1

Introduction

Traumatic craniofacial injuries are a common occurrence and are managed by specialists from various disciplines, including otolaryngologists. This entails management of both soft tissue and bony injuries. Complications can occur in both the short- and long-term care of these patients. In this case report, we present 2 complications that occurred in a patient more than 40 years after sustaining a traumatic craniofacial injury and discuss their management, including review of the existing literature.

2

Case report

A 63-year-old man was referred to the otolaryngology clinic at the Clement J. Zablocki VA Medical Center in Milwaukee for evaluation of abnormal findings on a computed tomographic (CT) scan. He had recently been evaluated by a regional VA clinic for atypical neurologic symptoms including headaches, gait disturbances, and upper limb paresthesias, which later resolved. A CT scan of the head was done in the course of his workup. This did not identify a definitive source of these symptoms but did identify abnormal soft tissue masses for which he was referred; a magnetic resonance imaging was contraindicated in this patient because of the presence of metal hardware.

His medical history was significant for a severe motor vehicle crash in 1969 where he sustained panfacial trauma including fractures of the left orbit, zygoma, maxilla, and mandible. Details of the initial injury are unavailable. As a result of his injury, he lost vision in his left eye and required extensive reconstructive surgery of his face including open reduction and internal fixation of the left midface fractures. He later underwent permanent tarsorrhaphy of the nonfunctional left eye due to severe and persistent exposure keratitis. When seen in clinic, he also reported a long history of left-sided nasal congestion and epistaxis since the time of his injury, which had been increasing in severity and frequency. Nosebleeds had been occurring on a daily basis for the past year for which he had sought care on several occasions. He had undergone nasal cautery approximately 3 weeks before being seen and had been using nasal saline spray since with minimal improvement in his symptoms.

Anterior rhinoscopy revealed a significant rightward septal deviation. Nasal endoscopy revealed the presence of granulation tissue at the head of the left middle turbinate. This granulation tissue was associated with 2 wires, which entered the nasal cavity from the lateral nasal wall ( Fig. 1 ). Review of the patient’s CT scan confirmed the presence of the fixation wire and its location ( Fig. 2 ). With the patient’s consent and after application of topical anesthetic, wire cutters were used to cut the wires as close to the lateral nasal wall as possible, and the wire fragments were removed. Review of the imaging also demonstrated soft tissue masses in the posterior septum ( Fig. 3 ) and left orbital apex ( Fig. 4 ), which were thought to be consistent with mucoceles resulting from his remote history of craniofacial trauma.

View of left nasal cavity with 0° endoscope showing wires entering from the lateral wall of the nasal cavity and ending in the middle turbinate.

Location of fixation wires as seen on axial image from noncontrast CT of the head.

Posterior septal mucocele as seen on axial image from noncontrast CT scan of the head.

Left orbital apex mucocele as seen on axial image from noncontrast CT of the head.

When seen in follow-up, the patient reported relief of his left-sided nasal obstruction. He continued to experience intermittent epistaxis but at a lesser severity and frequency, and preventative measures were instituted. Discussion with the patient ensued regarding management of his mucoceles. Surgical drainage was recommended to prevent development of further orbital or intracranial complications to which the patient agreed and provided written informed consent. Because of the location of the orbital lesion and the distortion of the anatomy from the trauma, assistance from the oculoplastics service was arranged.

The patient was subsequently taken to the operating room, and general anesthesia was induced. First, to expose the orbital mucocele and protect the orbital contents, an external approach via Lynch incision was performed by the oculoplastic surgeons. This technique was selected over the transcaruncular method due to the prior permanent tarsorrhaphy. The dissection was carried posteriorly along the lamina papyracea in the subperiosteal plane. The anterior ethmoid artery was encountered and cauterized. When the mucocele was identified, a malleable retractor was placed to isolate and protect the orbital contents. Next, the mucocele was approached endoscopically via anterior and posterior ethmoidectomies with the assistance of image guidance. Then, with the orbital contents safely retracted, the lamina was penetrated and taken down using through-cutting instruments, widely opening the mucocele and marsupializing it into the nasal cavity. The posterior septal mucocele was also marsupialized to allow continued drainage. Recovery was uneventful, and the patient was doing well on postoperative visit with no apparent complications. Follow-up is in place to continue surveillance for recurrent or additional mucocele formation.