Management of Penetrating Anterior Skull Base Injury from Transnasal Foreign Body

We report the unusual case of a 35-year-old man who presented post self-insertion of a foreign body (a toothbrush with the bristled end snapped off) transnasally while suffering from a drug-induced psychosis. The tip of the retained object extended intracranially as far as the right foramen of Munro and caused unilateral obstructive hydrocephalus requiring emergency external ventricular drain insertion. There was no evidence of significant intracranial hemorrhage on initial imaging but the postcommunicating segments of both anterior cerebral arteries were significantly displaced by the object. After deliberating the safest surgical approach, we elected to perform a bifrontal craniotomy to approach the anterior fossa floor inter-hemispherically, to gain proximal control of the anterior cerebral arteries and protect them from laceration. Once this was achieved, the foreign body was removed transnasally by the ENT surgeon, who had performed prior ligation of the ipsilateral anterior ethmoidal artery to prevent catastrophic nasal hemorrhage. Nasoendoscopy revealed surprisingly little damage to the nasal cavity. The skull base defect was repaired utilizing split calvarial bone graft obtained during the craniotomy, and a vascularized pericranial flap. Postoperatively the patient did not develop a CSF leak and displayed no signs of meningitis. His psychosis self-resolved within two weeks postoperatively and he was discharged home after a 2-week course of intravenous antibiotics and with psychiatry input. A delayed postoperative MRI demonstrated no obvious abscess, empyema or cerebral infarction. On review of the literature, such extreme cases of skull base penetrating injury appear to be rare and there is little technical advice available on optimal surgical strategies. This case provides an opportunity to discuss the management of such injuries and adds to a currently scarce body of knowledge on the topic.

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No conflict of interest has been declared by the author(s).