Crayon in the Orbit and Sinuses in a Pediatric Patient.

Penetrating transorbital injury with skull base involvement is a rare occurrence from a crayon. We report a case of a 2-year-old male who sustained a penetrating crayon injury through the right orbit and lamina papyracea into the posterior ethmoid sinus complicated by cerebrospinal fluid leak. There have been no other reported cases of this type of injury by a crayon.

Large wooden orbital foreign body: case report and literature review.

Orbital trauma is often associated with foreign bodies. Wooden foreign bodies pose an urgent need for removal owing to their reactive nature and the high risk for infection. Though visual prognosis depends on associated ocular trauma, in selected cases, excellent visual and cosmetic outcomes are possible. An 18-year-old woman presented to our trauma facility with a history of fall directly onto a wooden stick from a height. On examination, there was a large wooden foreign body in the left medial orbit, extending into the ethmoidal sinus as visualised on imaging. After administration of perioperative antibiotics, the foreign body was removed in toto using careful tissue dissection and the soft tissue was closed in layers. Postoperatively at six months, the vision in the left eye was 20/20 with mild ptosis. Early surgery, careful dissection of soft tissues and adequate infection prophylaxis can lead to good outcomes in such cases.

Craniofacial penetration by a wooden stick.

INTRODUCTION: Penetrating craniofacial injuries caused by stick-like foreign bodies occur as a result of accidents particularly in children, and often lead to significant morbidity. CASE SUMMARY: We describe a 5-year-old boy who sustained facial trauma after falling on a wooden stick which penetrated his left cheek. At the initial visit, his vital and neurological signs were normal. However, the stick had penetrated the frontal lobe to a depth of 3cm via the orbital cavity and the anterior skull base. The stick was successfully removed while visualizing the anterior skull base in an endoscopic transethmoidal approach. A follow-up examination one year after the accident demonstrated normal visual acuity and ocular motility, with no diplopia, tearing or pain. DISCUSSION: Penetrating facial injuries caused by stick-like objects carry a significantly higher risk of serious neurological involvement. Even if penetrating facial injuries sometimes appear trivial, the external injury site is often insufficient to determine the position of the object within the head. Although the cheek is a rare entry site for intracranial injuries, the extent of damage should be assessed fully before attempting removal.

Wounding potential of 4.4-mm (.173) caliber steel ball projectiles.

From time to time, severe or fatal injuries caused by small caliber air rifle projectiles are seen. In forensic sciences, the theoretical wounding potential of these weapons and projectiles is widely known. Usually, shots against the skull were reported and, in these cases, penetrating the eyes or thin bone layers of the temporal region. Amongst a huge number of different projectiles available for air guns, sub-caliber 4.4-mm (.173) caliber steel ball projectiles were used in an unusual suicide case. This case led to fundamental questions concerning wound ballistics. An 82-year-old man shot once against his right temporal region and twice into his mouth with a 4.5-mm (.177) caliber air rifle. Because of the exceptionally deep penetration of the base of the skull and the use of spherical-shaped sub-caliber air rifle projectiles, terminal ballistic features were analyzed and compared to results published in forensic literature. Test shots using the same weapon and similar projectiles were fired into ballistic gelatin to measure and calculate basic wound ballistic variables of cal. 4.4-mm (.173) steel balls. In comparison, further test shots with cal. 4.5-mm (.177) steel balls BB (ball bearing), flat-headed and pointed air rifle pellets ("diabolos") were carried out. The theoretical penetration depth in solid bone was calculated with 36.4 mm, and test shots in gelatin from hard contact produced an on-average wound track of 120 mm underlining the potential wounding effect. Furthermore, spherical projectiles could roll back and forth within the barrel, and an air cushion between projectile and breechblock can reduce muzzle velocity by more than half, explaining the retained missile in the temporal region.

Nonfatal Cervical-Neck Lesion With a Wooden Foreign Body: Diagnosis and Management.

Penetrating cervical lesions caused by a foreign body are rare events. The neck is a complex and delicate body region, given the important vascular structures it holds. The most frequent fatal complications often involve vascular injuries, and as a consequence, the mortality rate increases by approximately 50%. Civilian patients are mainly victims of violence or motor vehicle accidents and rural accidents involving neck are not very common. When a cervical lesion is because of a wooden foreign body, infectious risk increases for its organic peculiarity. The authors report a rural nonfatal cervical lesion in a civilian, and its management.

Cuerpo Extraño Etmoideo-Esfenoidal: a propósito de un caso / Ethmoid-Esphenoidal foreign body. A propos of a case

Introducción: los cuerpos extraños en Otorrinolaringología son infrecuentes en los senos paranasales debido a la localización de los mismos subyacente a los huesos del complejo maxilofacial, se necesita de grandes traumas que fracturen estas cubiertas protectoras para que cualquier objeto extraño pueda alojarse en ellos, de esta forma solo se describen en grandes accidentes, catástrofes sísmicas o en las guerras por municiones de cualquier tipo que impacten en la cara. A veces no son diagnosticados y olvidados por impericia médica o por ausencia de recursos para su exploración en países pobres o envueltos en conflictos. Presentación de caso: se reporta el caso de MPG paciente femenina Ugandesa de 41 años que llega a Emergencias del Mbarara Regional Referral Hospital en Uganda después de verse involucrada en accidente de tránsito mientras conducía su auto a gran velocidad sufriendo graves lesiones Maxilo-faciales, en el examen se detecta cuerpo extraño en el complejo sinusal etmoideo derecho y al practicarse una TAC se descubre que el mismo penetra 0,5 cm en la pared anterior del seno Esfenoidal homolateral. Discusión: se trata de cuerpo extraño etmoideo-esfenoidal derecho consistente en parte del cristal de espejo retrovisor de la conductora del vehículo que en mediciones tomográficas medía aproximadamente 4,5 cm largo por 2,7 cm de ancho y que penetró en el sitio al fracturarse el hueso propio nasal de ese lado con exposición de las celdas etmoidales, estas celdas en su interior se asemejan a la estructura de un panal de abejas con tabique delgados y débiles que facilitan el avance hacia la profundidad del cuerpo extraño e inclusive son fácilmente legradas en la cirugía de ese grupo sinusal. Se extrae en salón de operaciones bajo anestesia general. Conclusiones: los cuerpos extraños sinusales son raros en Otorrinolaringología solo descritos en conflictos bélicos por municiones, en grandes cataclismos o accidentes graves de tránsito(AU)

Introduction: foreign Bodies in Otolaryngology are not so common in paranasal sinuses due to the location of them, subjacent to the maxillofacial bone; big traumas that fracture these protective covering are necessary in such a way that any foreign body could penetrate on them, so this is only described in huge accidents, seismic catastrophes or in wars through bullets that impact the face. Sometimes they are not diagnosed and they are therefore forgotten due to the medical inexperience or the lack of resources for its exploration in least developed countries. Case presentation: it is reported the case of a 41 years old Ugandan female who arrived to Emergency room after has been involved in a traffic accident while she was driving her car at high speed. She suffered serious maxillofacial lesions, and in the physical examination it was detected a foreign body in the right ethmoid-esphenoidal sinusal complex, and after the CAT it was confirmed that the FB penetrated 0,5 cm in the anterior wall of the homolateral sphenoid sinus. Discussion: a consistent ethmoid-esphenoidal foreign body in a part of the crystal of the rearview mirror that in tomographic measures it was about 4,5cm length for 2,7 wide, and it penetrated after the fracture of the nasal bone, with exposures of the ethmoidal cells; these cells are like the structure of a honey comb with thin and weak divisions that facilitate the advance towards the deepness of the foreign body and they are easily scraped in surgery. It was removed with general anesthesia. Conclusions: sinusal foreign bodies are extremely weird in Otolaryngology conditions; they are only described in war conflicts, earth disasters and traffic accidents. That is the reason why in countries at war and in disasters there foreign may be forgotten for medical inexperience or the lack of resources for its proper diagnosis(AU)

Head Spear Gun Injury: An Atypical Suicide Attempt.

Weapon injuries with spear gun are rare. The aim of this case report is to report the emergency and surgical management when this event occurs. A 35-year-old man attempted suicide with a spear gun. The entry of the shaft was localized through the submental area without an obvious exit point. The projectile passed through the tongue and palatal bone. A tracheotomy was performed. Preoperative cranial computed tomography (CT) showed the harpoon was gone upward through the submental area, the oral cavity, the ethmoid paranasal sinus, the cribriform plate, and the frontal region without vessel damages. Under general anesthesia, the harpoon was pulled out in order to extract the shaft tip and the articulated wishbone. Osteo-meningeal defect of the ethmoid roof was closed using a middle turbinate flap. There were no neurologic deficit and no cerebro-spinal rhinorrhea at his 3-year follow-up visit. The trajectory of the shaft is different between attempted suicide and accident. Cranial CT scan is helpful to show the trajectory of the shaft. Angiogram can be helpful to see the relations between the tip shaft and the vessels. The knowledge of the shaft tip and the imagery findings are important to decide the best surgical approach.

Micetoma etmoidal-orbitario por Bipolaris sp. Presentación de caso / Ethmoid-orbital mycetoma caused by Bipolaris sp. Case report

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Accidental migration of a dental implant into the ethmoid sinus following a transalveolar sinus elevation procedure.

BACKGROUND: Migration of a dental implant into the paranasal sinuses may be the result of sinus membrane perforation, loss of osseointegration, and lack of initial stability. The majority of displaced implants migrate into the maxillary sinus, which may cause sinusitis. PURPOSE: The purpose of this study is to report an extremely rare ethmoid sinus migration of a dental implant after crestal approach in a resorbed posterior maxilla. MATERIALS AND METHODS: A 60-year old Korean male with a noncontributory medical history was referred from a local clinic to remove the migrated dental implant in the right ethmoid sinus. The patient had symptoms of mild sinusitis. The implant had been placed 6 months earlier through the bone-added transalveolar approach in a severely resorbed maxilla. RESULTS: The displaced implant was removed through the intraoral approach. A lateral window was made and an endoscopic surgery was performed to remove the implant. Healing was uneventful, and sinusitis symptom had ceased. CONCLUSION: The crestal approach for severely resorbed posterior maxillae should be performed when there is a potential for primary stability. If bone quality is poor and initial stability cannot be achieved, lateral window sinus elevation procedure is a better option for successful implant placement. Migrated implant may be removed with antrostomy and endoscopic surgery.

Frontal sinus fractures with suspected outflow tract obstruction: a new approach for sinus preservation.

OBJECTIVE: The description of a new approach for the management of patients with frontal sinus fractures and associated obstruction of the frontal outflow tract to, restore sinus function and avoiding sinus obliteration. SUBJECTS AND METHODS: In a prospective study, 21 patients with anterior wall frontal sinus fractures associated with potential obstruction of the frontal outflow tract, underwent rigid internal fixation and intraoperative guarded nasal endoscopic debridement of any bony spicules and lacerated mucosa to clear the frontal recess. Patients were followed up clinically and radiologically by CT to assess the status of the frontal sinus and to detect any manifestations of frontal sinusitis or any other complications. RESULTS: Seventeen patients completed the postoperative follow-up while four patients were excluded from the study. Postoperative follow-up ranged from 6 to 34 months with a mean of 20 months. All patients had associated craniofacial fractures. Follow-up CT scans showed complete restoration of frontal sinus ventilation and mucociliary clearance for 13 patients. Four patients showed frontal sinus mild mucosal thickening without signs of chronic sinusitis. CONCLUSION: Patients with anterior wall frontal sinus fractures associated with frontal sinus outflow tract obstruction could be successfully managed with rigid internal fixation and intraoperative guarded endoscopic debridement of any bony spicules and lacerated mucosa to clear the frontal recess. This type of management could increase the chance of frontal sinus preservation and decrease the need for frontal sinus obliteration for similar patients.

Biomechanical investigation of naso-orbitoethmoid trauma by finite element analysis.

Naso-orbitoethmoid fractures account for 5% of all facial fractures. We used data derived from a white 34-year-old man to make a transient dynamic finite element model, which consisted of about 740 000 elements, to simulate fist-like impacts to this anatomically complex area. Finite element analysis showed a pattern of von Mises stresses beyond the yield criterion of bone that corresponded with fractures commonly seen clinically. Finite element models can be used to simulate injuries to the human skull, and provide information about the pathogenesis of different types of fracture.

Frontobasilar fractures: proposal for image reviewing algorithm.

OBJECTIVE: The aim of this study was to develop and test the utility of a novel systematic protocol to analyze CT images of patients with trauma in the anterior cranial base and upper midface. MATERIAL AND METHODS: The radiological data and primary reports of 27 consecutive patients with a frontal skull base fracture treated in two tertiary care hospitals from 2007 to 2011 were scrutinized. A novel algorithm for systematic image reviewing was used to assess the CT images and the findings were compared with the primary radiological reports. RESULTS: The systematic review detected a substantial number of fractures and defects in anatomical structures that had not been systematically reported in the primary, on-call reports. Anterior skull base fracture was not initially reported in 32% of the patients; however, the algorithm detected this in 93% of them. The corresponding rates for fracture through cribriform plate were 28% and 72% and for fracture through the sella or hypophyseal area 22% and 78%. There were two fractures of the clivus and these were initially missed. CONCLUSIONS: Despite the failure to identify these fractures radiologically in the primary setting, all patients were still considered to have received appropriate treatment, but, the use of an image-reviewing algorithm will enhance the specificity of CT in the diagnosis of frontobasilar fractures.

Traumatic sinolacrimocutaneous fistula managed with endonasal dacryocystorhinostomy and anterior ethmoidectomy.

A 31-year-old man with epiphora and mucous discharge from a traumatic lacrimal fistula underwent a computed tomographic dacryocystogram, revealing a fistula extending from the anterior ethmoid air cells through the lacrimal sac to the overlying skin with coexisting nasolacrimal duct obstruction. Endoscopic dacryocystorhinostomy enabled complete marsupialization of the lacrimal sac and agger nasi air cell, removing the tract between these structures. Simultaneous probing of the common canaliculus and fistula tract under direct visualization allowed the identification of the internal fistula origin in relation to the internal ostium on the lateral sac wall. The fistula was excised with a trephine over a guide wire via an external approach. Use of the endoscopic technique for excision of acquired lacrimal fistulas may be especially helpful in cases with coexisting nasolacrimal duct obstruction where the fistula extends to the sinus cavity or suspected foreign bodies.

Transcutaneous medial canthal tendon incision to the medial orbit.

PURPOSE: The surgical approach to the medial orbit allows superior exposure of the medial orbital wall and nasal bones, extending to the orbital apex, with excellent cosmetic results. METHODS: This is a retrospective database study of all patients (N = 98) undergoing a transcutaneous medial canthal tendon incision in practice during 2009. This 1.5- to 2.0-cm incision is made just anterior to, in the same plane as, and shaving the anterior ramus of the medial canthal tendon. After exposing the origin of the anterior ramus of the medial canthal tendon, the periorbita along with the attached medial canthal tendon is elevated, exposing the entire medial orbital wall from the orbital strut to the trochlea. Anterior dissection allows access to the nasal bones to the dorsum of the nasal bridge. The parameters studied in this report were the complication rates (including scarring requiring revision, telecanthus, diplopia related to the technique, and injury to the optic nerve or other orbital structures) and photographic evidence of the final cosmetic result of this approach. RESULTS: During 2009, 173 surgical procedures were performed through the transcutaneous medial canthal tendon incision. The procedures comprised 89 fracture repairs of the nasal or ethmoid complex, 2 naso-orbito-ethmoid fracture repairs, 4 cases of isolated nasal fracture repair, 37 medial wall decompressions for ophthalmic Graves disease, 13 cases of subperiosteal abscess drainage, and 28 dacyrocystorhinostomies using a slightly modified incisional position. The inferior oblique was not cut or released in any of these cases. There were no observed cases of medial canthal webbing, injury to orbital structures, telecanthus, optic neuropathy, or iatrogenically induced diplopia related to the technique. By definition, the authors' follow-up time is limited to less than 2 years in each case; however, all complications, which the authors have considered for this report, would have been readily observable in this postoperative period. CONCLUSIONS: The small incision, transcutaneous medial canthal approach offers excellent and safe exposure of the medial wall, nose, and the orbital apex. The authors differentiate this transcutaneous medial canthal tendon incision from the less cosmetically acceptable, larger and more anterior Lynch incision. This medial canthal tendon incision has, and continues to be, a workhorse in the authors' approach to the medial orbit and nose while offering unparalleled exposure with an excellent safety and complication profile.

Occurrence, types and severity of associated injuries of paediatric patients with fractures of the frontal skull base.

OBJECTIVES: To clarify the occurrence, sites, and types of associated injuries in paediatric patients with fractures of the anterior skull base. STUDY DESIGN: Retrospective analysis of files of 49 patients aged up to 18 years. RESULTS: Associated injuries were observed in 91.8% of the patients. Observed most frequently were fractures of the skull vault (85.7%), brain injury (59.2%), facial fracture (42.9%), lung contusion (18.4%) and fractures of the upper extremities (14.3%). Multiple injuries were observed in 55.1% and polytrauma in 42.9%. The mortality rate was 10.2%. CONCLUSIONS: Paediatric patients with fractures of the anterior skull base frequently present with associated injuries, with many having, multiple associated injuries including polytrauma. These patients should be treated in multidisciplinary trauma units.

[An unusual case of gunshot wounds caused with an air gun]. / Niezwykly przypadek postrzalu z broni pneumatycznej.

A 28-year-old woman was shot in the face with an air gun while driving a car. The patient was examined in the Department of Forensic Medicine in Katowice. An inconspicuous scar was found near the medial angle of the right eye. Further ophthalmological and radiological examinations revealed the presence of small foreign bodies in the vitreous body of the right eye, the sphenoid sinus and the ethmoid cells. The authors issued an expert opinion, in which they stated that the sustained injuries had not caused any significant organ dysfunction.

Treatment outcomes of endoscopic repairs of sinonasal cerebrospinal fluid leaks.

OBJECTIVE: The objectives of the study were to evaluate the clinical characteristics of cerebrospinal fluid (CSF) leaks and determine the clinical parameters affecting endoscopic repair of CSF leaks of the anterior and central skull base. MATERIALS AND METHODS: A retrospective study was undertaken to analyze the clinical characteristics of 28 patients who underwent endoscopic treatment of sinonasal CSF leaks between 2002 and 2009. RESULTS: The causes of sinonasal CSF leaks were traumatic (n = 27) and spontaneous (n = 1). The sites of CSF leaks included the frontal sinus and frontal recess (n = 9), ethmoid sinus (n = 9), sella and clivus (n = 6), and sphenoid sinus (n = 4). The success rate at first-attempt endoscopic repair was 86% (24/28). Cerebrospinal fluid leaks from the frontal sinus/recess had a high failure rate (44% [4/9]). Recurrent frontal CSF leaks were successfully salvaged by an open-endoscopic approach. The final success rate at second attempt was 93% (26/28). Among the variables affecting initial endoscopic success, the location of CSF leak and direct visualization were significant factors (P = 0.008 and 0.018, respectively [Fisher exact test]). No postoperative complications were noted. CONCLUSIONS: Our results showed that endoscopic repair of sinonasal CSF leaks is an effective treatment with a success rate of 93%. Open-endoscopic repair of frontal CSF leaks is feasible in treating endoscopic failures of frontal CSF leaks.