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Intraorbital Foreign Body Removal by Lateral Orbitotomy Approach
Sangeeta P Varty*, Manjiri A. Gupte**, RP Jehangir***, SB Ogale***
 

Abstract
We report a case of a 14 year old male who presented to us with proptosis, chemosis and decreased vision following a fall from a tree. The diagnosis of an intra orbital foreign body evaded us, as an immediate CT scan failed to show it. A subsequent CT scan showed a hyperdense shadow in the superolateral aspect of the orbit, suspicious of a foreign body, which was removed by the lateral orbitotomy approach.

 

Introduction
Wooden orbital foreign bodies are difficult to diagnose and remain undetected in the orbit , as they are not well visualized by X-rays or CT scans.1

We present a case of an intraorbital wooden foreign body that required two surgical explorations for its removal. On initial endoscopic orbital decompression a haematoma was drained and we failed to locate the foreign body. The second exploration, using a lateral orbitotomy approach revealed a large intraorbital wooden foreign body in the lateral extraconal space. The patient rcovered fully and regained visual acuity of 6/18. On literature scan, it was found that only one similar case of orbital foreign body was evacuated using this approach by Gierek T. et al.2 We also report serial CT scan changes in a wooden intraorbital foreign body when examined in acute and chronic stage. Detailed CT findings are reviewed and management of such a case is discussed.

Case History
A 14 year-old male, presented in our casualty with a history of fall from a tree one-week back. The patient came with left eye proptosis, chemosis, lid oedema and decreased vision. On examination he had proptosis 25 mm and restricted extra-ocular movements in all directions. His visual acuity was finger counting at 1 m. There was a contused lacerated wound on the medial aspect of the upper lid which was sutured.

Emergency CT scan of the paranasal sinuses and orbit revealed a fracture of the lateral wall of the left orbit and a soft tissue density was seen on the medial, superior and lateral aspect of the orbit, which was reported as a haematoma (Fig. 1).

The patient’s clinical findings prompted us to an emergency endoscopic orbital decompression. The haematoma was approached endoscopically by breaching the lamina papracea and drained.

However even after a week post-operatively, the proptosis and the chemosis did not resolve. The vision improved marginally to finger counting at 2 m. Hence a repeat CT scan of the paranasal sinuses with orbital cuts was performed which revealed a defect in the lamina papracea due to the previous intervention. There was a soft tissue shadow in the superior and lateral aspect of the orbit and a suspicious high density lesion in the lateral aspect of the orbit which was not seen in the previous scan (Fig. 2).

A left Kronlein-Resse-Berk lateral orbitotomy was planned. The superolateral haematoma was drained and a hard object was palpable under the orbital periosteum. The periosteum was incised and a 2- inch wooden foreign body (tree bark) and its pieces were delivered. (Fig. 3).

Post- operatively, the vision improved to 6/18 in the affected eye, proptosis, chemosis subsided and the patient achieved a full range of extra-ocular movements.

Discussion
Wooden orbital foreign bodies are difficult to diagnose because :

  1. The wound of entry may be absent or small therefore easily missed.1,3
  2. They may remain latent or may have a late spontaneous extrusion.3
  3. CT scan may not reveal wooden foreign bodies.4,5

The diagnosis of an orbital foreign body therefore requires a high index of suspicion.

Wooden foreign bodies in an acute stage, on CT scan are less dense than fat, mimicking air bubbles. On MRI wooden foreign bodies give a lower signal than fat on both T1 and T2 weighted images and hence MRI is superior to CT scan for their diagnosis.5

In the chronic stage, intra orbital wooden foreign bodies are isodense or denser than soft tissue. This is due to inflammatory process that the dry wood may become wet within a few days, resulting in dramatic increase in attenuation on CT.5

In our case the wooden foreign body was missed in the acute stage on CT as it was seen as an air bubble in the orbital fat. (Fig. 1). It was only in the later stage that the same foreign body showed increased density on CT, which aroused our suspicion (Fig. 2).

We have used the Kronlein-Reese-Berk lateral orbitotomy approach for lateral orbital wall decompression, to remove the missed wooden foreign body.6



Fig. 1 : Early CT scan revealing a suspicious
haematoma of the orbit.


Fig. 2 : Late CT scan revealing a suspicious high
density lesion.
   


Fig. 3 : The wooden orbital foreign body.
 


The classic Kronlein operation, which involves an osteoplastic resection of the lateral wall of the orbit was introduced in 1889 and modified by Berke in 1953.7

This approach was used for tumours located at the superolateral and inferior compartment of the orbit like tumours of the lacrimal gland, meningioma, neuroma , and cavernous angioma.8

In our case this approach gave direct exposure to the foreign body, was safe and cosmetically good. A team approach is recommended which included an otolaryngologist and an ophthalmologist to prevent injury to the eye.

References

  1. Rajah V. A wooden orbital foreign body. J Laryngol Otol 1993; 107 : 735-6.
  2. Gierek T, Markowski J, Paluch J, et al. The case of a large orbital foreign body evacuated by lateral orbitotomy using the Kronlein-Reese-Berke method. (Article in Polish): Otolaryngol Pol 2000; 54 (5) : 603-5. Abstract
  3. Anita Banerjee, Amitava Das, Pankaj Kumar Agarwal, et al. Late spontaneous extrusion of a wooden intraorbital foreign body. Indian J Ophthalmology 2003; 51 : 83-4.
  4. Erkan Mutlukan , Brian W Fleck, James F Cullen, et al. Case of penetrating orbitocranial injury caused by wood. British Journal of Ophthalmology 1991; 75 : 374-6.
  5. A Uchin, A Kato, Y Takase, et al. Intraorbital wooden and bamboo foreign bodies CT. Neuroradiology 1997; 39 : 213-5.
  6. Joseph C Maroon, John S Kennerdell. Lateral microsurgical approach to itraorbital tumours. J Neurosurgery 1976; 44 : 556-61.
  7. Joseph C Maroon, John S. Kennerdell. Surgical approach to the orbit. Indication and techniques. J Neurosurgery 1984; 60 : 1226-35.
  8. Robert A. Weisman, Donald Kikkawa, Kristen S. Moe. David Osguthorpe. Orbital tumours, skull Base Tumour Surgery, otlaryngol. Clin North Am 2001; 34 (6) : 1157-74.

STATINS FOR SEPSIS?
‘Limited human data hint at reduced mortality rates in bacteraemic patients, and a reduced risk of sepsis in patients with bacterial infections concurrently taking statins’
There is unequivocal evidence that statins are effective and safe in preventing cardiovascular morbidity and mortality. However, in addition, very early data suggest that statins may modulate the inflammatory cascades associated with sepsis. In the April issue of The Lancet Infectious Diseases, Marius Terblanche and colleagues argue that research is needed to determine whether statins are a safe and beneficial treatment for critically ill septic patients, and whether they are effective at preventing sepsis in high-risk clinical settings.

Lancet Infect Dis 2006; 6 : 242.

 

 

*Associate Professor; **Resident; ***Professor, Department of Ophthalmology and Department of ENT, KEM Hospital, Mumbai.

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