INTRODUCTION

Orbital floor fractures were first recognized and documented by MacKenzie and Lang in 1844, following earlier investigations by Gessier, von Becker, and others [1]. In the late 19th century, Buck and McCoy reported the surgical repair of orbital floor fractures using stainless steel wires and antral bone fragments, respectively [1]. By the 1960s, the orbital floor was being reconstructed with alloplastic materials and bone replacements. In 1957, Smith and Regan described the mechanism behind orbital floor fractures [1].

Due to its intricate anatomical structure comprising both soft and hard tissues, the orbit is particularly susceptible to injury. Ocular trauma is common following facial injury, especially upper face and forehead injuries. Blunt trauma to this region may result in an isolated orbital “blowout” fracture or a combined orbital and midface fracture [2]. Diplopia is one of the most frequent effects of orbital floor fractures, with other symptoms including decreased vision, enophthalmos, infraorbital numbness, and restricted ocular movement. Restoring the orbit’s anatomic structure through prompt surgical intervention is essential for preserving visual function and appearance [3]. We present a unique case of penetrating orbital floor injury caused by a lodged wooden foreign body, which resulted in no ocular or intracranial complications.

CASE REPORT

A 16-year-old male patient presented to the department of oral and maxilloficial surgery with a 2-month history of pus discharge from his right cheek. He also reported trauma resulting from a fall from a tree, which did not cause him to lose consciousness. Initially, he was taken to a nearby hospital, where an otorhinolaryngologist suspected a right maxillary wall fracture and referred him to an oral and maxillofacial surgeon; however, he did not follow up. A week later, he noticed swelling on his right cheek, prompting a consultation with a general practitioner who performed a stab incision in the infraorbital region and a vestibular incision to drain the pus. The patient also reported that four to five foreign body particles (small wooden pieces) had been retrieved intraorally 2 days earlier.

On examination, the patient had a Glasgow Coma Scale score of 15 and normal extraocular muscle movements, with no signs of neurological or vision deficits. The affected side was tender and firm, with active pus discharge. Computed tomography (CT) revealed a foreign body and radiopacity in the right maxillary sinus along with loss of integrity of the orbital floor and infraorbital rim (Fig. 1). The results of other routine laboratory investigations were within normal limits.

The treatment strategy included retrieval of the foreign body, the Caldwell-Luc procedure, and reconstruction of the right orbital floor under general anesthesia. The right maxillary vestibular region was infiltrated with local anesthesia containing epinephrine (1:80,000) after obtaining informed written consent. A 4-0 Vicryl (Ethicon) suture was used to place the right tarsorrhaphy. Intraorally, markings were established in the regions corresponding to teeth 11 through 16, over the foreign body. Using a No. 15 blade, incisions were made to raise a full-thickness mucoperiosteal flap, through which the foreign body—a 4-cm wooden piece—was identified and retrieved via the vestibular incision (Fig. 2C, D).

The Caldwell-Luc procedure was applied to the right maxillary sinus. This involved creating a 1.5×1 cm bony window, curetting the diseased sinus lining, and performing copious irrigation with saline and betadine.

An infraorbital incision of approximately 4 cm was created by extending the previously made stab incision. Blunt dissection was carried out through the subcutaneous tissue and orbicularis oculi muscle until the periosteum was reached. A periosteal incision was then performed, enabling identification of the infraorbital nerve and dissection to the posterior limit of the orbital floor fracture. A 0.3 mm thick orbital mesh was placed and fixed to the infraorbital rim with two 1.5×4 mm screws. Autologous platelet-rich fibrin was subsequently applied below the mesh (Fig. 2A, B).

A communication was established between the infraorbital incision and the intraoral site. Rolled gauze soaked in mupirocin ointment was packed into the right maxillary sinus, and after nasal antrostomy, a communication was created through the right inferior meatus. The opposite end of the gauze was passed through the nostril and secured to the forehead. The bony window was then covered with a buccal fat pad, followed by multilayered closure (Fig. 2E). The lower eyelid was secured with 5-0 Prolene (Ethicon), pulled upward, and stabilized with micropore tape (Fig. 2F). A course of intravenous ceftriaxone and metronidazole was administered along with analgesics.

At 2 weeks postoperatively, paresthesia was noted in the right infraorbital and right lateral nasal regions, as determined by a two-point discrimination test. At 6 weeks, the paresthesia in these regions was still present, but had improved. Ten weeks later, the paresthesia was confined only to the right infraorbital region. At 6 months postoperatively, only mild paresthesia was noted along the surgical scar (Fig. 3), and the patient reported satisfaction with the outcome.

Ethics statement

Written informed consent for publication of the research details and clinical images was obtained from both the patient and his guardian, as the patient was a minor.

DISCUSSION

The prevalence of orbital foreign bodies is comparatively high in men (75%–96%) and younger individuals (15–37 years old). Assaults are the primary cause of orbital penetration by large foreign bodies (36.3%), followed by motor vehicle accidents (12.1%) and falls over blunt objects (33.3%). Most reported cases in the literature involve male patients (84.85%), with an average age of 27.7 years (range, 4–66 years) [4,5].

A detailed history can reveal the type of injury and the object involved, and the clinical presentation can range from asymptomatic to visual disturbances, pain, and swelling. A thorough assessment including radiological investigations is necessary because physical examination alone frequently underestimates the severity of such injuries [6].

Diagnosing penetrating orbital foreign bodies is inherently complex, as it depends on the material composition and anatomical position of the foreign body. Metallic and glass foreign bodies are the most frequently encountered, typically eliciting minimal inflammatory responses in periorbital fat, although materials such as copper can provoke significant reactions. In contrast, organic foreign bodies like wood, though relatively rare, often trigger acute inflammatory responses that can evolve into chronic conditions with severe complications if left untreated. These complications include periorbital abscess formation, panophthalmitis, orbitocutaneous fistulas, cavernous sinus thrombosis, and even extension into the central nervous system. Due to their porous structure, wooden foreign bodies are particularly susceptible to microbial contamination, which raises the risk of infection [7]. In our case, because of the entrapment of the foreign body, a localized collection of pus developed and was drained via a stab incision before the patient presented to our department. Continuous pus discharge from the right infraorbital stab incision site and the intraoral laceration site was also noted.

Although CT is considered the gold standard for these injuries, a thorough trauma history, careful ocular examination, and diligent review of diagnostic imaging are necessary for an accurate diagnosis. Misdiagnosis and missed diagnosis frequently occur during the initial visit because of the diverse clinical manifestations and imaging characteristics of intraorbital wooden foreign bodies [8].

A thorough clinical evaluation of the orbital region, particularly the conjunctival fornices, by an ophthalmologist is critical in cases with a suggestive history. Diplopia must be ruled out. In the present case, diplopia and any other lacerated wounds were excluded. Entry wounds from penetrating injuries are often subtle and may be overlooked, especially when associated with edema of the conjunctiva, eyelids, and periorbital skin, which can obscure the wound under redundant folds.

Imaging is crucial for locating infraorbital foreign bodies; modalities include radiographs, ultrasonography, CT, and magnetic resonance imaging (MRI). Ultrasonography is preferred in emergencies because it is noninvasive, cost-effective, and able to exclude metallic foreign bodies. Negative ultrasonography findings can safely guide progression to MRI. Although CT is highly effective at detecting dense materials such as metal and glass, its sensitivity is diminished for low-density organic materials like wood [7].

On CT, dry wood may appear as linear, circular, or oval hypodense areas resembling air pockets. Hydrated wood is more challenging to detect because its density approximates that of the surrounding orbital fat. The clarity of CT for wooden foreign bodies improves when these objects are not superimposed on paranasal sinus air spaces or intraorbital air pockets. Repeating CT scans during periods of inflammation may improve the visibility of foreign bodies, as the inflammatory response can increase contrast. Although the role of MRI in detecting organic foreign bodies remains a topic of debate, it is occasionally warranted when CT results are inconclusive [7]. In the present instance, a CT scan was performed before surgery after noting that wooden splinters had been retrieved from the patient’s upper labial vestibule. Axial views revealed the presence of a foreign body with surrounding pockets of air and a loss of integrity of the infraorbital rim (Fig. 1).

In cases involving orbital fractures, the choice of incision is crucial. A literature review demonstrated a continuous increase in the use of the transconjunctival approach over the past 10 years and a parallel decline in the mid-lower eyelid approach, while the use of the subciliary approach remained constant. The transconjunctival incision offers superior visualization and a smaller risk of lower eyelid retraction compared with the subciliary technique. However, when lateral canthotomy is also performed, the lateral canthus is displaced, and entropion becomes more common. Since the subtarsal lower eyelid incision (mid-lower eyelid approach) provides direct access to the infraorbital rim with minimal risk of retraction, it remains a viable option, especially for elderly patients with noticeable wrinkles [3]. In our case, the preexisting stab incision in the right infraorbital region—made by the general practitioner—was used to address the orbital fracture.

In conclusion, this case holds a unique position in orbital trauma management because, despite the forceful fall, the foreign body did not penetrate the orbital cavity or injure the eyeball, although it did fracture the orbital floor. There was potential for the foreign body to have become lodged in the orbital cavity or even in the anterior cranial fossa. Despite the foreign body remaining entrapped for more than 2 months, no ocular or intracranial complications occurred. The trauma resulted in crushing of the infraorbital nerve, leading to paresthesia at the affected site as well as perforation of the orbital floor and discontinuity of the inferior orbital rim, yet causing no ocular injury. Without timely intervention, it could have been anticipated that the infection would spread, leading to ocular and intracranial complications.

ARTICLE INFORMATION

Author contributions

Conceptualization: all authors; Investigation: all authors; Methodology: all authors; Project administration: all authors; Visualization: all authors; Writing–original draft: all authors; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Conflicts of interest

The authors have no conflicts of interest to declare.

Funding

The authors received no financial support for this study.

Acknowledgments

The authors thank Drs. Shailesh Kokkal and Sunil Gowda (Coorg Institute of Dental Sciences, Virajpet, India) and the Rural India Health Project Hospital (Ammathi, India) for their support.

Data availability

Data sharing is not applicable as no new data were created or analyzed in this study.

Fig. 1.

Computed tomography image of a 16-year-old male patient presenting with a traumatic injury. (A) Axial and (B) coronal views showing radiopacity of right maxillary sinus indicating thickening of sinus lining. (C, D) Coronal views showing radiopacity of right maxillary sinus indicating thickening of sinus lining.

Fig. 2.

Intraoperative images. (A) Placement of orbital mesh for floor reconstruction. (B) Platelet rich fibrin placement. (C) Bony window created via the intraoral vestibular incision to curette the infected sinus lining. (D) Retrieved foreign body. (E) Packing of the sinus with mupirocin-soaked gauze. (F) Lower eyelid secured with 5-0 Prolene (Ethicon), pulled upward, and stabilized with micropore tape.

Fig. 3.

Clinical images of the patient. (A) Preoperative appearance. (B) At 6-month postoperative follow-up. Written informed consent for publication of the clinical images was obtained from both the patient and his guardian, as the patient was a minor.

REFERENCES

• 1. Kirby EJ, Turner JB, Davenport DL, Vasconez HC. Orbital floor fractures: outcomes of reconstruction. Ann Plast Surg 2011;66:508–12.ArticlePubMed
• 2. Zhou HH, Liu Q, Yang RT, Li Z, Li ZB. Ocular trauma in patients with maxillofacial fractures. J Craniofac Surg 2014;25:519–23.ArticlePubMed
• 3. Gosau M, Schoneich M, Draenert FG, Ettl T, Driemel O, Reichert TE. Retrospective analysis of orbital floor fractures: complications, outcome, and review of literature. Clin Oral Investig 2011;15:305–13.ArticlePubMedPDF
• 4. Maneksha V, Kavya S, Chakrabarty S. Rubber tree fruit in the eye: a case report of large organic foreign body in orbit. Indian J Ophthalmol Case Rep 2022;2:560–2. Article
• 5. Amaral MB, Costa SM, de Araujo VO, Medeiros F, Silveira RL. Penetrating orbital trauma by large foreign body: case series study with treatment guidelines and literature review. J Maxillofac Oral Surg 2023;22:39–45.ArticlePubMedPMCPDF
• 6. 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.ArticlePubMedPMCPDF
• 7. Tite DJ, Batstone MD, Lynham AJ, Monsour FN, Chapman PJ. Penetrating orbital injury with wooden foreign body initially diagnosed as an orbital floor blowout fracture. ANZ J Surg 2002;72:529–30.ArticlePubMedLink
• 8. You YY, Shi BJ, Wang XY, et al. Intraorbital wooden foreign bodies: case series and literature review. Int J Ophthalmol 2021;14:1619–27.ArticlePubMedPMC

Figure & Data

References

Citations

Citations to this article as recorded by