The full extent of the damage from apparently trivial orbital puncture wounds in children can be difficult to assess. The frequent lack of history suggestive of a retained foreign body and the lack of signs and symptoms may be misleading. Reports of serious intracranial infections following this type of injury'"1' should prompt aggressive evaluation for this possibility aimed at diagnosis and localization of the foreign body and its immediate removal via the surgical route with the best access to the foreign body. The purpose of this communication is to emphasize the danger inherent in these injuries; to demonstrate the value of thorough radiographic evaluation in the acute and chronic phase; and to suggest a diagnostic approach to patients presenting with orbital puncture wounds.
RD, an 8-year-old male, fell from a skateboard in December 1 976. The patient was promptly seen in a local hospital emergency room. He did not volunteer carrying anything in his hands at the time of the accident and although there was no loss of consciousness, the patient was lethargic. A small puncture wound was noted in the right upper lid medially and there was swelling of the right upper eyelid. The patient was hospitalized for observation; skull x-rays taken on admission were reported as normal. The patient was discharged three days later with residual swelling of the right upper eyelid. The puncture wound never healed perfectly.
Six weeks after discharge the patient was rehospitalized because of proptosis of the right eye, headache, vomiting, nuchal rigidity and a purulent discharge from the puncture site. A CT scan, performed on 2/18/77, demonstrated in the right middle cranial fossa an irregular area of diminished density that showed circumferential enhancement with intravenous contrast media (Fig. 1). A diagnosis of a right temporal lobe abscess was made and right temporal craniotomy performed. Purulent material was evacuated and the shaggy and friable wall of an abscess cavity removed. At the conclusion of the craniotomy, an exploration of the puncture wound site and its sinus tract and the tissues of the medial orbital wall was carried out byanophthamologistand otolaryngologist. No foreign body was found. E coli was cultured from both the brain abscess and the drainage tract Systemic antibiotics were given. The postoperative course was complicated by the development of communicating hydrocephalus several weeks later. A ventriculoperitoneal shunt was placed. A purulent discharge persisted from the original puncture wound. In May 1977, the patient again complained of headache, nausea, and vomiting. A CT scan demonstrated postshunt hydrocephalus with recurrent abscess in the righttemporal lobe (Fig, 2). A right temporal craniotomy drained the temporal lobe abscess. No foreign body was found, although the right orbital roof, fissure, and orbital contents were not explored. Postoperatively, the patient slowly improved. A left hemiparesis, left facial weakness, and a dense left homonymous hemaniopsia were detected.
Fig. 1. CT scan with circumferential enhancement of the right temporal lobe abscess with intravenous contrast material (black arrows).
Fig. 2. CT scan revealing recurrent abscess at the right temporal lobe (black arrows) with shunt in place (white arrows) and dilated ventricle.
Fig. 3. Draining puncture wound site, right upper lid.
The patient was then referred to the Bascom Palmer Eye Institute for further evaluation. Examination revealed a visual acuity of 20/30 in the right eye and 20/20 in the left eye. There was moderate swelling of the right upper and lower lids, proptosis of the right globe and a draining puncture site medially Fig. 3). Corneal sensation, pupils, motility, and fundus examination were normal. A dense left homonymous hemaniopsia was present. OKN responses were normal horizontally and vertically. Thin section tomography of the orbits demonstrated enlargement of the right superior obital fissure (Fig. 4). On 8/17/77 a right frontotemporal craniotomy revealed a recurrent brain abscess with necrosis of most of the right temporal lobe. Sinus tracts and pockets of purulent material extended into the right parietal and occipital lobes. The abscess was excised along with most of the temporal lobe and all of the involved brain tissue from the parietal and occipital areas were removed as well. Exploration of the superior orbital fissure revealed a wooden foreign body extending from the orbit through thefissure into the middle cranial fossa. Unroofing of the orbit and fissure was required to remove the foreign body. No exploration of the orbit or the puncture wound was performed from below. The foreign body proved to be an irregular, flat piece of wood measuring 38 mm (Fig. 5a and b).
Fig. 4. Tomography of the orbits demonstrating enlargement of the right superior orbital fissure (black arrows).
Postoperatively, the patient's course was complicated by seizures that were controlled by Dilantin. The puncture wound site healed spontaneously. When last seen on 9/7/79, his residua were a dense left homonymous hemaniopsia with a positive OKN sign on targets taken to the right and left hemiparesis involving primarilythe left hand and foot. Hehasbeen free of seizures for two years.
This case illustrates the dreadful consequences of apparently trivial orbital puncture wounds with retained orbital foreign bodies. Involvement of intracranial structures may be unsuspected until very serious signs of meningitis, brain abscess, vascular shunting, seizures, and alteration in state of consciousness indicate the true nature and extent of the injury.1-"1 The ophthalmologist is often the first physician to evaluate the patient with orbital puncture wounds. The possibility of a retained foreign body with intraorbital and intracranial contamination should always be born in mind even when the history is negative for that possibility as it was in this child until the boy was closely questioned about the months after the injury.
Fig. 5(a) Intracranial view of wooden foreign body extruding through the right superior orbital fissure into the right middle cranial fossa (black arrow); (b) view of the wooden foreign body following its removal.
The second point of importance in the management of these patients is that once the diagnosis is suspected, efforts to locate and evaluate the foreign body should be promptly undertaken. Acute phase radiological evaluation should include conventional skull, orbital, and sinus films. The demonstration of pneumocephalus"'17'18 fracture or foreign body through the optic canal or superior orbital fissure signifies intracranial involvement. Computed tomographic scanning of the intracranial contents and orbits has proven increasingly valuable in evaluating this type of injury.10'19
The intracranial complications from this type of injury have been divided into immediate and late. Immediate damage, such as cerebral laceration, parenchymal, submeningeal and intraventricular hemorrhage, often are accompanied by sufficient neurological symptomatology to allow rapid diagnosis of intracranial penetration. Late vascular complications, such as carotid cavernous fistula5'13"16 also readily indicate their presence. Of the late complications, the possibility of retained foreign body and intracranial penetration must be considered because of the danger of intracranial infection. During the antibiotic era (since 1944), the infection rate has been reported as high as 64%.4 A mortality of 25% occurred in one series. Infections have also occurred with foreign bodies of iron,1'6 graphite,7'10 plastic,9 and glass.'6 In many cases in these various series, intracranial penetration was not suspected and diagnostic evaluation not undertaken until signs and symptoms of major intracranial disease were apparent.2-4
When the foreign body is located, it then becomes a matter of clinical judgment as to what surgical approach is best. Often, a neurosurgical approach with sufficiently extensive exposure to explore the roof of the orbit, the middle cranial fossa, and the superior orbital fissure proves best, particularly when the foreign body may have penetrated or partially penetrated any of the bony walls or orifices of the orbit.
Retained orbital foreign body produces devastating consequences, particularly when there is central nervous system involvement. A case is presented of a retained orbital foreign body that presented through the superior orbital fissure and caused recurrent brain abscesses and hydrocephalus. Clinical and xray evidence of foreign body has been reviewed and the management of these injuries discussed.
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