An Unusual Penetrating Stab Injury in the Maxillary Sinus- A Case Report

EDWIN P. ESTONILO, MD

Edgardo Penserga, MD, FPCS

Reynaldo O. Joson, MD, MS Surg

OSPITAL NG MAYNILA MEDICAL CENTER

Department of Surgery

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Key Words: Penetrating Stab Injury, Maxillary Sinus

Reprint Request: Edwin Estonilo, M.D.

Department of Surgery, Ospital ng Maynila Medical Center

Ommcsurgery@yahoogroups.com

ABSTRACT

A Filipino patient presented a penetrating stab injury by a ball point pen in the maxillary area, right. The purpose of this report is to create awareness among health professionals and the public of the potential danger of penetrating stab injury involving the maxillary area. Skull x-ray showed (See Appendix A) opacity in the maxillary area. The object was a ball point pen lodged about 4 cm deep in the maxillary area, right. The patient was discharged on the 3rd postoperative day with no complications. Discussion focused on the dire consequences (damage adjacent major vessels or neural tissue), and what to do when a penetrating stab injury happened (close monitoring for adverse event and early medical professional consult).

INTRODUCTION:

Penetrating stab injuries of the maxillary area represent a higher incidence compared with high-velocity blunt injuries. Mostly at risk are the maxillary and ethmoid sinuses and the orbit. Involvement of the sphenoid and frontal sinuses is uncommon. Trauma to the maxillary sinus can be dangerous because of the anatomical relation to the surrounding vascular and neural structures and its threatening consequences when damage of these structures occurs. Craniofacial blunt injuries in pediatric patients with involvement of the brain are rare and may be disastrous.

This is a case report of a Filipino patient who was stabbed in the right maxillary area. There are two reasons why this case report is being made. First is for the benefit of the health professionals - to make them aware that injury in the maxillary sinus is a potential cause of severe bleeding and infection which could cause fistula. Awareness will facilitate early and correct diagnosis and early treatment thereby promoting successful patient management. Second is for the benefit of the public – to make them aware that injury in the maxillary sinus can cause bleeding and infection. Awareness will promote avoidance of early removal of the penetrating instrument that would further complicate the condition.

CASE REPORT

A 25 year old male, married from Manila was admitted at Ospital ng Maynila Medical Center- Surgery/Trauma Emergency Room with a penetrating stab wound at the maxillary area, right. The man was assaulted earlier that day with a ball point pen. There was no reported alteration of consciousness or vital signs before arrival. On presentation, the man was fully conscious with a Glasgow Coma Scale score of 15. The ball point pen was still positioned in the right maxillary area (Figure 1). Neurological examination showed no focal deficits, and all vital signs were normal. The globe was intact, all extra ocular movements were full and there was no proptosis or enophthalmos. On physical exam, palpation along the superior maxilla is unremarkable. No noted epistaxis or bleeding per orem.

We did not resort to arteriography as there were no signs to suspect significant vascular injury. The ball point pen was removed by a maxillofacial team under general anesthesia, and the entry wound was sutured. No major bleeding or liquorrhoea was noted from the wound.

Postoperative course was uneventful. Patient was discharged after three days. Oral medications (analgesics and antibiotics) were continued at home. He was followed up after one week and the sutures were removed.

DISCUSSION

Penetrating craniofacial injuries might have disastrous consequences. The entry of foreign objects can be transoral, transnasal, or transorbital. A variety of penetrating instruments have been described as scissors, nails, knives, toys, wooden branches, ballpoint pens, broken tooth brushes, and antennas. After stabilization of the patient, a careful multidisciplinary clinical and radiological evaluation in the emergency room needs to take place before further therapy is started. CT scan of the neurocranium and the paranasal sinuses is mandatory to understand the pathway of the penetrating object. Cerebral angiography is necessary to rule out serious bleeding complications from traumatic aneurysms or other vascular complications such as carotid cavernous sinus fistula, vessel occlusions, and still-silent vessel perforations when a clinical suspicion exists.

The removal of fixed penetrating foreign objects is not recommended until all details of the route and the damaged structures are known. It has been shown that the outcome in cases in which the foreign body was immediately removed is more often fatal compared with cases in which the foreign body remained in situ. This is said to be due to secondary injuries by twisting or rocking movements of the foreign body that may damage adjacent major vessels or neural tissue. With a multidisciplinary team and under controlled circumstances, the removal of the foreign body can be performed. In the case presented herein. Neurosurgical intervention was not necessary. However, the choice of the approach depends on the experience of the surgeon. The 6-month follow-up exam of the patient showed complete recovery without any functional defects. Careful and interdisciplinary management is mandatory.

REFERENCES

1. LaFrentz JR, Mair E, Casler J. Craniofacial ballpoint pen injury:

Endoscopic management. Ann Otol Rhinol Laryngology

2000;109:119–22.

2. Al-Sebeih K, Karagiozov K, Jafar A. Penetrating craniofacial injury in a pediatric patient. J Craniofac Surg 2002;13:303–7.

3. Kitajiri S, Tabuchi K, Hiraumi H. Transnasal bamboo foreign body

lodged in the sphenoid sinus. Auris Nasus Larynx 2001;28:365–7.

4. DeWeese, David; Sanders, William. Textbook of Otolaryngology. Sixth Edition.