Endoscopic Management of Transnasal Intracranial Penetrating Foreign Bodies

Abstract

ConclusionAs experience with endoscopic sinus surgery has grown, so have its extended applications. Endoscopic management of transnasal intracranial foreign bodies can be successfully performed in selected patients and yields an improved cosmetic outcome and a decreased risk in complications.The patient was a 21 year old male who was driving intoxicated and sustained a motor vehicle accident. Patient was ejected from his vehicle and launched toward a tree. Patient presented to our institution with a tree branch which had entered the left aspect of his oral cavity piercing through his gingival labial sulcus, traveling into his left nasal cavity, penetrating through the septum into the right nasal cavity, traveling intracranially and piercing white matter. There was no evidence of a CSF leak at time of presentation.CT Head was performed which showed the skull base defect produced by penetrating organic foreign body.Penetrating intracranial foreign bodies were removed using endoscopic sinus equipment. The resulting CSF leak was repaired at the same time.In the literature there are three other patients with transnasal intracranial penetrating foreign bodies managed endoscopically. Of these patients, one had an organic substance, whereas the other two patients had metallic foreign bodies. Endoscopic removal was successful in all patients and the CSF leak was repaired in all patients with a multi-layered closure following retrieval of the foreign body. One patient had a lumbar drain placed at time of retrieval whereas one patient had endoscopic removal with assistance of image guidance. None of the patients suffered complication including meningitis, CSF leak, brain abscess, hydrocephalus, neural/vascular injury or death, which are all associated with craniotomy.Intracranial foreign bodies generally require a craniotomy approach which is associated with a significant risk of perioperative morbidity. Whereas the transnasal endoscopic approach is a minimally invasive technique with lower associated morbidity/mortality. One may still need to manipulate surrounding brain parenchyma although there is no added potential risk, as there is with a craniotomy where the frontal lobe is retracted.Recommendations for endoscopic management of intracranial penetrating foreign bodies includes: use of Image guidance, neurosurgical consultation, and angiography to assess for intracranial vascular injury which should be considered a contraindication to the endoscopic approach, as vigorous bleeding would compromise endoscopic visualization.

Penetrating transorbital injury by a coloring pencil in a 3-year-old child: A case report

“…The patient then developed cerebrospinal rhinorrhea, which was successfully resolved by an endoscopic surgical intervention. Mzimbiri et al 5,12 described a 2-year-old boy who injured his right eye with a chopstick that had penetrated the orbital roof and entered the frontal lobe after fracturing the frontal sinus. The chopstick and bone fragments were removed through its trajectory by a subfrontal craniotomy.…”

“…This management strategy differs from the recommendation of the Guidelines for the Management of Penetrating Brain Injury. 12 After the operation, the patient immediately underwent CT and CTA, and a physical examination was performed. No abnormalities were observed, and the patient was discharged uneventfully.…”

Presentation, Workup, and Management of Penetrating Transorbital and Transnasal Injuries: A Case Report and Systematic Review

“…3,5,12–16 Endoscopic surgery has allowed for a safe and minimally invasive approach for removal of the FB. 3,5,12–16 In our case, the skull base was exposed endoscopically with the i n situ FB, which allowed for visualization during removal and subsequent repair. Familiar endoscopic techniques can then be used for repair of CSF leaks with a high success rate because traumatic CSF leaks often heal well.…”

Intracerebral bullet removal through an endoscopic transnasal craniectomy

“…[6161721–25] Since 2004, endoscopic transnasal removal of intracranial foreign bodies has been reported. [820]…”

“…[68161720–25] To our knowledge, intracranial bullet extraction through an endoscopic transnasal craniectomy (ETC) has never been reported before, which is also related to the low frequency of favorable positioning of the bullet and to the high mortality rate. This report details the operative technique for a unilateral keyhole craniectomy of the anterior skull base with subsequent multilayer reconstruction.…”