British Journal of Neurosurgery, 2014; Early Online: 1–2 © 2014 The Neurosurgical Foundation ISSN: 0268-8697 print / ISSN 1360-046X online DOI: 10.3109/02688697.2014.977778
SHORT REPORT
Removal of a penetrating orbital and anterior fossa foreign body using an eyebrow incision Tiffany Berrington1, Bernard Chang2 & Simon Thomson1 1Department of Neurosurgery, Leeds General Infirmary, Leeds, UK and 2Department of Ophthalmology, St James University
Br J Neurosurg Downloaded from informahealthcare.com by University of Utah on 12/02/14 For personal use only.
Hospital, Leeds, UK
traversing the orbit and penetrating 16 mm intra-cranially, and CT angiography (CTA) demonstrated no major vessel involvement (Fig. 1). A combined left-sided craniotomy and eye exploration for the removal of the foreign body was performed as a joint procedure between neurosurgery and ophthalmology on the day of presentation. A supra-orbital eyebrow incision, extending laterally from the supra-orbital notch was the chosen approach. Developing meningitis was evident with milky coloured cerebrospinal fluid (CSF) and the brain was found to be very oedematous. It was not possible to get under the frontal lobe without excessive retraction; therefore, the Sylvian fissure was split to expose the carotid artery, the cisterns were opened and CSF was drained and sent for microscopy, culture and sensitivity at which point the brain became much slacker. All these structures were easily reached from an eyebrow craniotomy. The bamboo was then found using minimal frontal lobe retraction (Fig. 2). There was limited penetration into the brain. The brain was easily lifted off the bamboo and the ophthalmology team then
Abstract In this case, we present an underutilised eyebrow approach for removing penetrating foreign bodies of the orbit extending into the anterior fossa floor. Excellent visualisation of the sub-frontal region is achieved and a large trauma craniotomy is avoided, but care must be taken to preserve the supra-orbital and fronto-temporal nerves. Keywords: operative experience; penatrating wound; surgical approach; trauma; meningitis; neuroanatomy
Introduction Intra-orbital foreign bodies are uncommon, most frequently affecting younger male patients.1 They are usually the result of accidental injury, both high and low velocity, are of varying size and occur with a variety of materials. They can lead to significant damage to both the eye and brain with significant resulting functional impairment. With low-velocity trauma, as in the case detailed here, the damage is usually limited to areas directly in contact with the foreign body. Organic materials, even when small, will usually require removal. Larger foreign bodies require removal, but small inorganic foreign bodies may be tolerated and left in place if asymptomatic.1,2
Case presentation A 28 year old, otherwise healthy male presented to hospital with a bamboo shard penetrating his left orbit. The injury was sustained while gardening during which the patient had bent down onto the bamboo. There was no loss of consciousness, Glasgow Coma Score (GCS) was 15/15 on admission, there was significant periorbital oedema making assessment of vision difficult but it appeared largely intact, and pupil reactions and eye movements were normal. He complained of worsening headache which began one hour following the injury and he was becoming drowsy before surgery. His head computerized tomography (CT) showed the bamboo shard
Fig. 1. A modified axial CT scan showing the track of the bamboo as it passes through the orbit and penetrates the anterior fossa floor.
Correspondence: Dr. Tiffany Berrington, Department of Neurosurgery, Leeds General Infirmary, Leeds, LS1 3EX, UK. E-mail: [email protected] Received for publication 5 July 2014; accepted 12 October 2014
1
2
T. Berrington et al.
Discussion
Br J Neurosurg Downloaded from informahealthcare.com by University of Utah on 12/02/14 For personal use only.
Fig. 2. An intracranial view showing the end of the bamboo penetrating the anterior fossa floor (top).
proceeded to dissect along the bamboo from below. The bamboo could then be removed, in one piece, through the orbit and under direct observation both within the cranium and next to the globe (Fig. 3). Antibiotic orbital washout was performed; washout of the cranial cavity was performed with saline alone. The anterior fossa floor defect was repaired using periosteum and fibrin glue. The craniotomy was closed with miniplates, the galea was closed with vicryl and 4/0 ETHILON was used in the skin. Recovery, to a GCS of 15/15, and normal motor function occurred rapidly, without further intervention. Post-operatively vision and orbital movement was preserved, there was no CSF leak. The CSF sample taken in theatre was reported as polymorphs ⫹⫹⫹ but grew no organisms. Intravenous antibiotics and antibiotic eye drops were given, after which the patient was clinically well and was discharged home. At follow-up in clinic after six weeks, he was asymptomatic with normal forehead sensory function, but there was a palsy of the frontalis on the operated side. This occurred secondary to an injury to the frontalis branch of the facial nerve as it crosses the fat pad within the temporalis fascia.
Intra-orbital foreign bodies pose a threat to both vision and life, and careful, systematic assessment of the patient is required. After the initial insult and surgical removal of the foreign body, further threats to both life and vision remain.2 With the proximity of the orbit to the para-nasal sinuses, the often contaminated nature of the initial injury poses a great risk, particularly when the foreign body consists of organic material as in this case. Early surgical removal, careful washout, empirical antibiotics and a high degree of suspicion with a low threshold for further antimicrobial treatment is, therefore, of particular importance in cases such as this. Here, the standard neurosurgical approaches might have been bicoronal or pterional approaches. The supra-orbital eyebrow incision as used in this case is underutilised yet offers a number of advantages over a larger craniotomy. If performed correctly, the supra-orbital approach allows good visualisation of the anterior fossa, suprasellar cisterns and Sylvian fissure with excellent cosmetic results. In addition to the cosmetic benefits, the small incision size means the risk of excessive bleeding is low and a faster recovery is likely. All these factors increase patient and surgeon satisfaction. Furthermore, the scalp flap with both pterional and bicoronal approaches would have covered the orbit and made the ophthalmological approach difficult. Excellent knowledge of anatomy is required to prevent nerve injury when making the incision. Placement of the incision lateral to the supra-orbital notch as in this case is an important point as it avoids damage to the supra-orbital nerve and thus forehead numbness. Damage to the frontotemporal branch of the facial nerve with resulting frontalis muscle palsy is a risk of this procedure. The nerve is found in the fat pad between the two layers of the temporalis fascia, it is at risk with a more lateral supra-orbital approach.
Conclusion In this case we present an underutilised cranial approach that can be easily combined with orbital surgery for removing penetrating foreign bodies that have come through the anterior fossa floor from the orbit. Excellent visualisation of the subfrontal region can be achieved and CSF can be drained from the chiasmatic cisterns to help relax the brain. A large trauma craniotomy can thus be avoided, but care must be taken to preserve the supra-orbital and fronto-temporal nerves. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References
Fig. 3. A view of the left eye showing the point of entry of the bamboo through the sclera, inferior to the cornea.
1. Al-Mujaini A, Al-Senawi R, Ganesh A, Al-Zuhaibi S, Al-Dhuhli H. Intraorbital foreign body: clinical presentation, radiological appearance and management. Sultan Qaboos Univ Med J 2008;8:69–74. 2. Moretti A , Laus M, Crescenzi D, Croce A . Peri-orbital foreign body: a case report. J Med Case Rep 2012;6:91.
SHORT REPORT
Removal of a penetrating orbital and anterior fossa foreign body using an eyebrow incision Tiffany Berrington1, Bernard Chang2 & Simon Thomson1 1Department of Neurosurgery, Leeds General Infirmary, Leeds, UK and 2Department of Ophthalmology, St James University
Br J Neurosurg Downloaded from informahealthcare.com by University of Utah on 12/02/14 For personal use only.
Hospital, Leeds, UK
traversing the orbit and penetrating 16 mm intra-cranially, and CT angiography (CTA) demonstrated no major vessel involvement (Fig. 1). A combined left-sided craniotomy and eye exploration for the removal of the foreign body was performed as a joint procedure between neurosurgery and ophthalmology on the day of presentation. A supra-orbital eyebrow incision, extending laterally from the supra-orbital notch was the chosen approach. Developing meningitis was evident with milky coloured cerebrospinal fluid (CSF) and the brain was found to be very oedematous. It was not possible to get under the frontal lobe without excessive retraction; therefore, the Sylvian fissure was split to expose the carotid artery, the cisterns were opened and CSF was drained and sent for microscopy, culture and sensitivity at which point the brain became much slacker. All these structures were easily reached from an eyebrow craniotomy. The bamboo was then found using minimal frontal lobe retraction (Fig. 2). There was limited penetration into the brain. The brain was easily lifted off the bamboo and the ophthalmology team then
Abstract In this case, we present an underutilised eyebrow approach for removing penetrating foreign bodies of the orbit extending into the anterior fossa floor. Excellent visualisation of the sub-frontal region is achieved and a large trauma craniotomy is avoided, but care must be taken to preserve the supra-orbital and fronto-temporal nerves. Keywords: operative experience; penatrating wound; surgical approach; trauma; meningitis; neuroanatomy
Introduction Intra-orbital foreign bodies are uncommon, most frequently affecting younger male patients.1 They are usually the result of accidental injury, both high and low velocity, are of varying size and occur with a variety of materials. They can lead to significant damage to both the eye and brain with significant resulting functional impairment. With low-velocity trauma, as in the case detailed here, the damage is usually limited to areas directly in contact with the foreign body. Organic materials, even when small, will usually require removal. Larger foreign bodies require removal, but small inorganic foreign bodies may be tolerated and left in place if asymptomatic.1,2
Case presentation A 28 year old, otherwise healthy male presented to hospital with a bamboo shard penetrating his left orbit. The injury was sustained while gardening during which the patient had bent down onto the bamboo. There was no loss of consciousness, Glasgow Coma Score (GCS) was 15/15 on admission, there was significant periorbital oedema making assessment of vision difficult but it appeared largely intact, and pupil reactions and eye movements were normal. He complained of worsening headache which began one hour following the injury and he was becoming drowsy before surgery. His head computerized tomography (CT) showed the bamboo shard
Fig. 1. A modified axial CT scan showing the track of the bamboo as it passes through the orbit and penetrates the anterior fossa floor.
Correspondence: Dr. Tiffany Berrington, Department of Neurosurgery, Leeds General Infirmary, Leeds, LS1 3EX, UK. E-mail: [email protected] Received for publication 5 July 2014; accepted 12 October 2014
1
2
T. Berrington et al.
Discussion
Br J Neurosurg Downloaded from informahealthcare.com by University of Utah on 12/02/14 For personal use only.
Fig. 2. An intracranial view showing the end of the bamboo penetrating the anterior fossa floor (top).
proceeded to dissect along the bamboo from below. The bamboo could then be removed, in one piece, through the orbit and under direct observation both within the cranium and next to the globe (Fig. 3). Antibiotic orbital washout was performed; washout of the cranial cavity was performed with saline alone. The anterior fossa floor defect was repaired using periosteum and fibrin glue. The craniotomy was closed with miniplates, the galea was closed with vicryl and 4/0 ETHILON was used in the skin. Recovery, to a GCS of 15/15, and normal motor function occurred rapidly, without further intervention. Post-operatively vision and orbital movement was preserved, there was no CSF leak. The CSF sample taken in theatre was reported as polymorphs ⫹⫹⫹ but grew no organisms. Intravenous antibiotics and antibiotic eye drops were given, after which the patient was clinically well and was discharged home. At follow-up in clinic after six weeks, he was asymptomatic with normal forehead sensory function, but there was a palsy of the frontalis on the operated side. This occurred secondary to an injury to the frontalis branch of the facial nerve as it crosses the fat pad within the temporalis fascia.
Intra-orbital foreign bodies pose a threat to both vision and life, and careful, systematic assessment of the patient is required. After the initial insult and surgical removal of the foreign body, further threats to both life and vision remain.2 With the proximity of the orbit to the para-nasal sinuses, the often contaminated nature of the initial injury poses a great risk, particularly when the foreign body consists of organic material as in this case. Early surgical removal, careful washout, empirical antibiotics and a high degree of suspicion with a low threshold for further antimicrobial treatment is, therefore, of particular importance in cases such as this. Here, the standard neurosurgical approaches might have been bicoronal or pterional approaches. The supra-orbital eyebrow incision as used in this case is underutilised yet offers a number of advantages over a larger craniotomy. If performed correctly, the supra-orbital approach allows good visualisation of the anterior fossa, suprasellar cisterns and Sylvian fissure with excellent cosmetic results. In addition to the cosmetic benefits, the small incision size means the risk of excessive bleeding is low and a faster recovery is likely. All these factors increase patient and surgeon satisfaction. Furthermore, the scalp flap with both pterional and bicoronal approaches would have covered the orbit and made the ophthalmological approach difficult. Excellent knowledge of anatomy is required to prevent nerve injury when making the incision. Placement of the incision lateral to the supra-orbital notch as in this case is an important point as it avoids damage to the supra-orbital nerve and thus forehead numbness. Damage to the frontotemporal branch of the facial nerve with resulting frontalis muscle palsy is a risk of this procedure. The nerve is found in the fat pad between the two layers of the temporalis fascia, it is at risk with a more lateral supra-orbital approach.
Conclusion In this case we present an underutilised cranial approach that can be easily combined with orbital surgery for removing penetrating foreign bodies that have come through the anterior fossa floor from the orbit. Excellent visualisation of the subfrontal region can be achieved and CSF can be drained from the chiasmatic cisterns to help relax the brain. A large trauma craniotomy can thus be avoided, but care must be taken to preserve the supra-orbital and fronto-temporal nerves. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References
Fig. 3. A view of the left eye showing the point of entry of the bamboo through the sclera, inferior to the cornea.
1. Al-Mujaini A, Al-Senawi R, Ganesh A, Al-Zuhaibi S, Al-Dhuhli H. Intraorbital foreign body: clinical presentation, radiological appearance and management. Sultan Qaboos Univ Med J 2008;8:69–74. 2. Moretti A , Laus M, Crescenzi D, Croce A . Peri-orbital foreign body: a case report. J Med Case Rep 2012;6:91.
