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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 59  |  Issue : 4  |  Page : 385-387

Intraorbital wooden foreign body mimicking traumatic emphysema: An intriguing case report


1 Department of Ophthalmology, IMS and SUM Hospital, Bhubaneswar, Odisha, India
2 Department of Ophthalmology, LBK Medical College and Hospital, Saharsa, Bihar, India

Date of Submission21-Apr-2021
Date of Decision07-Jul-2021
Date of Acceptance04-Aug-2021
Date of Web Publication21-Dec-2021

Correspondence Address:
Dr. Jasmita Satapathy
Department of Ophthalmology, IMS and SUM Hospital, Bhubaneswar - 751 003, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjosr.tjosr_46_21

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  Abstract 


We report the case of a 73-year-old woman who sustained left orbital injury following a fall over a bush, 2 days ago. Computed tomography (CT) of the orbit demonstrated preseptal soft tissue swelling along with a low-attenuation streak of air density focus abutting inferior rectus muscle, mimicking emphysema. The presence of a wooden foreign body was suspected, and magnetic resonance imaging (MRI) was advised. Subsequently, a wood splinter measuring 26 mm × 6 mm was removed on surgical exploration. Low-density signals relative to surrounding orbital fat on CT scan should evoke suspicion of a retained wooden foreign body. Early clinical suspicion and adjunctive MRI scan would help in recurrence-free treatment.

Keywords: Case report, intraorbital foreign body, orbital imaging, traumatic emphysema, wooden foreign body


How to cite this article:
Satapathy J, Kumar A. Intraorbital wooden foreign body mimicking traumatic emphysema: An intriguing case report. TNOA J Ophthalmic Sci Res 2021;59:385-7

How to cite this URL:
Satapathy J, Kumar A. Intraorbital wooden foreign body mimicking traumatic emphysema: An intriguing case report. TNOA J Ophthalmic Sci Res [serial online] 2021 [cited 2022 Jan 27];59:385-7. Available from: https://www.tnoajosr.com/text.asp?2021/59/4/385/333172




  Introduction Top


Organic foreign bodies such as wood cause recurrent infection, which can give rise to various sight-threatening as well as life-threatening complications.[1] Many a time, the diagnosis is delayed as these foreign bodies are difficult to be detected on standard imaging techniques such as ultrasound and computed tomography (CT) scan.[2] Other diagnostic modalities such as magnetic resonance imaging (MRI) in suspected cases are of immense help.[3] Early diagnosis and timely intervention are of key importance to prevent further complications in such cases. Here, we report a case of intriguing presentation of retained intraorbital wooden foreign body mimicking traumatic emphysema.


  Case Report Top


A 73-year-old female presented with a history of fall over a bush while plucking flowers 2 days ago. On examination, a lacerated wound was noticed inferomedially and 20 mm below the lower lid margin of the left eye with purulent discharge. The wound measured 10 mm long and 5 mm wide [Figure 1]. Her visual acuity was 20/30 in both eyes. In the left eye, there were severe chemosis, conjunctival congestion, axial proptosis, and limited ocular movements in all directions of gaze. While dressing the wound, small broken wood particles were noticed which were removed carefully. A noncontrast CT of the head with three-dimensional skull was advised. The scan revealed preseptal soft tissue swelling along with a low-attenuation streak of air density focus closely abutting inferior rectus muscle mimicking traumatic emphysema, with associated extraconal fat stranding [Figure 2]. However, as the air bubble had irregular margin, the presence of a wooden foreign body was suspected which was then confirmed by MRI [Figure 3]. No bony injury was seen and no abnormality was detected in the brain on imaging. The patient was started on systemic broad-spectrum antibiotic. Transconjunctival orbitotomy was planned to explore orbital floor, under general anesthesia. As the patient had poor glycemic control at presentation, insulin was started in a titrated dose and surgical exploration was performed 2 weeks later after adequate control of blood sugar. A wooden stick measuring 26 mm × 6 mm was removed [Figure 4]a and [Figure 4]b. Following surgery, her visual acuity was 20/30 in both eyes. On 2 weeks of follow-up, the eye was quiet and there was no proptosis [Figure 5]. Ocular movement was full in all directions of gaze. Entry wound was healed and there was no pus discharge. Visual acuity was 20/30 in both eyes. At 6 months of follow-up, the patient was maintaining good vision and there were no complaints.
Figure 1: Clinical photograph showing periorbital edema, conjunctival chemosis, and mild proptosis of left eye. There is an entry wound located inferomedially, 20 mm below the left eye lower lid

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Figure 2: Axial (left), coronal (middle), and left sagittal (right) computed tomography scans showing radiolucent foreign body (white arrow) in the extraconal space of the left orbit with surrounding fat stranding. Note the foreign body mimics air bubble

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Figure 3: Magnetic resonance imaging of brain and orbit (left) T2-weighted and (right) with contrast showing a linear foreign body (white arrow) located medial to inferior rectus muscle and closely apposed to the muscle with surrounding inflammation

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Figure 4: (a) Intraoperative color photograph showing transconjunctival orbitotomy with removal of foreign body. (b) Photograph showing a linear and irregular wooden foreign body measuring 26 mm × 6 mm (Courtesy: Dr. Suryasnata Rath, Consultant, Ophthalmic Plastic Surgery, Orbit and Ocular Oncology services, LVPEI, Bhubaneswar)

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Figure 5: Clinical photograh 2 weeks after surgery showing complete resolution of orbital cellulitis and the entry wound. Note that there is no limitation of extraocular movement on the affected side

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  Discussion Top


Orbital injuries with retained foreign bodies can cause varying degree of ocular morbidity by causing infections along with direct mechanical effects. Sometimes, they are associated with life-threatening consequences.[4] Although the mechanism of injury defines the clinical presentation to a large extent, in most cases, timely intervention can have a favorable outcome.

Some metallic and most inorganic foreign bodies are inactive, while the organic materials such as wood act as a great medium for bacterial growth.[1] They can be presented with granuloma, discharging sinus, cellulitis, and abscess which can later spread to central nervous system.[1],[5] Hence, early surgical exploration is necessary when organic intraorbital foreign body (IOFB) is suspected. In our patient, the organic nature of the foreign body, large size, and periorbital infection were the indications for surgical exploration though the vision at presentation was good. Wooden foreign bodies are fragile, and therefore, complete removal is difficult. Retained fragments tend to disintegrate with time and cause recurrent infection.[1] However, in our patient, the wooden foreign body could be removed completely with no remnant fragment. This was possible probably due to early diagnosis.

CT is the most sensitive imaging modality when an IOFB is suspected.[3] It not only detects retained foreign body, but also helps to find out associated bony fractures, surrounding tissue response, and if there is intracranial extension of infection. However, it may produce false-negative results at times.[3] Studies have reported that, on CT scan, wooden foreign bodies may mimic air bubbles depending on their hydration status.[5],[6] MRI may be used as an alternate method in such cases only after ruling out the presence of metallic foreign body.[3] Wood appears hypointense to fat on T1- and T2-weighted studies due to its high air content.[7] It is seen as a dark empty space of varied shapes depending on the plane of section. Despite all these available highly sensitive and specific imaging modalities, detecting organic foreign body remains challenging in most cases.[8]

In our case, we did CT scan to find out the presence of IOFB as well as associated bony fractures, if any. As the picture was confusing on CT scan, we did MRI to confirm the presence of wooden foreign body. There was no direct injury to the eye ball and optic nerve in our patient. Hence, the vision was good at presentation and it was maintained after surgery.


  Conclusion Top


Careful history about the mechanism of injury, high index of suspicion, and appropriate imaging technique will guide to diagnose the presence of retained IOFB in most cases. Although CT is the diagnostic modality of choice to detect IOFBs, an MRI scan should be combined as an adjunctive when they are inconclusive on CT. Moreover, it should be kept in mind while suspecting wooden foreign bodies that they can mimic air spaces on CT. Irregular margins of the air-like images of wooden foreign bodies can differentiate them from traumatic emphysema.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

We thank Dr. Suryasnata Rath, Consultant, Ophthalmic Plastic Surgery, Orbit and Ocular Oncology Services, LVPEI, Bhubaneswar, for performing surgery and providing us intraoperative photographs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Shelsta HN, Bilyk JR, Rubin PA, Penne RB, Carrasco JR. Wooden intraorbital foreign body injuries: Clinical characteristics and outcomes of 23 patients. Ophthalmic Plast Reconstr Surg 2010;26:238-44.  Back to cited text no. 1
    
2.
Li J, Zhou LP, Jin J, Yuan HF. Clinical diagnosis and treatment of intraorbital wooden foreign bodies. Chin J Traumatol 2016;19:322-5.  Back to cited text no. 2
    
3.
Javadrashid R, Golamian M, Shahrzad M, Hajalioghli P, Shahmorady Z, Fouladi DF, et al. Visibility of different intraorbital foreign bodies using plain radiography, computed tomography, magnetic resonance imaging, and cone-beam computed tomography: An in vitro study. Can Assoc Radiol J 2017;68:194-201.  Back to cited text no. 3
    
4.
Zhou L, Li SY, Cui JP, Zhang ZY, Guan LN. Analysis of missed diagnosis of orbital foreign bodies. Exp Ther Med 2017;13:1275-8.  Back to cited text no. 4
    
5.
Schreckinger M, Orringer D, Thompson BG, La Marca F, Sagher O. Transorbital penetrating injury: Case series, review of the literature, and proposed management algorithm. J Neurosurg 2011;114:53-61.  Back to cited text no. 5
    
6.
Sanli AM, Kertmen H, Yilmaz ER, Sekerci Z. A retained wood penetrating the superior orbital fissure in a neurologically intact child. Turk Neurosurg 2012;22:393-7.  Back to cited text no. 6
    
7.
Peterson JJ, Bancroft LW, Kransdorf MJ. Wooden foreign bodies: Imaging appearance. AJR Am J Roentgenol 2002;178:557-62.  Back to cited text no. 7
    
8.
Ananth Kumar GB, Dhupar V, Akkara F, Praveen Kumar S. Foreign body in the orbital floor: A case report. J Maxillofac Oral Surg 2015;14:832-5.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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