Combined transcranial and transnasal endoscopic approach in transnasal-penetrating intracranial injury: A rare case report

Abstract

Introduction: Transnasal-penetrating intracranial injuries are rare traumatic brain injuries that can cause serious and fatal brain damage and a high mortality rate and necessitate immediate multidisciplinary surgical management. We describe an uncommon case whereby a patient who presented with an accidental penetrating injury of the brain was found to have a wooden transnasal-penetrating intracranial object.

Case presentation: A 28-year-old man consulted an ear, nose, and throat (ENT) surgeon after complaints of headache for two days, a history of epistaxis, and vomitus. The right side of the nose had been punctured by wood as a result of falling from a motorcycle. A computed tomography (CT) scan led to diagnosis of a transnasal penetrating intracranial injury. Removal of the transcranial foreign body was carried out jointly by a neurosurgeon and ENT surgeon. Postoperatively, antibiotics were given for 14 days, and the patient was discharged without neurological deficit.

Clinical discussion: Early diagnostic procedures, such as CT scan of the skull to assess trajectory and extent of vascular and brain tissue injury, are required for appropriate surgical planning and post-operative treatment of such patients. Surgery was performed by combined transcranial and transnasal endoscopy to identify the skull base, dura mater defect, and brain tissue damage. Removal of the corpus alienum by transnasal endoscopy yielded a good outcome.

Conclusion: Combined transcranial and transnasal endoscopic approach showed better result than transcranial approach only. The wooden foreign body can be completely eliminated transnasally without active bleeding using this approach. The patient was discharged with good outcome.

Keywords: Case report; Endoscopic endonasal approach; Foreign body; Penetrating intracranial injury; Transcranial; Wooden object.

Fig. 1

An anteroposterior X-ray of the skull, showing a blood clot with a radiopaque appearance in the right nostril (red arrow). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 2

A non-enhancement head CT scan (axial plane) showing a hypodense lesion extending from the right nasal cavity to the cerebral parenchyma of the right frontotemporal lobe, corresponding with the pneumocephalus apparent after extraction of the wood (A, B, C). The white arrow indicates a hyperdense lesion corresponding to contusion of the frontal lobe region (A). The sagittal plane shows fractures in the ethmoidal bone and right sphenoidal bone (D). A non-enhancement post-surgery head CT scan, axial plane (E, F, G). Arrows indicate the bilateral frontal lobe and right periventricular contusion cerebri (red arrow) and the right frontotemporal bone defect post craniectomy (yellow arrow). Sagittal plane, (H): the ethmoid bone was closed by a musculus temporalis graft (white arrow). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 3

After durotomy, exploration and irrigation of the wood fragments were carried out (A and B). Evaluate the bleeding and bleeding control (C).

Fig. 4

Transnasal endoscopy. The wooden foreign body (A) was extracted by up-ten forceps (B). Concha inferior (red arrow), septum nasi (yellow arrow). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)