Chopstick penetration of the posterior cranial fossa: case report

ELSEVIER

Trauma

CHOPSTICK PENETRATION OF THE POSTERIOR CRANIAL FOSSA: CASE REPORT Toshihiko Kuroiwa, M.D., Harushi Tanabe, M.D., Daiji Ogawa, M.D., and Tomio Ohta, M.D. Department of Neurosurgery, Osaka Medical College, Osaka, Japan

Kuroiwa T, Tanabe H, Ogawa D, Ohta T. Chopstick penetration of the posterior cranial fossa: case report. Surg Neurol 1995;43:

68-9. A very rare case of wooden foreign body intrusion into the posterior cranial fossa is reported. The patient, a 16-month-old girl, fell down while holding chopsticks and was injured in the right pre-auricular region. Computed tomographic scans revealed a linear low-density area ranging from the right external auditory meatus to the fourth ventricle through the petrous portion of the temporal bone, passing near the middle cerebellar peduncle. Right temporal craniotomy was performed to abrade the petrous bone, resulting in removal of the chopstick fragment. The patient had an uneventful postoperative course and was discharged in ambulant condition, only

with right hearing difficulty. KEY WORDS

Head injury, intracranial foreign body, posterior cranial fossa, wooden foreign body.

I

ntracranial penetration by a wooden foreign body is relatively rare. In most cases, the wooden foreign body has penetrated a relatively thin bone, as in the orbital roof, temporal squama, or cribriform plate [l-5]. Penetration into the posterior cranial fossa, which is encircled by thick bone, is extremely rare indeed.

CASEREPORT A 16month-year-old girl fell down while playing with one of her mother’s chopsticks. She was injured in the right preauricular region. About 6 cm of the chopstick tip broke off. The patient was transported to our institute; she was drowsy, with repeated severe vomiting. Cerebrospinal fluid flowed Address reprint requests to: Toshihiko Kuroiwa, M.D., Department of Neurosurgery, Osaka Mishima Critical Care Medical Center, 1l-l Minami Akutagawacho, Takatsuki city, Osaka 569, Japan. Received May 25, 1994; accepted July 19, 1994. 009~3019/95/$9.50 SSDI 00903019(94)00107-2

from the right pre-auricular wound (Figure 1). Although skull x-rays failed to show the chopstick fragment, computed tomographic (CT) scans revealed a linear lowdensity area originating in the right external auditory meatus, passing through the petrous bone of the temporal bone, penetrating the posterior cranial fossa immediately above the jugular foramen, passing near the middle cerebellar peduncle, and reaching the fourth ventricle (Figure 2). The low-density area was of -140 to -150 Hounsfield Units. No intracranial hemorrhage was found on the CT scans. Angiography was refused by her parents. Right temporal craniotomy was conducted. The petrous bone was exposed and abraded including tympanic cavity along the chopstick fragment, which was then removed with gentle traction. No bleeding occurred after its removal. If necessary, an extensive craniotomy would be performed. The dead space was filled with bone wax, fibrin glue, and oxcell. No obvious wound was noted in the skin of the external auditory canal. The chopstick was made of miscellaneous small trees, coated with Japanese lacquer (urushi) (Figure 3). The patient had an uneventful postoperative course, free from infection or cerebrospinal fluid leakage. Although right hearing difficulty developed as a sequela, she was discharged in an ambulant condition. Because acoustic nerve functioning was positive in the acoustic brain stem response, tympanoplaty is scheduled for the future.

DISCUSSION The posterior cranial fossa is extremely rarely penetrated by a wooden foreign body, because it is surrounded by thick bone. In the present case, a chopstick fragment, deeply penetrating the temporal skin to the temporal bone and sliding posteri0 1995 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010

Chopstick

Penetration

of the Posterior

Surg Neurol 1995;43:68-9

Cranial Fossa

69

The chopstick fragment removed from the posterior cranial fossa; beside it is an intact chopstick. Photograph showing a small wound near the right external auditory meatus.

orly, intruded into the external auditory meatus, where the point of the fragment was fixed, and further penetrated the petrous bone. The mechanism of injury was very peculiar, This is an extremely rare accident even in Japan, where the use of chopsticks is very common; therefore it is re ported here.

REFERENCES pencil injuries. 1. Bursick DM, Selker RG. Intracranial Surg Neurol 1981;16:427-431. 2. Hansen JE, Gudeman SK, Holgate RC, Saunders RA. Penetrating intracranial wood wounds: clinical limita-

Computed ventricle.

tomographic

scans

showing

a low-density

tions of computerized tomography. J Neurosurg 1988; 68:752-56. Healy JF. Computed tomography of a cranial wooden foreign body. J Comut Assist Tomogr 1980;4:555-6. Jooma R, Bradshaw JR, Coakham HB. Computed tomography in penetrating cranial injury by a wooden foreign body. Surg Neurol 1984;21:236-8. Miller CF, Brodkey JS, Colombi BJ. The danger of intracranial wood. Surg Neural 1977;95-103. COMMENTARY

The only reason to publish this article is to illustrate the numerous possibilities children have to damage themselves. Also, the authors, in my opin-

ion, share this advice. However the presented modality is certainly original! In any event, the case represents a mere curiosity, as even the happy end is not an original event in children with similar accidents. Concezio di ROCCO, M.D. Rome, Italy

area from the external

auditory

meatus

to the fourth