Missed Diagnosis of an Intraorbital Foreign Body of Homemade Fireworks Origin: A Case Report

Abstract

Purpose: We report a rare case of traumatic injury to the eye caused by homemade fireworks in a Chinese juvenile patient with a metal ring left in the orbit after having been sutured at the Emergency Department. Methods: An 11-year-old boy presented with a traumatic injury to the right eye from homemade fireworks. Following initial assessment involving maxillofacial computed tomography (CT) and suturing at the Emergency Department, he was transferred to our department for further evaluation because of his poor sight 1 day later. On examination, a skin laceration beneath the right eyebrow was noted, but the superior orbit was not fully visible on the maxillofacial CT performed 1 day previously. Therefore, an orbital CT scan was carried out on the second day, which showed a hyperdense ring embedded in the superior border of the orbital wall; the ring was surgically removed. On postoperative day 7, a fundus examination revealed resolving vitreous hemorrhage, blunt traumatic retinal detachment, and a large retinal tear superior to the macula. The patient refused to take surgery for retinal detachment into consideration. Therefore, we opted for oral steroids and careful observation. Results: After 2 months' observation, the large retinal tear had healed and white fibrous scar tissue had developed, and the retinal detachment superior to the macula had reattached itself spontaneously. The patient's vision had further improved to 20/200. During 1 year of follow-up, he remained clinically stable. Conclusion: To avoid missing the diagnosis, a complete history of the mechanism of injury and accurate imaging still prove most useful. Complete removal of the foreign body by the emergency physician is necessary because of the ocular toxicity of an iron-containing foreign body. As evidenced by the current case, oral steroids and observation for a period of several months is a management of choice for traumatic retinal detachment and retinal tear superior to the macula associated with homemade fireworks in children.

CT Findings of Firework Injuries to the Head and Neck

“…1 Yet, we have identified only 24 unique cases of fireworks injuries in the head and neck with CT imaging described in the literature with only 4 case series. [8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25] Here, we presented 18 additional cases that demonstrated a wide range of CT findings, including soft tissue swelling and Previous studies have also demonstrated that fireworks injuries disproportionately affect children, young adults, and males, 1-3 which is consistent with findings from our series of cases. Furthermore, the 24 cases in the literature showed a variety of CT findings: 13 cases with skull/maxillofacial fractures, 13,[15][16][17]20,25 7 cases with globe rupture, 9,12,16,20 10 cases with foreign bodies, 9,11,14,15,[18][19][20][21][22][23] 11 cases with intracranial hemorrhage or hematoma, 8,10,11,13,16,17,…”

“…1 Yet, we have identified only 24 unique cases of fireworks injuries in the head and neck with CT imaging described in the literature with only 4 case series. [8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25] Here, we presented 18 additional cases that demonstrated a wide range of CT findings, including soft tissue swelling and emphysema; extensive skull fractures; ocular injuries, such as globe rupture; the presence of retained foreign bodies; and intracranial injuries, such as subdural and subarachnoid hemorrhage.…”

“…1,3 Despite the well-documented prevalence of fireworks injuries, only 24 cases of fireworks-related injuries to the head and neck region with computed tomography (CT) imaging have been reported in the literature dating back to 1984. [8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25] These were mostly case reports, 8,[11][12][13][14][15][17][18][19][21][22][23][24][25] and case series are scarce with each one including 2 to 3 cases with CT imaging. 9,10,16,20 In addition, there has been no study reviewing CT imaging findings of fireworks injuries to the head and neck in the past literature.…”

<p>Unusual Missed Diagnosis of Foreign Body: A Case Report</p>

“…A computed tomography (CT) scan is considered the gold standard in imaging modality for metallic foreign bodies. 3 However, CT findings can vary. It is imperative to maintain a high index of suspicion in to avoid misdiagnosis.…”

“…It is imperative to maintain a high index of suspicion in to avoid misdiagnosis. 3 To avoid missing the diagnosis, careful evaluation and detailed imaging of the globe and surrounding structures, including the brain and paranasal sinuses, is indicated.…”