TY - JOUR
AU - Reiter, Evan R.
AB - Foreign bodies may be introduced into the paranasal sinuses or cranium through a variety of traumatic or iatrogenic events. A variety of open and, more recently, endoscopic approaches have been used for the removal of sinonasal foreign bodies. Intracranial foreign bodies, however, typically require retrieval via a craniotomy approach, which continues to carry significant perioperative risks. We describe the first reported case of an intracranial foreign body removed using the transnasal endoscopic approach with intraoperative image guidance. We discuss the preoperative evaluation required for this approach to be applied safely and successfully in properly selected cases.An increasing number of reports describe the safe removal of a variety of foreign bodies from the paranasal sinuses. However, removal of intracranial foreign bodies typically requires a craniotomy approach, which carries a significant risk of perioperative morbidity. In the otolaryngology community, growing experience with endoscopic and modern imaging techniques has led to the application of the transnasal endoscopic approach to a broadening range of skull-base abnormalities. Intracranial foreign bodies may cause significant patient morbidity and mortality. Herein, we describe a minimally invasive transnasal endoscopic approach to remove sinonasal and intracranial foreign bodies and propose indications for its use.REPORT OF A CASEA 34-year-old male prison inmate with schizophrenia presented to the emergency department complaining of several days of left eye pain and swelling unresponsive to broad-spectrum oral antibiotic therapy. Three months earlier he had undergone extraction of his left maxillary third molar. He denied changes in visual acuity but reported mild diplopia with upward gaze. He had no epistaxis, clear rhinorrhea, or headache, but had moderate left-sided nasal congestion. On further questioning, he admitted passing multiple foreign bodies through the tooth extraction site over the previous months, most of which had not returned from the insertion site.Examination revealed an 8-mm oroantral fistula at the socket of the left maxillary third molar (tooth No. 16) from which a clear plastic drinking straw was protruding. Left orbital erythema and proptosis was also present. Anterior rhinoscopy findings were unremarkable. Rigid nasal endoscopy demonstrated left-sided nasal congestion but no purulent discharge or visible foreign bodies. Ophthalmologic examination revealed increased intraocular pressure but no visual loss or restriction of eye movement.Computed tomography (CT) demonstrated multiple tubular foreign bodies of varying lengths and diameters within the left maxillary and ethmoid sinuses. In addition, left orbital intraconal air and a defect in the left posterior ethmoid roof were noted. Two intracranial metallic foreign bodies were also present at the skull base, the first traversing from a posterior ethmoid cell into the anterior cranial fossa, the second located completely above the posterior ethmoid roof (Figure 1). Cerebral angiography demonstrated no injury or compression of the anterior cerebral arteries.Figure 1.Imaging of sinonasal and intracranial foreign bodies. A, Axial computed tomographic (CT) image showing multiple tubular foreign bodies in the left maxillary sinus. B, Axial CT image showing 2 metallic intracranial foreign bodies. C, Coronal CT image showing intracranial foreign body.The patient was taken to the operating room for Stryker-Leibinger optical image-guided endoscopic retrieval of the sinus and intracranial foreign bodies, with neurosurgical backup for possible frontal craniotomy. Following creation of a wide maxillary antrostomy, a total of 15 pieces of plastic tubing of varying sizes were extracted under endoscopic visualization (Figure 2).Figure 2.Foreign bodies removed through the transnasal endoscopic approach. The metallic pen nibs (arrows) were removed from the skull base and brain, while the other items were removed from the left maxillary and ethmoid sinuses. The ruler, pictured for scale, is 6 in long.A left anterior and posterior ethmoidectomy was then performed. Considerable mucosal edema was identified at the ethmoid roof. Following partial removal of this mucosa, the lower metallic foreign body was identified and retrieved using a Blakesley forceps. This appeared to be the nib from a ballpoint pen (Figure 2). A 1- to 2-mm round hole in the ethmoid roof was present, but no cerebrospinal fluid (CSF) leakage was visible.Next, using CT image guidance, we noted a second 3- to 4-mm skull base defect discrete from, and slightly posterior to, the first site. A small rent in the dura was visible. Even with careful probing and use of image guidance, the foreign body could not be palpated. A small amount of bone was thus removed to enlarge the defect to approximately 6 to 8 mm. The dura was carefully incised with a sickle knife and reflected medially. Again with careful probing and the aid of image guidance, the foreign body was identified 3 to 5 mm above the ethmoid roof (Figure 3). Given the small dimensions of the bony defect and the need to minimize trauma to the surrounding brain tissue, a small otologic alligator forceps was used to retrieve the foreign body. At its removal, a small amount of purulent fluid was released, followed by a slow leak of CSF.Figure 3.A, Intraoperative photograph of intracranial metallic ballpoint pen nib. Photograph taken with 0° telescope during removal with an otologic alligator forceps, with resultant release of purulence. B, Coronal, axial, sagittal, and 3-dimensional images of the intracranial metallic objects from the Stryker-Leibinger optical image-guided system.A left middle turbinate bone and mucosal free graft was used to cover both skull-base defects. This was secured in place with fibrin glue, absorbable gelatin sponges, and an 8-cm nasal tampon. A lumbar drain was placed by the neurosurgical service. Postoperative CT showed minimal intracranial free air with no evidence of frontal lobe injury. The patient had no neurologic or ophthalmologic sequelae and no evidence of CSF leakage. His periorbital edema and diplopia resolved completely by postoperative day 2. Following removal of the nasal packing and lumbar drain on postoperative day 5, he was discharged to the prison infirmary to complete a 2-week intravenous antibiotic regimen.COMMENTIntroduction of foreign bodies into the paranasal sinuses or cranium may occur through a variety of traumatic or iatrogenic events. In general, sinonasal foreign bodies should be removed to prevent complications ranging from sinusitis to damage to nearby vital structures. Meningitis, CSF leak, brain abscess, hydrocephalus, neural or vascular injury, and death may result from the presence of intracranial foreign bodies.For these reasons, surgical removal is typically indicated when the perioperative risks associated with removal are acceptable.The endoscopic transnasal approach has been used successfully for retrieval of a variety of foreign bodies of the paranasal sinuses.The low associated morbidity has led endoscopic approaches to supplant open approaches in the removal of sinonasal foreign bodies in most centers. However, depending on the nature and location of the foreign body, combined approaches may be necessary to allow removal of all fragments. Pagella et alused an endoscope passed through the canine fossa to extract a metallic dental foreign body from the maxillary sinus. Mori et alused a combined transorbital and transethmoid endoscopic approach to extract numerous wooden foreign bodies from the orbit, ethmoid, and sphenoid sinuses.Intracranial foreign bodies are typically extracted using a craniotomy approach. This is not without significant morbidity, even in elective cases under sterile conditions.There has been increasing experience presented in the literature regarding endoscopic approaches to skull-base lesions.To date there are few reports describing retrieval of intracranial foreign bodies using an endoscopic approach.In a case presented by Mohanty and Manwaring,an air gun pellet entered the brain through the left forehead region and lodged in the left frontal lobe. A frontal craniotomy was performed to allow removal of intraparenchymal bone fragments. A rigid endoscope was then passed along the entry track through the brain, and the pellet removed without resultant neurologic sequelae. There have been no cases reported in the English-language literature in which an endoscopic transnasal approach was used to remove an intracranial foreign body.A number of cases have been reported regarding orbital, sinonasal, and intracranial penetration by writing implements.Most of these reports involve accidental impalement induced by falls in children or self-inflicted injuries by psychiatric patients, as in the present report. Reported complications from such injuries include carotid artery occlusion without neurologic sequelae, cerebral abscess, mental status changes, and CSF rhinorrhea.In the present case, the patient presented primarily with complaints and examination findings consistent with sinusitis and secondary orbital cellulitis. Symptoms suggestive of the presence of an intracranial foreign body were lacking, and the foreign bodies were found incidentally on imaging. Although purulence was encountered during removal of the intracranial foreign body, there were no signs or symptoms of brain abscess or meningitis. This may be due to the rather short (believed to be several days) interval between introduction and removal of the foreign bodies or presentation in the quiescent phase of brain abscess formation. The lack of overt CSF rhinorrhea on presentation in this patient may have been due to his failure to report ongoing symptoms or rather due to blockage of CSF drainage by the intranasal polypoid disease or intracranial inflammatory response.The case presented here demonstrates that intracranial foreign bodies located near the skull base may be safely removed using endoscopic techniques. Neurosurgical consultation and preoperative angiography were critical in assessing for intracranial vascular injury, which should be considered a contraindication to the endoscopic approach. Vigorous bleeding would certainly compromise endoscopic visualization, while transnasal treatment with cauterization or packing would pose considerable risk of intracranial hematoma formation or stroke. We found preoperative CT imaging to be essential in determining the extent of bony injury within the ethmoid labyrinth, the site of intracranial penetration within the posterior ethmoid cells, and the proximity of the intracranial foreign body to the ethmoid roof and dura. Use of intraoperative image guidance allowed prompt recognition of the small entry site at the skull base and so served to limit the extent of bone removal necessary for extirpation of the foreign body. This led to a rather straightforward repair of the resultant CSF leak at the end of the procedure.In the present case, we believe that the use of image guidance clearly helped locate the foreign body in the brain. By minimizing the required manipulation of brain parenchyma for identification of the foreign body, it greatly reduced the potential risks of injury to the surrounding brain tissue and intracranial bleeding.While manipulation of the surrounding brain parenchyma with resultant injury is a significant concern with the endoscopic approach, the same is true for the far more invasive craniotomy approach. Craniotomy requires similar manipulation of brain tissue at the site of the foreign body and carries the potential for added trauma due to frontal lobe retraction. For this reason, we believe that the use of the endoscopic approach with image guidance may in fact lessen the risk of brain injury due to retrieval of selected intracranial foreign bodies. Clearly more experience with this approach throughout the otolaryngologic community will be necessary to verify its safety and potential advantages.In summary, foreign bodies penetrating intracranially through the paranasal sinuses may be successfully removed endoscopically. Neurosurgical consultation, multiplanar CT imaging, and angiography are essential in establishing the feasibility and safety of this approach by helping the surgeon to determine the precise nature, location, and depth of the foreign body. Intraoperative image guidance is an invaluable adjunct in such cases. The otolaryngologist should also arrange preoperatively for neurosurgical assistance in the operating room, in the event that endoscopic retrieval is unsuccessful. We believe that endoscopic transnasal removal of selected penetrating foreign bodies may be undertaken, potentially obviating the need for craniotomy and its associated morbidity.PFoyMSharrCerebral abscesses in children after pencil-tip injuries.Lancet.1980;2:662-663.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=6106783&dopt=AbstractEGonulABayseferSKahramanCauses of infection and management results in penetrating craniocerebral injuries.Neurosurg Rev.1997;20:177-181.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9297719&dopt=AbstractDJLoesWRSmokerAHMenezesPen injury: a rare complication.Pediatr Neurol.1987;3:44-47.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=3334008&dopt=AbstractRAlsarrafJWBailetSelf-inserted sphenoid sinus foreign bodies.Arch Otolaryngol Head Neck Surg.1998;124:1018-1020.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9738813&dopt=AbstractJRLafrentzEAMairJDCaslerCraniofacial ballpoint pen injury: endoscopic management.Ann Otol Rhinol Laryngol.2000;109:119-122.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10685559&dopt=AbstractNBhattacharyyaRKWenokurEndoscopic management of a chronic ethmoid and sphenoid sinus foreign body.Otolaryngol Head Neck Surg.1998;118:687-690.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9591873&dopt=AbstractFPagellaEEmanuelliPCastelnuovoEndoscopic extraction of a metal foreign body from the maxillary sinus.Laryngoscope.1999;109:339-342.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10890790&dopt=AbstractSMoriSFujiedaTTanakaHSaitoNumerous transorbital wooden foreign bodies in the sphenoid sinus.ORL J Otorhinolaryngol Relat Spec.1999;61:165-168.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10325558&dopt=AbstractAMCabantogMBernsteinComplications of first craniotomy for intra-axial brain tumour.Can J Neurol Sci.1994;21:213-218.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8000976&dopt=AbstractERThalerMKotapkaDCLanzaDWKennedyEndoscopically assisted anterior cranial skull base resection of sinonasal tumors.Am J Rhinol.1999;13:303-310.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10485018&dopt=AbstractRFThomasWTMonacciEAMairEndoscopic image-guided transethmoid pituitary surgery.Otolaryngol Head Neck Surg.2002;127:409-416.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12447234&dopt=AbstractWMadeiTAltscherRNistorKHoeraufEndoscopic projectile extraction in treatment of a gunshot injury to the head [in German].Dtsch Med Wochenschr.1998;123:1139-1142.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9793017&dopt=AbstractAMohantyKManwaringEndoscopically assisted retrieval of an intracranial air gun pellet.Pediatr Neurosurg.2002;37:52-55.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12138222&dopt=AbstractGADavisADHolmesGLKlugDelayed presentation of transorbital intracranial pen.J Clin Neurosci.2000;7:545-548.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11029239&dopt=AbstractSSharifGRobertsJPhillipsTransnasal penetrating brain injury with a ballpoint pen.Br J Neurosurg.2000;14:159-160.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10889896&dopt=AbstractCorrespondence: Evan R. Reiter, MD, Box 980146, Department of Otolaryngology–Head and Neck Surgery, Virginia Commonwealth University Medical Center, Richmond, VA 23298-0146 (ejreiter@comcast.net).Submitted for publication October 21, 2003; final revision received February 26, 2004; accepted March 18, 2004.
TI - Endoscopic Transnasal Management of Intracranial Foreign Bodies
JO - JAMA Otolaryngology - Head & Neck Surgery
DO - 10.1001/archotol.130.8.985
DA - 2004-08-01
UR - https://www.deepdyve.com/lp/american-medical-association/endoscopic-transnasal-management-of-intracranial-foreign-bodies-yoAIJaWmk3
SP - 985
EP - 988
VL - 130
IS - 8
DP - DeepDyve
ER -