Abstract

Background: To the best of our knowledge, there are no reports of penetrating orbitocranial injury (POCI) caused by a shoji frame.

Case Description: A 68-year-old man fell in his living room and was stuck headfirst by a shoji frame. At presentation, marked swelling was noted in the right upper eyelid, with the edge of the broken shoji frame exposed superficially. Computed tomography (CT) revealed a hypodense linear structure located in the upper lateral sector of the orbit, partially protruding into the middle cranial fossa. Contrast-enhanced CT revealed intact ophthalmic artery and superior ophthalmic vein. The patient was managed with frontotemporal craniotomy. The shoji frame was extracted by pushing out the extradurally located proximal edge from the cranial cavity and simultaneously pulling the distal edge from the stab wound in the upper eyelid. Postoperatively, the patient received intravenous antibiotic therapy for 18 days.

Conclusion: POCI can be caused by shoji frames as a result of an indoor accident. The broken shoji frame is evidently delineated on CT, which can result in prompt extraction.

Keywords: Indoor accident, Penetrating orbitocranial injury, Shoji frame, Treatment

INTRODUCTION

Penetrating non-missile injuries to the head are an infrequent entity that commonly occurs as an accident.[ 3 ] Penetrating orbital injuries (POCIs) caused by wooden foreign bodies are rare, but distinct accidents that have been sporadically documented so far.[ 1 - 5 , 7 , 8 , 10 - 15 ] These injuries are commonly diagnosed using computed tomography (CT). However, wooden foreign bodies that migrate into the orbital and cranial cavities can be missed or misinterpreted on CT.[ 6 , 7 , 11 - 13 , 15 ]

Shoji is a traditional Japanese style architecture that typically divides the indoor rooms and the hall that faces outdoors. Shoji is commonly wooden, takes the structure of lattice frames over which Japanese papers are stuck, and slides laterally to come and out of the room. Only one penetrating head injury caused by a shoji frame has been reported in literature.[ 9 ] However, to the best of our knowledge, POCI caused by a shoji frame has not yet been reported.

Herein, we present such a case wherein a shoji frame was successfully extracted through frontotemporal craniotomy.

CASE PRESENTATION

A 68-year-old Japanese man fell in his living room and was stuck headfirst by a shoji frame. The patient visited a local ophthalmologist the day after the injury in the right upper eyelid, where he was suspected of penetrating orbital injury by a broken shoji frame. At presentation, the patient was well oriented. However, marked swelling and redness were noted on the right upper eyelid. In addition, the edge of the broken shoji frame was superficially exposed in the lateral part of the eyelid [ Figure 1 ]. Watery discharge from the wound was noted. His visual acuity appeared intact on confrontation test. Considerable restriction of ocular movement was found on the lateralward gaze, while other extraocular movements were intact. The blood examination revealed normal findings. Cranial CT revealed a linear structure in the upper lateral sector of the orbit. It appeared homogeneously hypodense, well demarcated, and partially protruded into the middle cranial fossa. Contrast CT showed that the ophthalmic artery and superior ophthalmic vein were intact [ Figure 2 ]. Under general anesthesia, the patient was positioned supine and underwent a right frontotemporal craniotomy. Initially, the site of the localized inner protrusion of the middle fossa (MF) dura, caused by the proximal edge of the broken shoji frame, was identified from the intradural side [ Figure 3a ]. The site was accompanied by a tiny laceration of the dura, while cerebral contusion or subdural hemorrhage was not observed. Next, the proximal edge of the broken shoji frame was secured from the extradural side [ Figure 3b ]. The edge was then pushed out from the cranial cavity using a Penfield dissector, while simultaneously pulling the distal edge through the stab wound in the upper eyelid [ Figure 3c ]. Using these methods, the shoji frame was successfully extracted in two pieces without hemorrhagic complications. The frame was flat, measured 1 cm in width and 5 cm in length, and had smooth surfaces [ Figure 4 ]. Wound debridement was made around penetrating site in the upper eyelid. Postoperatively, the patient received intravenous antibiotic therapy with ceftriaxone sodium hydrate (4 g/day) for 18 days, which was sensitive for possible contamination of staphylococcus epidermidis. Marked swelling and redness initially found in the upper eyelid resolved 2 weeks after surgery without infectious complications. Visual deterioration was not identified. However, restriction of ocular movement on the lateralward gaze persisted, accompanied by horizontal skin depression in the affected upper eyelid [ Figure 5 ]. The patient followed an uneventful post-treatment course for a year without administration of antibiotic agents, with stable findings on periodic magnetic resonance imaging (MRI).

Figure 1:

Photograph of the patient at the presentation, right oblique view, shows marked swelling and redness centered in the right upper eyelid, with the edge of broken shoji frame exposed superficially in the lateral part of the eyelid, as indicated with asterisk.

Figure 2:

Non-contrast axial (a), coronal at the equator level of the bulb (b) and orbital apex (c), and sagittal (d) computed tomography, 3 mm in slice thickness, show a homogeneously hypodense, linear structure located in the upper lateral sector of the orbit, partially protruding into the middle fossa. Contrast-enhanced axial computed tomography revealed the ophthalmic artery (OA) and superior ophthalmic vein (SOV) to be intact (e). ACP : Anterior clinoid process, LRM : Lateral rectus muscle, SRM: Superior rectus muscle, Arrow: Fracture in the sphenoid bone, Arrowheads: Displaced inner table of the sphenoid bone, Asterisk: Broken shoji frame.

Figure 3:

Intraoperative photos present step-by-step procedures of extraction. (a) Intradural view: site of the proximal edge of broken shoji frame is identified as a localized inner protrusion of the MF dura (arrowhead). (b) Extradural view: proximal edge of the shoji frame (arrowhead) is marked with pyoktanin blue. (c) Extradural view: proximal edge of the shoji frame (arrowhead) is being pushed out from the cranial cavity using a Penfield dissector (double asterisk). SV : Sylvian vein, MF: Middle fossa.

Figure 4:

Photograph of shoji frame extracted in two pieces. The flat frame measures 1 cm in width and 5 cm in length. The surfaces of the frame are smooth. Arrowhead: Proximal edge of the shoji frame; Asterisk: superficially exposed, distal part of the shoji frame.

Figure 5:

Photographs of frontal (a) and right lateral (b) views of patients, captured 2 weeks after surgery, show resolution of marked swelling and redness found in the right upper eyelid, accompanied by horizontal skin depression (arrow).

DISCUSSION

POCIs caused by wooden foreign bodies are rare. To the best of our knowledge, only ten cases including the present patient have been reported to date.[ 1 - 3 , 5 , 8 , 11 , 14 , 15 ] The mean age of these patients was 40.4 years with a male predominance.

All patients underwent a frontotemporal craniotomy or its modifications, followed by empirical antibiotic therapy. Treatment outcomes were satisfactory in seven of ten patients, while ophthalmoplegia persisted in two patients. The condition of the remaining patient was complicated by severe bacterial ophthalmitis as a result of residual foreign bodies in the orbit [ Table 1 ]. In the present case, an extradural maneuver aiming to push out the migrated shoji frame, through a frontotemporal craniotomy, was effective in exposing the proximal edge and extracting it from the distal side. In addition, the homogeneously flat shape and smooth surfaces of the shoji frame could be attributed to successful extraction. Considering the CT findings at the initial presentation, injury to the lateral rectus muscle, presumably occurring in the orbital apex, was thought to result in persistent ophthalmoplegia.

Table 1:

Summary of reported penetrating orbitocranial injuries.

In the present case, a wooden foreign body was removed through a frontotemporal craniotomy. It was located in the upper lateral sector of the orbit, while partially protruded into the middle cranial fossa accompanied by fractures and possible dura tears. Therefore, we adopted craniotomy, instead of lateral orbitotomy, feasible for both intra-, and extradural procedures.

Wooden foreign bodies migrated in the orbital and cranial cavities have been documented to be missed on CT, indicating the diagnostic value of MRI in POCI cases.[ 6 , 7 , 11 - 13 , 15 ] In the present case, the broken shoji frame located in the upper lateral sector of the orbit and anterior MF was satisfactorily discriminated from the surrounding bony, muscular, and vascular structures on CT. Therefore, the patient underwent surgery without MRI evaluation. CT may provide valuable information on shoji frames penetrating into the orbital and cranial cavities, in addition to lessening the need for MRI, especially in an emergent setting. In contrast, if located adjacent to the nasal and paranasal cavities, it is less discernible from these cavities, because the shoji frame, a piece of dry wood, appears similar hypodensity on CT.

Broken shoji frames could be a strong weapon that can penetrate into the skull.[ 9 ] Therefore, the shoji frame may cause indoor POCI in Japanese style houses.

CONCLUSION

POCI can be caused by a shoji frame as a result of an indoor accident. The broken shoji frame is evidently delineated on CT, which can result in prompt extraction after injury.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Disclaimer

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.

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