Multi-disciplinary surgical management of ocular and maxillofacial ballistic injury: A case report

Abstract

Introduction and importance

Injury to the maxillofacial region is of great importance due to the highly sensitive area, and the vital structures it carries. Special surgical wounding techniques must be used due to the significant tissue destruction. We report a unique case of a ballistic blast injury in a pregnant woman in a civilian setting.

Case presentation

A 35-year-old pregnant female, in the third trimester, presented at our hospital after ballistic ocular and maxillofacial injuries. Due to the complex nature of her injury, a multi-disciplinary team consisting of otolaryngologists, neurosurgeons, ophthalmologists, and radiologists was formed to manage the patient. She was managed by performing an evisceration followed by an enucleation and a spherical implant, then underwent mandibulo-maxillary fixation due to a foreign body medial to the left ramus. This initial management plan proved to be effective until two (2) years later, she presented with new onset meningocele and active CSF rhinorrhea and meningitis, due to a left anterior skull base defect. The patient was then managed by reconstructive orbital and ethmoidal roof surgery. In addition, her pregnancy had favorable outcomes after an uneventful delivery.

Clinical discussion

Civilian setting injuries are specifically sensitive due to the lack of proper protection, such as in this case. This patient, a pregnant victim of a ballistic blast injury, was managed successfully by a multidisciplinary team through multiple reconstructive surgeries yet presented with a late life-threatening complication.

Conclusion

Long-term follow-up for such complex cases is recommended due to the possibility of late complications, despite adequate surgical management.

Highlights

• •Injury to the maxillofacial region carries a significant importance due the essential bodily functions it carries (ex: breathing, eating, smell, and sight).
• •A case of a pregnant civilian who sustained an explosive blast injury.
• •A patient with multiple facial injuries and rupture of the left eye globe requiring a multi-disciplinary team consisting of otolaryngologists, neurosurgeons, ophthalmologists, and radiologists to carry out the treatment plan.
• •Late complications of ocular and facial injuries include meningocele, meningitis, and CSF leak as a result of anterior skull base defect.

1. Introduction

Injury to the maxillofacial region carries significant importance to various sensitive and essential bodily functions that include breathing, eating, smell, and sight [1]. Moreover, cases of severe facial traumas are often accompanied by intracerebral injury [2]. In settings of war, the high-energy force conveyed through the high-speed objects often leads to destructive craniomaxillofacial injuries that are frequently associated with soft and hard tissue loss [3]. One of the troublesome areas to be involved in such traumas is the orbit and its contents as it may lead to endophthalmitis and ultimately vision loss [4]. Eye injuries account for about 10 % of all battle injuries [5]. Globe injuries, oculoplastic injuries, and neuro-ophthalmic injuries have been reported in the ocular blast traumas [6]. Such injuries with base of skull defect can result in cerebrospinal fluid (CSF) rhinorrhea and increase susceptibility to dangerous sequelae of orbital cellulitis and meningitis [7]. Herein, we present a case of a civilian war victim with a blast injury to the head that was managed by a multi-disciplinary team at a tertiary care hospital. The present case has been reported in line with the SCARE 2020 criteria [8].

Special surgical wounding techniques must be taken into consideration by healthcare providers in war sites, due to the significant tissue destruction in such injuries, in opposition to the typical wounds encountered by civilians, as war weapons create complex injuries with multidimensional wounding. The extent of destruction depends on multiple variables, including distance from the site, the extent of cover, and the proper protective gear. The type of injury ranges from small penetrating wounds to devastating complex ones. On the contrary, larger missiles with larger fronts, such as bullets that spread on collision, cause more injury and larger cavitation. Finally, ocular trauma is one of the main domains in Trauma Life Support as it is important to identify signs of ruptured globe injury and provide initial management, before the specialized care under the Ophthalmology department [9].

2. Presentation of case

We report a case of a 35-year-old pregnant female, third trimester (28–30 weeks), who was referred to our tertiary care hospital, one week after sustaining an explosive blast injury, which resulted in multiple facial injuries, including a cut wound over the left forehead, and rupture of the left eye globe with no light perception.

On admission, the patient and her fetus were stable, with complete vision loss in the left eye. The patient was neurologically intact despite a frontal contusion in the brain. Computed Tomography (CT) scan showed a left frontal contusion with condylar fracture, shattered medial wall and roof of the left orbit, left globe rupture, and foreign body insertion in the right globe (Fig. 1).

Fig. 1.

CT scan of the paranasal sinuses for pre-surgical evaluation of the skull base defect.

Initially, the patient underwent left eye globe evisceration due to the existing orbital fracture, and a conformer was fitted in the socket as a placeholder for future prosthesis placement. The patient also underwent mandibulo-maxillary fixation due to a foreign body medial to the left ramus and tenderness at the left angle. The postoperative course was uneventful. A year later, as planned, the patient underwent left eye enucleation of the sclera and removal of a free fractured bone piece from the lateral orbit. A spherical implant was then placed behind the posterior tenon for volume reconstruction in the left eye. The patient also underwent repair by GORE-TEX frontalis sling as management for superior divisional oculomotor nerve palsy and left upper lid (LUL) paralytic ptosis. The postoperative course was uneventful, and she was satisfied with the cosmetic results.

Two years later, the patient developed an episode of meningitis with cerebrospinal fluid (CSF) leak and left orbital cellulitis, following an upper respiratory tract infection. Investigation revealed a remote fracture of the orbital groove with dehiscence of bone in the left superior ethmoidal sinus and fracture of the lamina papyracea with a small encephalocele. The previously placed foreign body PMMA implant and the GORE-TEX slings were removed as part of the management plan for meningitis. Medical management with Intravenous (IV) antibiotics for meningitis and left orbital cellulitis were started until the infection improved clinically. The patient also received a dose of the pneumococcal vaccine.

Findings of the CT and Magnetic Resonance Imaging (MRI) scans necessitated a multi-disciplinary team consisting of otolaryngologists, neurosurgeons, ophthalmologists, and radiologists to be formed to carry out the treatment plan. Following the diagnosis of base of the skull defect and meningocele, the patient was scheduled for reconstructive orbital and ethmoid roof surgery following recovery from the meningeal and left orbital infection. According to the CT scan, investigation, and multi-disciplinary team, reconstruction was mandated since the defect was a potential source of meningitis.

To begin with, a left functional endoscopic sinus surgery (FESS) and left exploration of the anterior skull base from frontal sinus to planum sphenoidal was performed for better access and visualization of the defect. The ethmoidal roof defect was identified and reconstructed by underlay technique, using a flap harvested from the left middle turbinate. Next, a superior orbital approach was used by ophthalmologists. The left upper crease was opened and dissected up to the superior orbital rim periosteum, which was cut lateral to the supratrochlear foramen. The periosteum was elevated, and blunt, sharp dissection was performed to reach the superior orbital roof boney defect. Active CSF leakage was repaired by neurosurgeons using fat harvested from the abdominal wall and sealing material (TISSEEL). Finally, otolaryngologists strengthened the grafted tissue and applied nasal dressings. A CSF lumbar drain was also inserted to reduce intracranial pressure and preserve the patency of the sealed defect for the next five (5) days.

Postoperatively, the patient was gradually improving until recovery. She was referred to the ophthalmologist for left upper lid (LUL) ptosis and left orbit volume evaluation. The LUL had fibrous strands that functioned as frontalis slings in place of the previously inserted GORE-TEX. The left orbit volume was found to be sufficient as a result of the orbital roof repair. The patient's conjunctival socket was adequate; however, the old ocular prosthesis was not suitable anymore, and a new ocular prosthesis fitting was done. The patient is currently in stable condition. The postoperative course was uneventful, and imaging was reassuring. Her two (2) years follow-up showed no recurrence of the CSF leak and no evidence of meningitis since the reconstructive surgery.

The patient had favorable pregnancy outcomes, she was initially seen and assessed by the obstetrics department after the injury. Examinations and fetal well-being scan showed reassuring results, a biophysical profile score of 8/8, normal interval growth, and normal fetal blood flow. She was booked for an elective cesarean section (c/s) due to her previous obstetrics history of four c/s. The patient tolerated the surgery very well with no complications postoperatively. She was discharged two weeks later in stable condition along with her newborn.

3. Discussion

Military experiences frequently report ocular blast injuries. Nevertheless, such injuries in a civilian setting have been rarely reported. In this case, the patient had multiple sharp missile injuries with small fronts, resulting in little injury or cavitation. Despite their small size, the eyes are vulnerable to blast injuries due to lack of protection or spectacles contributing to the injury [10]^, [11]. In severe ocular injuries including those resulting from blast traumas, management often involves evisceration or enucleation of the affected globe. These procedures help reduce the chances of sympathetic ophthalmia (SO), control pain, replace volume, and optimize the cosmetic appearance [12]. In this reported case, the victim was a civilian who suffered complex craniofacial injuries including orbital wall fractures and left globe rupture, she was managed by performing an evisceration followed by enucleation and a spherical implant for volume reconstruction. This initial management plan proved to be effective as she displayed a favorable outcome.

Two (2) years later, the patient had a meningocele, active CSF rhinorrhea, and meningitis which is believed to be the result of a left anterior skull-base defect. This complication was not unusual since globe injuries, oculoplastic injuries, and neuro-ophthalmic injuries with base of a skull defect, can result in cerebrospinal fluid (CSF) rhinorrhea and increase susceptibility to dangerous sequelae of orbital cellulitis and meningitis [7]. The timely and effective closure of skull-base defects is critical to avoid the progression of these complications. A multidisciplinary team consisting of otolaryngologists, neurosurgeons, ophthalmologists, and radiologists was formed to tackle this life-threatening, delayed complication. The patient underwent reconstructive orbital and ethmoid roof surgery following recovery from meningitis and cellulitis. To repair the CSF rhinorrhea, and to provide a less invasive procedure, a shared decision was made to seal multiple defects of the orbital ethmoidal roof. Rhinologists opted for an endonasal endoscopic approach combined with supraorbital approach to sealing the multiple defects in the superior orbit and ethmoid, rather than a craniotomy approach, which is known to be safe, effective and is a valid alternative to the cranial approach [13].

4. Conclusion

This patient's complication presented late despite adequate initial management. Therefore, we recommend longer follow-ups for such complex cases to avoid serious complications.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Ethical approval

Ethical approval was provided by the author's institution.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Guarantor

Naif H. Alotaibi, MD.

Research registration number

Not applicable.

CRediT authorship contribution statement

• Aroub Almaghrabi: wrote the manuscript, acquisition, analysis, or interpretation of data for the work.

• Haifa A. Alsheikh: wrote the manuscript, acquisition of information.

• Abdullah Alkhani: wrote the manuscript, acquisition of information.

• Humoud Aldahash: developed the theoretical formalism, final approval of the version to be published.

• Amal Almalki: developed the theoretical formalism, final approval of the version to be published.

• Naif H. Alotaibi: wrote the manuscript, developed the theoretical formalism, substantial contributions to the conception or design of the work, final approval of the version to be published.

Conflict of interest

The authors declare that there is no conflict of interest.