Endoscopic endonasal removal of a sphenoidal sinus foreign body extending into the intracranial space

ABSTRACTSphenoidal sinus foreign bodies are very rare entities that are often associated with a cranial and/or orbital trauma. In this paper, a case of a metallic foreign body that pierced the sphenoid sinus and penetrated into the intracranial space due to a work accident is presented. A 29-year-old male was referred to our clinic due to a right orbital penetrating trauma. Skull X-ray and computed tomography (CT) scans demonstrated a foreign body inside the sphenoidal sinus, extending to the left temporal fossa. The foreign body was removed using an endoscopic endonasal technique, and the skull base was reconstructed with a multilayer closure technique. There were no complications during or after the operation. Postoperative result was perfect after three months of follow up.

Key words:Endoscopic endonasal; foreign body; intracranial; sphenoid sinus.

INTRODUCTIONParanasal sinus foreign bodies are very uncommon in the literature.[ 1] Most incidences of these objects usually occur with trauma, penetrating injuries, motor vehicle accidents, and iatrogenic and intracranial lesions.[2-5] In addition, paranasal sinus foreign bodies are found in the frontal and maxillary sinuses relatively more often than the ethmoidal and sphenoid sinuses.[ 2,6,7] The foreign body usually reaches the sphenoid sinus through the orbit or the nostril.[8] Their close relationship to the adjacent vascular and neural structures makes sphenoidal sinus injuries a potentially life-threatening occurrence.[9] An endoscopic endonasal approach is usually selected for the removal of these objects.[9-12] If the foreign body is completely intracranial, an open surgical approach could be selected.[3,5,10] Because of better illumination and direct visualization, the endoscopic endonasal approach has proven accuracy for removal of these paranasal sinus foreign bodies. Furthermore, endoscopic endonasal approach demands a well-known anatomy of the spheno-ethmoidal region because of the presence of important and vital structures such as the ICA, optic nerves and the ethmoidal arteries.[13] In this paper, a successful endoscopic endonasal removal of an uncommon case of a metallic foreign body located in the sphenoidal sinus extending into the intracranial space due to an orbital injury is presented.

CASE REPORTA 29-year-old man, working as a professional mason, came to the emergency room for a work accident. The accident occurred when a metallic piece broke off of a marble cutting machine and became enlodged in his head through his right lower eyelid. His wound was sutured and the patient was referred to our clinic. He had a right periorbital ecchymosis, conjunctival hemorrhage and a sutured wound on his right lower eyelid (Figure 1). The neurological examination was completely normal without any vision impairment. A skull Xray showed a radiopaque foreign body in the sphenoidal sinus region (Figure 2). A computed tomography (CT) scan showed a probable metallic, 4 cm long foreign body that fractured the vomer and the nasal septum, pierced the lateral wall of the sphenoidal sinus and reached into the pteriogopalatine fossa, and settled next to the Internal Carotid Artery (ICA) (FigureLater, the patient underwent surgery via binostril endoscopic endonasal transsphenoidal approach, using 0- and 30-degree rigid endoscopes. A 40x3 mm metallic foreign body that pierced into the vomer and nasal septum was visualized during the procedure (Figure 5a). There was no bleeding or cerebrospinal fluid (CSF) leakage. The posterior nasal septum and anterior wall of the sphenoidal sinus were removed to mobilize the foreign body before it was gently removed (Figure 5b). A 3 mm diamater laceration and CSF leakage was observed in the left lateral wall of the sphenoidal sinus where the deep end of the foreign body was enlodged. The dura defect was closed with multilayer skull base reconstruction technique using free fat and tensor fascia lata autografts combined with fibrin sealant. Nasal packing was not used.