbital pene- trating head injury with a door key. J Craniomaxillofac Surg 25:353– 355, 1997. 30. Tsao YH, Kao CH, Wang HW, et al. Transorbital penetrating injury of paranasal sinuses and anterior skull base by a plastic chair glide: Management options of a foreign body in multiple anatomic com- partments. Otolaryngol Head Neck Surg 134:177–179, 2006. 31. Udwadia RA, Maniar D, and Acharya M. A transethmoid transorbital foreign body. J Laryngol Otol 108:441–442, 1994. 32. Windle-Taylor PC. Transorbital injury from a harpoon involving the paranasal sinuses. ORL J Otorhinolaryngol Relat Spec 40:278–284, 1978. 33. Wu MR, Shih CT, and Yeh CW. Transorbital penetrating injury of the paranasal sinuses. J Laryngol Otol 112:1202–1204, 1998. e

and remained asymptomatic. 3 Chan et al. 7 reported a 49-year-old man with a suicide attempt that involved a chopstick inserted into the intracranial cavity and then removed. The patient developed menin- gitis; however, the patient had no noted CSF leak and, therefore, was managed medically, without surgical treatment. Despite these examples, surgery is most often necessary for the controlled removal of the FB and for repair of anatomic barriers, e.g., the skull base. Several of the more recent case reports focus on endoscopic management of these patients. 3,5,12–16 Endoscopic surgery has allowed for a safe and minimally invasive approach for removal of the FB. 3,5,12–16 In our case, the skull base was exposed endoscopi- cally with the i n situ FB, which allowed for visualization during removal and subsequent repair. Familiar endoscopic techniques can then be used for repair of CSF leaks with a high success rate because traumatic CSF leaks often heal well. Complications of these penetrating injuries are variable, depending on the velocity and trajectory of the object. In terms of neurologic complications, meningitis was the most common. Patients with de- layed presentation were more likely to have meningitis. Four of the seven patients with delayed presentation reported meningitis as a complication, including one patient who also developed a brain ab- scess. 8,11,17,18 Orbital complications most commonly were transient decreased vision and/or ophthalmoplegia. As with our patient, tran- sorbital injuries were rarely associated with globe rupture. The liter- ature only identified two cases of globe rupture, 19,20 which is thought to be because intraorbital contents can be displaced away from the penetrating injury and thereby prevent injury to the globe. Therefore, most cases (6/8 [75%]) of permanent blindness in our review were attributed to optic nerve injury. 1,2,4,11,19–22 Also, vascular injury with a purely transorbital trajectory can be common because the FB traveling at a low velocity is often directed by the cone-shaped orbit to the cavernous sinus and carotid. 1,2 FBs with a transorbital only trajectory often present with an orbital or intracranial hematoma. However, due to the oblique trajectory of the FBs that were assessed ( i.e., with sinus involvement), vascular injury was relatively rare. Suspicion for vas- cular injury usually prompted obtaining CT angiography and/or magnetic resonance angiography, or formal angiogram, and only two cases of patients with vascular injury were noted in our review. 1,4 CONCLUSION Transorbital and transnasal penetrating injuries are uncommon; the extent of injury is determined by the velocity and trajectory of the object most commonly caused by falls, assaults, or MVCs. The mate- rial of the FB can determine its infectious potential. Appropriate workup includes a high index of suspicion because patients can present with seemingly benign superficial injuries. CT imaging with complementary MRI as appropriate should be obtained to identify the trajectory and at-risk structures. Appropriate management includes recruitment of a multidisciplinary team of otolaryngologists, neuro- surgeons, and ophthalmologists to expeditiously treat the patient. 23–33 REFERENCES 1. Mzimbiri JM, Li J, Bajawi MA, et al. Orbitocranial low-velocity pen- etrating injury: A personal experience, case series, review of the literature, and proposed management plan. World Neurosurg 87:26– 34, 2016. 2. Schreckinger M, Orringer D, Thompson BG, et al. Transorbital pen- etrating injury: Case series, review of the literature, and proposed management algorithm. J Neurosurg 114:53–61, 2011. 3. Bhatjiwale MG, Goel A, and Muzumdar DP. Transnasal intracranial entry of a flying wire fragment. Br J Neurosurg 15:256–258, 2001. 4. Burkhardt JK, Holzmann D, Strobl L, et al. Interdisciplinary endo- scopic assisted surgery of a patient with a complete transorbital intracranial impalement through the dominant hemisphere. Childs Nerv Syst 28:951–954, 2012. 5. Bai W, Shao C, Sun W, et al. Conservative management of transnasal intracranial injury. Am J Otolaryngol 32:165–167, 2011.

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