420

UNUSUAL RETAINED

J Oral Mexillofac 49:420-421.

FOREIGN BODY IN THE ORBIT

Surg

1991

Unusual Retained Foreign Body in the Orbit IOANNIS DIMITRAKOPOULOS, MD, DDS,* NICOLAOS LAZARIDIS, AND DIMITRI KARAKASIS, MD, DDS$-

Although orbital injuries are common, the longterm retention of foreign bodies in the orbit is relatively rare. l-3 The purpose of this article is to present a case of a retained foreign body in the orbit of a 4-year-old child. The path of entry through a small penetrating wound of the left eyebrow and the final position were very unusual, and caused injury of the lacrimal gland. Eyelid swelling and intraorbital granuloma were the early complications. Late complications and factors leading to the retention of a foreign body in the orbit are discussed. Report of a Case A 4-year-old girl was referred to the Oral and Maxillo-

facial Surgery Clinic in August 1987 for evaluation of a persistent swelling of her left orbit. The patient’s mother stated that 7 months ago, the child had slipped and fallen over the corner of a wooden table, sustaining a small laceration on the lateral part of her left eyebrow. She had brought her immediately to the casualty department of another hospital, where no damage of the globe of the eye was found by the ophthalmologist. Radiographs did not indicate any orbital fracture and the wound was sutured. Three months later, the patient’s parents noticed a gradually increasing painless swelling on her left eyebrow. The girl was brought to her family physician, who prescribed antibiotics, but there was no improvement. Physical examination showed a generally healthy child. Clinical examination showed a well-circumscribed, compressible soft-tissue mass on the outer third of the left eyebrow just above the supraorbital rim, extending to the upper eyelid over the location of the lacrimal gland. A small scar was visible on the overlying skin (Fig 1). The

MD, DDS,t

bony contour and eye movements were normal. Radiographs were taken, which did not show evidence of any pathologic condition. The patient was scheduled for surgical exploration of the area. With the patient under general anesthesia, exploration revealed a piece of wood surrounded by a large amount of granulation tissue located deep in the orbit between the lacrimal gland and the eyeball (Fig 2). The foreign body was 15 mm long (Fig 3). When it was removed, a wide laceration of the palpebral process of the lacrimal gland was found. Further exploration did not show any additional fragments or trauma to the superior sclera. The wound was closed in layers and long-term follow-up showed no further problems.

Discussion Small wounds of the eyelids and periorbital tissues are often associated with retained orbital foreign bodies that may not be detected during initial examination. 134*5 In such cases, late complications, such as infraorbital granuloma,’ draining fistula,3 osteomyelitis,’ disturbance of vision,3*6 Brown’s type syndrome,3 brain abscess,‘33*7 and death,lX6 have been reported. The following factors have been considered to be factors in the retention of foreign bodies in the orbit after injuries of the eyelids and periorbital tissues:

Received from the Department of Oral and Maxillofacial Surgery, School of Dentistry, Aristotle University of Thessaloniki, Greece. * Lecturer. t Assistant Professor. $ Professor and Head. Address correspondence and reprint requests to Dr Dimitrakopoulos: Department of Oral and Maxillofacial Surgery, Aristotle University, Faculty of Dentistry, GR-54006, Thessaloniki, Greece. 0 1991 American geons

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FIGURE 1. Swelling of the lateral third of the upper eyelid and the small scar just below the outer aspect of the eyebrow.

DIMITRAKOPOULOS

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is the only useful method to localize successfully such orbital foreign bodies3q4 3. The orbital soft tissues tend to close around the retained foreign body in small penetrating wounds. When the injury is not associated with significant clinical signs during primary examination, the foreign body may be unsuspected and the wound closed with it in place. 4,7.1O.l1 4. The rate of retention is higher in children because it may not be possible to obtain an adequate history of the injury.4.6.‘0

FIGURE 2. Diagram showing the position of the foreign body in relation to the lacrimal gland and the globe of the eye. A, Recess for lacrimal gland; B, foreign body.

1. The orbit has the ability to accommodate large foreign bodies without disturbance of function because the globe of the eye only takes up one quarter of the volume of the orbit.5s.9 2. Diagnosis and localization may be confirmed with plain radiographs and tomograms if the foreign body is metallic, but in the case of deeply positioned radiolucent objects (eg, wood, glass, plastic), they may remain undetected in the orbit. Computerized tomography

The most common site of entry for foreign bodies excluding the globe, is through the lower region of the orbit.2.4-6 It is less common for entry to occur through the medial wall and the roof of the orbit,6*‘0 and even rarer through the superolateral region because of the protection by the strong bony orbital rim 679.10 In our case, the entry was through the superolatera1 region. The wedge-shaped, wooden foreign body penetrated the outer part of the left eyebrow, passed just below the supraorbital rim, and then obliquely upward and backward to damage the palpebral process of the lacrimal gland and end up embedded deep in the orbit between the globe and the orbital roof. Our case emphasizes the necessity for careful assessment of penetrating orbital wounds no matter how small they may appear. Long-term follow-up also is necessary even if patients remain symptomfree, as late complications are frequent.3,4*‘0 References

FIGURE 3. View of the foreign body and the surrounding granulation tissue.

1. Guthkelchs AN: Apparently trivial wounds of eyelids with intracranial damage. Br Med J 2:842, l%O 2. Beauchamo JO. Miller GR: Unusual orbital foreien 0-mbodv., Am J Ophthalmol 63:868, 1%7 3. Brock L, Tanenbaum HL: Retention of wooden foreign bodies in the orbit. Can J Ophthalmol 15:70, 1980 4. McCaughey AD: An unusual infraoribital foreign body. Br J Oral Maxillofac Surg 26:426, 1988 5. Quayle AA: The significance of small wounds of the eyelids. Br J Oral Maxillofac Surg 24: 17, 1986 6. Bartkowski SB, Kurek M, Stypalkowska J, et al: Foreign bodies in the orbit. Review of 20 cases. J Maxillofac Surg 12:97, 1984 7. Kazarian EL, Stokes NA, Flynn JT: The orbital puncture wound: intra cranial and complications of a retained foreign body. J Pediatr Ophthalrttol Strabismus 17:247, 1980 8. Mallins TJ. Ward-Booth RP. Allen ED: Orbital decomoression of dysthyroid eye disease. Br J Oral Maxillofac’Surg 28:29, 1990 9. Rowe NL, Williams JL: Maxillofacial Injuries. New York, Churchill Livingstone, 1985, p 26 10. Lalla M, Pillai S: Deep penetrating injury of the orbit with retained foreign body. Am J OphthaImol 59:922, 1%5 11. Sacks I, Matheson AT: Unusual infra-orbital foreign body. Br J Ophthalmol46:304, 1969

Unusual retained foreign body in the orbit.

420 UNUSUAL RETAINED J Oral Mexillofac 49:420-421. FOREIGN BODY IN THE ORBIT Surg 1991 Unusual Retained Foreign Body in the Orbit IOANNIS DIMITR...
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