Management of an Unusual Intranasal Foreign Body Abutting the Cribriform Plate: A Case Report and Review of Literature

Mingyang Gray, MD MPH1; Satish Govindaraj, MD1

1Department of Otolaryngology, Icahn School of Medicine at Mount Sinai

Mingyang Gray, MDDepartment of Otolaryngology—Head and Neck SurgeryIcahn School of Medicine at Mount Sinai, New York, NYEmail: mingyang.gray@mountsinai.org

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1. Svider PF, Sheyn A, Folbe E, et al. How did that get there? A population-based analysis of nasal foreign bodies. Int Forum Allergy Rhinol. 2014;4:944-949.2. Pagella F, Emanuelli E, Castelnuovo P. Endoscopic extraction of a metal foreign body from the maxillary sinus. Laryngoscope. 1999;109:339-342.3. Dodson KM, Bridges MA, Reiter ER. Endoscopic transnasal management of intracranial foreign bodies. Arch Otolaryngol Head Neck Surg. 2004;130:985-988.4. Onerci M, Ogretmenoglu O, Yilmaz T. Glass in the frontal sinus: report of three cases. J Laryngol Otol. 1997;11:156-8.5. Brinson GM, Senior BA, Yarbrough WG. Endoscopic management of retained airgun projectiles in the paranasal sinuses. Otolaryngol Head Neck Surg. 2004;130:25-30.6. Yarlagadda B, Jalisi S, Burke P, Platt M. Retrieval of projectile foreign bodies from the paranasal sinuses and skull base. Am J Rhinol Allergy. 2012;26:233-236.

References

A 35-year-old man with history of schizophrenia presented

three weeks after placing a screw in his nose. CT showed a

screw in the right ethmoid sinus abutting the cribriform plate.

While most nasal foreign bodies occur in children and are

removed at the bedside, intranasal foreign bodies in adults

often require further assessment. Due to a concern for skull

base defect, the patient was brought to the OR for removal of

the screw. With possible skull base or intracranial involvement,

it is important to evaluate the mechanism of injury and

intervene in a controlled environment.

Abstract

Case Report

Many reports of endoscopic removal of foreign bodies have

been made since the advancement of transnasal endoscopic

surgery in the 1980s. Pagella et al. also demonstrated

endoscopic retrieval of dental implants using trocars.[2] These

objects are often a result of accidental falls or projectiles with

few as a result of intentional placement. Dodson et al.

presented another case of a patient with schizophrenia that

similarly placed multiple objects into the sinuses through the

site of a molar extraction. Endoscopic retrieval of the objects

involved creating a larger skull base defect with one foreign

body that penetrated the ethmoid roof.[3]

There are many possible sequelae of these cases. Foreign

bodies that violate the skull base can cause meningitis, brain

abscess, CSF leak, and neural or vascular injury. Foreign

bodies in the paranasal sinuses can can cause chronic

inflammation, cutaneous fistula, rhinolith, lead poisoning, and

chronic pain.[3,4,5] While foreign bodies such as bullets are

often left in soft tissue elsewhere in the body, most intranasal

foreign bodies are removed due to increased risk for

infection.[5,6] There are conflicting recommendations regarding

prophylactic antibiotics but most favor antibiotic use.[6]

In one retrospective review of 13 retained metallic foreign

bodies in the sinuses and/or skull base, three had involvement

of the skull base like our patient.[6] The authors recommended

that objects that are safely accessible and at risk for infectious

complications should be removed. Due to the unique nature of

each injury and the scarcity in which they present, there is little

evidence-based protocol for the management of these injuries.

However, Yarlagadda et al. proposed an algorithm based on

their 10-year retrospective review.(Figure 6)

Discussion

A skull base defect or intracranial involvement may not be

apparent when evaluating a patient with an intranasal foreign

object. Conversely, a patient with suggestive imaging may not

have an alarming clinical presentation. In this case, the

patient’s history and initial imaging was concerning for the

need to repair a skull base defect. However, his ultimate

outcome was benign. It is important to utilize appropriate

resources in planning the management of these patients. Most patients will require operative exploration and possible repair.

Conclusions

The patient is a 35-year-old male with schizophrenia who

presented with a screw he placed in his right nostril three

weeks prior. He reported hearing voices that told him to put the

screw in his nose. He had a history of ingesting part of a can

that required exploratory laparotomy for removal. He denied

fever, nasal drainage, pain or vision changes. CT Head

confirmed the foreign body with dehiscence of anterior cranial

fossa prior to transfer to our institution.(Figures 1,2)

The patient was stable upon arrival and CT angiography did

not reveal any intracranial vascular injury. MRI was deferred

due to the potential interference of a screw in the magnetic

field. Cultures were taken and intravenous antibiotics were

started. Neurosurgery, Psychiatry, and Infectious Disease were

consulted. The patient later underwent an elective right

maxillary antrostomy, total ethmoidectomy and frontal

sinusotomy with removal of anterior skull base foreign body.

The screw was found to be covered in plastic. It was displaced

inferiorly away from the skull base and maneuvered out of the

nasal cavity. The skull base was inspected with no visible

defect or cerebral spinal fluid leak. Surgicel and Evicel tissue

glue was applied and held with Nasopore. The patient was

discharged on post-operative day #2 on oral antibiotics.

Outpatient, the patient appeared well with repeat CT showing

persistent elevation of the skull base.(Figure 3) MRI showed

leptomeningeal enhancement but no pathologic concerns such

as encephalocele.(Figure 4) He was seen six months later with

no complaints. Ethmoid and frontal sinuses were patent but the

maxillary os was not visible and there was synechia noted

between the septum and inferior turbinate.(Figure 5) The patient has since been lost to follow up.

Figure 2. Preop CT with radiopaque screw displacing anterior skull base.

Figure 4. Leptomeningeal enhancement but no encephalocele or other pathology.

Figure 1. Intranasal screw with tip displacing the cribriform plate.

IntroductionIntranasal foreign body is a common chief complaint among

the pediatric population. There were 6,418 cases (3.2%) in a 5-

year nationwide study of all ED visits and only 214 involved

adults.[1] Certain foreign bodies such as button batteries and

sharp objects require careful evaluation. Due to the low

incidence of intranasal foreign bodies among adults with

different mechanisms of injury, most literature report individual

cases. Here, we present an adult patient who inserted a screw into his ethmoid sinus that involved the anterior skull base.

sinuses. Thirty patients underwent successful removal of the retainedbullets. There were five patients who had retained bullets in themaxillary sinus (two), sphenoid sinus (two), or pterygomaxillaryfossa (one), of which four that developed sinusitis requiring antibiotictreatment. The demographics, associated injuries, and outcomes fromcases reported in the literature are in agreement with the seriespresented here.Based on the cases presented in the literature and in this series, an

algorithm was devised to guide management of retained foreignbodies of the paranasal sinuses and skull base (Fig. 4). The overallstability of the patient must be ensured by Advanced Trauma LifeSupport guidelines. When the patient is stabilized from a cardiovas-cular standpoint, clinical and radiological workup should determinethe location of retained foreign bodies and proximity to vital struc-tures. Observation may be chosen if operative retrieval comes at a riskto neurovascular structures or the retained projectiles are numerousand small. Safely accessible foreign bodies should be removed, pref-

erably with an endoscopic approach. Traumatic CSF leaks often re-spond to conservative measures, but those that are noted at the timeof projectile retrieval should be repaired intraoperatively.The findings of this study are in agreement with the existing

literature regarding method of retrieval, use of antibiotics, and man-agement of CSF leaks. An inherent limitation of the proposed algo-rithm is the lack of statistical power. As with all rare and uniqueentities, prospective study is not feasible and clinical decisions mustbe made for each case. Future prospective studies would be helpfulfor statistical validation of this algorithm. With the current retrospec-tive data presented, delayed retrieval or observation of select foreignbodies remains a viable option depending on the clinical scenario.

CONCLUSIONSRetained projectile foreign bodies in the paranasal sinuses and skull

base are an uncommon but challenging clinical problem for head andneck surgeons. Those foreign bodies that are accessible without risk toadjacent structures should be removed to prevent infectious sequelae.Foreign bodies that can not be retrieved without risk of further harmrequire close follow-up and monitoring.

REFERENCES1. Center for Disease Control and Prevention. Web-based Statistics

Query and Reporting System. 2008.2. Brinson GM, Senior BA, and Yarbrough WG. Endoscopic manage-

ment of retained airgun projectiles in the paranasal sinuses. Otolar-yngol Head Neck Surg 130:25–30, 2004.

3. Gross M, Regev E, Hamdan K, and Eliashar R. Penetrating rubberbullet into the ethmoid sinus: Should the bullet be removed? Otolar-yngol Head Neck Surg 133:814–816, 2005.

4. Lee D, Nash M, Turk J, and Har-El G. Low-velocity gunshot woundsto the paranasal sinuses. Otolaryngol Head Neck Surg 116:372–378,1997.

5. Bhatoe HS. Missile injuries of the anterior skull base. Skull Base14:1–8, 2004.

6. Kuhnel TV, Tudor C, Neukam FW, et al. Air gun pellet remaining inthe maxillary sinus for 50 years: A relevant risk factor for the patient?Int J Oral Maxillofac Surg 39:407–411, 2010.

7. Ben-David J, Fradis M, Podoshin L, and Bartal AH. Plasmacytomaarising in the vicinity of a foreign body in the nasal cavity. Laryngo-scope 91:1150–1154, 1981.

8. Lubianca Neto JF, Mauri M, Machado JR, et al. Air gun dart injury inparanasal sinuses left alone. Int J Pediatr Otorhinolaryngol 52:173–176, 2000.

9. O’Connell JE, Turner NO, and Pahor AL. Air gun pellets in thesinuses. J Laryngol Otol 109:1097–1100, 1995.

10. Tian HM, Huang MJ, Liu YQ, and Wang ZG. Primary bacterialcontamination of wound track. Acta Chir Scand Suppl 508:265–269,1982.

11. Ratilal B, Costa J, and Sampaio C. Antibiotic prophylaxis for prevent-ing meningitis in patients with basilar skull fractures. CochraneDatabase Syst Rev 1:CD004884, 2006.

12. Banks CA, Palmer JN, Chiu AG, et al. Endoscopic closure of CSFrhinorrhea: 193 cases over 21 years. Otolaryngol Head Neck Surg140:826–833, 2009.

13. Wise SK, Harvey RJ, Neal JG, et al. Factors contributing to failure inendoscopic skull base defect repair. Am J Rhinol Allergy 23:185–191,2009. e

Figure 4. Proposed algorithm for management of retained projectile foreignbodies of the paranasal sinuses and skull base. *Foreign bodies were consid-ered at risk of infectious complications when in the vicinity of exposedsinonasal mucosa. **Conservative treatment of cerebrospinal fluid (CSF) leakincludes bed rest, elevation of the head of bed, and lumbar drainage. ***Op-erative retrieval is via the endoscopic route when possible.

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Figure 3. Postop CT with persistent elevation of anterior skull base.

Figure 5. Patent ethmoid and frontal sinuses postop.

Figure 6. Management algorithm proposed by Yarlagadda et al.[6]