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Show PHOTO ESSAY Transorbital Intracranial Penetrating Injury From Impaling on an Earpick Taro Yamashita, MD, Takeshi Mikami, MD, Takeo Baba, MD, Yoshihiro Minamida, MD, Toshiya Sugino, MD, Izumi Koyanagi, MD, Tadashi Nonaka, MD, and Kiyohiro Houkin, MD FIG. 1. A. The earpick penetrates the left orbit above the eye. B. CT reconstruction shows the trajectory of the earpick { arrow). C. Three- dimensional CT shows the earpick { white arrow) reaching into the prepontine cistern via the superior orbital fissure { black arrowhead). The earpick is adjacent to the left internal carotid artery { black arrow). D. Intraoperative photograph shows the top of the earpick { black arrow) lying between the fifth cranial nerve { black arrowhead) and the sixth cranial nerve. The superior petrosal vein { white arrow) and seventh cranial nerve { white arrowhead) are shown. Abstract: An inebriated 86- year- old man impaled himself on a wooden earpick that penetrated through the superior orbital fissure into the prepontine cistern. The patient underwent surgery immediately by a lateral suboccipital approach, and the earpick was pulled out through the wound with control of hemorrhage from the cavernous sinus. He survived this event with no neurologic deficits apart from complete ipsilateral ophthalmoplegia and ptosis. Prompt imaging and surgical intervention allowing direct visualization of the foreign body and prevention of intracranial complications are part of proper management of this problem. (/ Neuro- Ophthalmol 2007; 27: 48- 49) Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan. Address correspondence to Takeshi Mikami, MD, Department of Neurosurgery, Sapporo Medical University, South 1 West 16, Chuo- ku, Sapporo 060- 8543, Japan; E- mail: tmikami@ sapmed. ac. jp An 86- year- old intoxicated man stood up, lost his balance, and fell down on a pen stand. The wooden earpick in the pen stand penetrated his left upper lid. On 48 J Neuro- Ophthalmol, Vol. 27, No. 1, 2007 Transorbital Penetrating Injury J Neuro- Ophthalmol, Vol. 27, No. 1, 2007 admission the patient was alert and oriented. The earpick had entered the left orbit just above the eye ( Fig. 1A). Visual acuity was normal in both eyes, but there was complete left ophthalmoplegia and ptosis. The pupillary diameters were 3 mm in the right eye with normal constriction to light and 6 mm in the left eye with no constriction to light. Three- dimensional CT scans documented the trajectory of the earpick ( Fig. IB). It had penetrated through the left superior orbital fissure, passed into the cavernous sinus just lateral to the left internal carotid artery, and protruded into the prepontine cistern ( Fig. 1C). The brainstem did not appear to be deviated or contused. The patient immediately underwent surgery under general anesthesia. The top of the earpick was visualized microscopically via a lateral suboccipital approach. The earpick lay between the left fifth and sixth cranial nerves ( Fig. ID). There was a little hematoma around the earpick but no active bleeding. The earpick was pulled gradually in the direction from which it had entered, at which point venous bleeding was observed from the cavernous sinus. However, hemostasis was easily achieved with oxidized cellulose sheets. The patient was alert just after the surgery, and his postoperative course was uneventful. He was discharged 1 month after the surgery with complete left ophthalmoplegia and ptosis but intact visual function. At the last follow- up examination 6 months after the injury, the deficits were unchanged, and visual function remained normal. Ocular or orbital injury in civilian life is rare. Most cases have been caused by pens, knives, or chopsticks ( 1- 4). Ophthalmologists and neurosurgeons have to consider the possibility of intracranial penetration and its path. There are three possible paths for penetration of the cranium through the orbit: through the orbital roof ( 3,5), the superior orbital fissure ( 6,7), and the optic canal ( 1). The most frequent path is through the orbital roof, and this often leads to frontal lobe contusion ( 3,5). The second most frequent path is through the superior orbital fissure, which occasionally results in the penetrating object's reaching the brainstem through the cavernous sinus ( 6,7). Our case demonstrated this latter pattern. Fortunately the top of the earpick reached only the prepontine cistern and did not injure the brainstem. The intracranial complications of transorbital penetrating injury include ventricular damage, brainstem injury, vascular injury, carotid- cavernous sinus fistula, pneumo-cephalus, subdural hemorrhage, subarachnoid hemorrhage, and intracerebral hemorrhage ( 8- 10). Thin- slice CT and its reconstruction are necessary to simultaneously evaluate the trajectory and possible complications of these penetrations. Wooden foreign bodies may sometimes be problematic for imaging diagnosis because intracranial wood may show various degrees of attenuation on CT ( 1). In our patient, the dry wood earpick displayed low attenuation. The favored strategy for the treatment of penetrating injury is early surgical exploration ( 2,3,5). Early radical debridement and removal of the retained fragment are mandatory to prevent potentially fatal infectious complications ( 11). Awooden foreign body is especially infectious because the porous organic material provides good culture conditions for bacterial agents ( 12). Thin- slice CTand MRI facilitate surgical exploration. REFERENCES 1. Matsumoto S, Hasuo K, Mizushima A, et al. Intracranial penetrating injuries via the optic canal. AJNR Am JNeuroradiol 1998; 19: 1163- 5. 2. Matsuyama T, Okuchi K, Nogami K, et al. Transorbital penetrating injury by a chopstick- case report. Neurol Med Chir ( Tokyo) 2001; 41: 345- 8. 3. Moehrlen U, Meuli M, Khan N, et al. An orbitocranial knife injury without functional deficit in a child. J Trauma 2004; 57: 396- 8. 4. O'Donoghue GT, Kumar R, Taleb FS. Unsuspected orbitocranial penetrating injury by a plastic pen cartridge: case report. J Trauma 2005; 58: 634- 7. 5. Kim S, Lee JY, Song JS, et al. Transorbital- intracranial injury by a chopstick: three- dimensional computed tomography. Acta Ophthalmol Scand 2005; 83: 609- 10. 6. Ildan F, Bagdatoglu H, Boyar B, et al. The nonsurgical management of a penetrating orbitocranial injury reaching the brain stem: case report. J Trauma 1994; 36: 116- 8. 7. Kahler RJ, Tomlinson FH, Eisen DP, et al. Orbitocranial penetration by a fern: case report. Neurosurgery 1998; 42: 1370- 3. 8. De Villiers JC, Sevel D. Intracranial complications of transorbital stab wounds. Br J Ophthalmol 1975; 59: 52- 6. 9. Maruya J, Yamamoto K, Wakai M, et al. Brain abscess following transorbital penetrating injury due to bamboo fragments- case report. Neurol Med Chir ( Tokyo) 2002; 42: 143- 6. 10. Smely C, Orszagh M. Intracranial transorbital injury by a wooden foreign body: re- evaluation of CT and MRI findings. Br J Neurosurg 1999; 13: 206- 11. 11. Hansen JE, Gudeman SK, Holgate RC, et al. Penetrating intracranial wood wounds: clinical limitations of computerized tomography J Neurosurg 1988; 68: 752- 6. 12. Miller CF, Brodkey JS, Colombi BJ. The danger of intracranial wood. Surg Neurol 1977; 7: 95- 103. 49 |
