Volume 4, Issue 2 , Pages 88-91, March 2009
Long wooden stick penetrating across the retromandibular, nasopharyngeal and contralateral orbital region in a child
Article Outline
Summary
Penetrating wooden stick in the maxillocranial region is rarely reported in children. A 2-year-old boy fell from a tree with a long wooden stick penetrating in the retromandibular region in an accident was sent to the hospital. An emergent operation was performed after CT scan and the wooden stick foreign body was successfully removed. The CT morphology, complications, and management in such cases are briefly discussed. This case is noteworthy because the patient was so lucky that the stick did not penetrate intracranially and he recovered without any complication including function of nose, eye and mastication and it is the first case of one of the smallest kids in literature. Nasal endoscope employed to re-examine the wounds for possible remains of foreign body is recommended in technical point of view.
Keywords: Wooden stick, Foreign body, Head and neck
1. Introduction
A wooden foreign body penetrating into the maxillocranial region is rarely reported in the literature. In most of the cases, the foreign body penetrating in a thin layer in this region [1], [2]. We report a case that a wooden stick penetrating across the retromandibular, nasopharyngeal and contralateral orbital region in a child.
2. Case report
A 2 years child was transported emergently to the department of otolaryngology because of a falling-down accident 5
h ago on his birthday. Physical examination showed that the child was very weak without cry or any active response to the surrounding, basic life parameters such as BP, R, T and P were almost stable, a wooden stick firmly inserted into the retromandibular region of the child (Fig. 1). No active bleeding from the mouth or nose was noticed but a transient bleeding from the nose and mouth was recalled by his parents. The child present no signs of respiratory difficulty but there is an obvious disability of right eye movement with the eyeball protruding a little. A CT scan demonstrated a low density column originating from the posterior margin of the left mandible, cross the nasopharynx to the periorbit of the right eye. The shadow of the wooden stick was 1mm even less away from the carotid artery accompanying with a swollen orophayngeal soft tissue, broken medial wall of the left orbit and blood accumulated right maxillary sinus (Fig. 2, Fig. 3). After careful evaluation of image and general condition of the child, an operation was performed to move the wooden stick. A retromandibular curved incision was made big enough to expose the stick. Nasal endoscope was applied to re-examine the deep wounds for remains of the stick before the stick as a whole being removed (Fig. 4). The postoperative procedure was eventless. Three years follow-up of the child revealed no handicapped function of eye, nose and oral organs.
Fig. 1.
A wooden stick firmly inserted into the retromandibular region of the child. A: magnification of the entry of wooden stick.
Fig. 2.
CT scan demonstrating concaved skin of entrance of wooden stick and swollen oropharyngeal soft tissue (A) and air-mimicking space implying the accommodation of wooden foreign body (B).
Fig. 3.
CT scan demonstrating fracture of posterior wall of maxilla and accumulation of blood of in the maxillary sinus (A) and fracture of medial wall of orbit with intraorbital soft tissue being pushed laterally and forward which resulting in protruding eyeball of the corresponding side (B).
Fig. 4.
Specimen of the wooden stick, about 10
cm long and 1.2cm in diameter, the debris was removed by endoscopic re-examination of the wounds.
3. Discussion
Cases of accidental penetration injury of the head and neck by foreign bodies are not rare, but such a long stick via an oblique route occurred in a child was not documented in the literature [3]. The child was so lucky because intracranial tissue escaped from the trauma, that avoided many complications [4], and an eventless postoperative procedure proved that no stick retained in the wounds [5], [6]. Removal of wooden foreign bodies is important because their porous consistency and organic nature are excellent media for microorganisms, and retained wooden foreign matters may result in cellulitis, abscess, or fistula formation. Wound infection is frequent and may be life threatening. Antibiotic treatment must therefore be started with good anaerobic coverage.
Radiography, CT, magnetic resonance imaging (MRI), and sonography have been advocated for the detection of retained foreign bodies. Foreign bodies are made of metal, plastic, or glass, each of which is generally easily detected with an ordinary X-ray. However, wooden foreign bodies are difficult to detect through ordinary X-ray, which is why their diagnosis is often missed or delayed [5], [7]. An embedded wooden foreign body can still be misinterpretated by CT morphology. On a non-enhanced CT scan, to carefully evaluated whether or not the carotid artery being involved is crucially important, it must be studied by the contexture of a series of sections. Some scholars also described new CT techniques to detect wooden foreign bodies [8].
In the appropriate trauma setting a penetrated and retained wooden foreign body must always be suspected. In cases with protruding eye ball periorbital injury or optic nerve trauma must be excluded. Nasal endoscope was employed to re-examine the wounds for possible remains of foreign body and got good results, thus it is recommended from the technical point of view.
References
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PII: S1871-4048(08)00056-7
doi:10.1016/j.pedex.2008.08.003
© 2008 Elsevier Ireland Ltd. All rights reserved.
Volume 4, Issue 2 , Pages 88-91, March 2009
