Intraorbital wooden foreign bodies (IOrbWFBs) carry a unique dilemma for the orbital surgeon. Often patients can present in a delayed fashion, and standard imaging may miss smaller particulate matter. Injuries may appear minimal or even absent as the entry wound is often missed [20]. Taş found that wooden foreign body size inversely correlated with time of presentation [21]. In his case series of 32 patients, 72 h or more had passed before patients presented with wooden foreign bodies that were less than 2 cm in size.

Typically, CT scans are the standard imaging modality for patients who present with traumatic injuries to the orbit (Fig.11.2). If suspicion is low for orbital foreign bodies, the radiologist may mistake wooden matter for air. Shelsta, in a study of 23 cases, had 13% patients with an unrecognized IOrbWFB after initial imaging [20]. However, Taş found that in all his 32 cases of IOrbWFB, the radiologist either recognized the FB or had a high suspicion of a possible FB [21].

In typical CT images, many types of wood in different hydrated states can be indiscernible in the black background of orbital fat [22]. Wood has absorption coefficients ranging from −999 to +54 HU depending on their origin, hydration, and size [22]. Because standard CT scans are performed at a window width of 200–350 HU, even large pieces of wood can be missed. To improve the context of revealing the FB, the window width should be increased to at least 1000 Hounsfield units (HU) to increase the background signal of the orbital fat. Bone windows (width, 4000 HU) can help discern IOrbWFB far greater than soft tissue windows. Expanding the window width is essential in locating and identifying an IOrbWFB.

If uncertain, an MRI may be an additional modality to help discern IOrbWFB location, size, and severity of injury. Traditionally, green wood or hydrated fresh wooden FB was more difficult to detect than dry wood, typically seen in construction zone accidents [23]. However, newer imaging techniques allow MRI studies to be very accurate in detecting any kind of wooden FB. In T1-weighted images, the IOrbWFB appears hypointense compared to the hyperintense orbital fat. Ring enhancement with gadolinium contrast may be seen particularly with small pieces of wood which can be surrounded by an artifact consisting of hyperintense spots, known as truncation artifact [22, 24]. Glatt and Custer studied wooden matter in environments consistent with orbital tissue [22, 25, 26]. They found that T1-weighted images created superior imaging quality and required less scanning time. They found MRI useful particularly in small vegetative matter.

Prior to the advent of modern antibiotics, the morbidity and even mortality of intracranial wood-related injuries were quite high [27]. The porous nature of wood and its exposure to the elements present an environment for bacterial growth [28]. A common misunderstanding of IOrbWFB is that they have a high or higher incidence of fungal infection. However, the literature and this author’s experience do not support empiric antifungal therapy [20]. No predominant bacterium is present in these injuries. Common species cultured from IOrbWFB include Staphylococcus epidermidis, Staphylococcus aureus, Enterobacter agglomerans, Clostridium perfringens, Escherichia coli, Serratia marcescens, and Citrobacter freundii [20, 21]. We recommend broad-spectrum coverage with vancomycin and a third-generation cephalosporin or single therapy with Zosyn and tailoring the antibiotic with patient response and cultured results.

We further advocate timely removal of the IOrbWFB at initial presentation. Although older pieces of literature considered removal of IOrbWFB unwarranted [29], improved orbit training and techniques help outweigh the benefits over the risks. Not only do the retained IOrbWFBs create a nidus for infection, but the extent of inflammation vegetative matter presents to the orbital tissue can be extensive [22]. Delay in treatment may lead to serious complications even months after the injury [30]. Any orbital injury with an extended timeline of recovery or persistent symptoms should be reviewed for a potential IOrbWFB.

IOrbFB that penetrates the intracranial space can complicate the trauma patient’s course. Most of these injuries occur through the thin bone along the roof of the orbit [27]. Other routes of penetration include the posterior foramen such as the superior orbital fissure [31].

Extension into the intracranial cavity can result in traumatic carotid aneurysm [32], cerebral abscess [33], cavernous sinus thrombosis [34], and superior orbital fissure syndrome, cranial nerve palsies, and cerebrospinal fluid leak [28].

Surgeons practicing all levels of facial trauma will encounter animal bites to the head and face. Traumatic bite injuries specific to the periorbital area can result in complex lacerations, nasolacrimal system injuries [35–37], ruptured globes [38], orbital fractures [39], and even death [40].

Accounting for approximately 1–5% of all emergency department visits, canine bites requiring medical attention occur more than 750,000 times per year in the United States [41, 42]. Four to 27% of all dog bites involve the periorbital area with ocular injuries [35, 43]. Sixty-five to ninety percent of dogs were known to the victim and either the victim’s or a friend/neighbor’s pet [35, 39]. The majority of patients are children with over 68% under the age of 10 [35–37, 39]. The younger the child (<4 years old), the more common that the injury involves the face [39, 41].

Microorganisms involved in an animal bite are wide ranging including both aerobic and anaerobic pathogens [44, 45]. The most common bacteria isolated from wound infections after bite injuries include Staphylococcus aureus and gram-negative organisms [37].

Canalicular injuries are characteristically common in dog bites involving the periocular space. Forty percent of patients with bites involving the eyelids have canalicular injuries often resulting from the lateral shearing forces on the medial lid structures [35]. Slonim advocated the use of Crawford bicanalicular stents, which is the author’s preferred technique, in the repair of canalicular injuries with primary closure of associate eyelid lacerations without other drains [37]. Topical antibiotics and oral cephalosporin use were prescribed for 5 days [37].

Initial management includes emergency room triage with airway protection and otolaryngology consultation for any airway or open neck injuries. After stabilization, appropriate broad-spectrum antibiotics should be initiated for deep wounds. Lackmann classified dog bites by level of injury [30]. Stage 3 and 4 injuries included deeper injuries to the level of muscle with a tissue defect. Antibiotic prophylaxis was recommended for these two classes of injury. Surgical management includes irrigation with debridement as necessary and early primary closure for uninfected wounds [35]. Wound culture at the time of injury provides little value because of the multiple organisms involved in both indigenous flora and nonindigenous microorganisms [37]. Additional care items in the initial consultation include following appropriate protocols for both rabies and tetanus treatments and prevention.

Previous management of animal bites to the face supported delayed wound closure while prophylactic antibiotics were initiated overnight [46]. Current large-scale studies establish optimal results with immediate repair with either primary closure or various flap techniques [47–50]. We advocate primary closure for all uninfected wounds. Subcutaneous sutures are kept to a minimum, but skin rotational flaps and microvascular reconstruction can be performed as the initial repair (Fig.11.3) [48].

Oral ampicillin-clavulanate (Augmentin) or intravenous ampicillin-sulbactam (Unasyn) is a reasonable first-line choice for both gram-positive and gram-negative coverage with clindamycin and bactrim/fluoroquinolone for those with penicillin allergy [35, 36, 48]. Recommended duration includes 5 days for prophylaxis and up to 14 days for an infected wound [48].