Transorbital penetrating injury: case series, review of the literature, and proposed management algorithm

Abstract

Transorbital penetrating injury (TPI), an uncommon subset of head trauma, requires prompt multidisciplinary surgical intervention. While numerous case reports appear in the literature, there is a lack of discrete recommendations for initial evaluation, surgical intervention, and postoperative care of patients with TPI. A retrospective review of 4 cases of TPI at the University of Michigan Health System was undertaken to assess for diagnosis, treatment, and follow-up. In addition, a PubMed search using the terms "penetrating orbital trauma," "penetrating orbital injury," "transorbital penetration," and "transorbital penetrating injury" were used to search for articles discussing the presentation and management of penetrating orbital trauma. All 4 of the patients at the University of Michigan underwent focused physical examination performed by a multidisciplinary trauma team followed by dedicated maxillofacial and head CT scanning. The patients' treatments varied, depending on the mechanism and extent of the injury. An analysis of the case series presented here as well as other published cases suggests an algorithm for diagnosis and treatment for patients with TPI, which includes focused evaluation, diagnostic imaging with maxillofacial CT scanning, and management of the injury that focuses on the path of penetration and the presence of the foreign body in situ at the time of presentation. Magnetic resonance imaging is indicated in patients who have indwelling wooden foreign bodies. Angiography should be performed in patients with suspected vascular injury. Treatment decisions should be made by a multidisciplinary team with input from neurosurgery, ophthalmology, otolaryngology, and maxillofacial surgery.

Cerebrovascular complications of transorbital penetrating intracranial injuries

“…A third trajectory of penetration is the optic canal. [5,6] Penetrating objects may have been directed centrally because of the funneling of low-velocity objects centrally as they can make their way into the skull through the low-resistance pathways mentioned above.…”

“…[5,6] The most frequent path is via the roof of the orbit since the superior orbital plate of the frontal bone is fragile, and during the injury, patients extend their heads backwards, exposing the orbital roof. The next most common route is via the superior orbital fissure.…”

“…[4] It represents an uncommon type of injury, [5,6] it occurs more frequently in children, [7,8] and its management has been reported to be a challenge. [9] Although uncommon, TIPI may result in grave complications such as cerebrovascular injury, central nervous system infections, cerebrospinal fluid fistulas, and venous thrombosis.…”

A successfully-treated case of penetrating facial trauma

“…Premature removal without adequate preparation can put the patient at risk for further injury or fatal bleeding if the object has caused a tamponade of the bleeding [9]. Our patient presented with corresponding brain hemorrhages with a great mass obscured on the follow-up CT scan, indicating that bleeding occurred after removal of the object.…”

Intraorbital Wooden Foreign Body: A Case Report

“…The quadrilateral pyramidal shape of the orbit directs foreign bodies either towards the roof of the orbit resulting in frontal lobe injury as when one falls from above or towards the superior orbital fi ssure as in low velocity injuries 3 . Wooden foreign bodies that have a sharp edge can penetrate deep into the orbit and cranial cavity even through a small entry wound 4 .…”