Penetrating Head Injury

Hx: A 60 yo male is transported to a trauma center for a penetrating head injury. EMS reports a hand tool penetrated the forehead and the patient is stable with a GCS of 15. He arrives and is able to give a history of using a chisel when it ricocheted and struck him mid forehead. He states he blew his nose and noticed tissue come out of the wound at which point he called EMS. He has a minimal headache. No other symptoms.

PMHx: None
SocHx: regular tobacco, occasional alcohol, no drugs

Exam: 

  • Vitals: BP 150/90, Pulse 85, Resp 16, Sat 100% RA, Temp 98.6 F(37C)
  • Head: small, 2cm puncture wound in the mid forehead with minimal blood. No tissue. No SQ air.
  • EENT: normal TMs, normal pharynx, normal neck, pupils equal and reactive bilaterally with full movements intact, normal nose with no rhinorrhea.
  • Resp: cleat bilaterally
  • Cardiovascular: heart regular, normal pulses
  • Abdomen: soft, non-tender
  • Extremities: warm and without injury

Frontal Sinus1.jpg

Differential:  

  • penetrating head injury
  • intra cranial injury
  • subdural hematoma
  • frontal sinus injury
  • superficial skin laceration

ED course:  

  • CT imaging of the head is performed revealing the following:
Frontal Sinus2.jpg

Red arrow: frontal bone fracture

Frontal Sinus3.jpg

Red arrow: frontal bone fracture

 

Frontal Sinus4.jpg

Frontal Sinus5.jpg

Red arrow: fracture extends into posterior wall (posterior table) of frontal sinus

 

Frontal Sinus6.jpg

Red arrow: fracture extends into posterior wall (posterior table) of frontal sinus

 

Frontal Sinus8.jpg

Brain window shows no hemorrhage or intracranial extension

  • CT examination revealed a frontal bone fracture extending downward into the frontal sinus. Although an air fluid level is present in the sinus, there is no evidence for intra-cranial extension, specifically no intra cranial air or blood to suggest violation of the dura.
  • Consultation with ENT and neurosurgery established a plan of care to include augmentin for 7 days for the sinus injury and outpatient follow up  for a repeat CT of the head to insure continued healing without intracranial extension.

Diagnosis: Acute Frontal Sinus Fracture 

Discussion: 

Penetrating head injuries have a high propensity for serious injury. In most states in the US, the presence of a penetrating injury to the head qualifies as sufficient criteria to transport a patient to a trauma center for evaluation. Although this patient had an otherwise normal exam, his injury resulted in a fracture that only extended into the frontal sinus. The CT images reflect involvement of the posterior wall (posterior table) of the sinus but fortunately without evidence of further extension. Given the patient’s lack of a CSF leak, a conservative approach was chosen. Treatment of a non-displaced posterior wall (posterior table) fracture of the fontal sinus is controversial. Algorithms  can include procedures as invasive as sinusotomy for endoscopic evaluation of the posterior wall and mucosa, with treatment including potential obliteration of the frontal sinus. However, others advocate for a more conservative approach. The decision algorithm typically involves the presence or absence of a CSF leak. If a CSF leak is absent, observation and conservative management of a non-displaced fracture can result in healing without the added risk of surgical exploration. In the presence of a CSF leak, treatment algorithms include inpatient observation with IV antibiotics which may result in spontaneous closure of the leak with delayed surgical intervention if the leak persists. The variance in treatment approach underscores the need for a collaborative approach between specialists. In this case, although the patient’s clinical exam was unremarkable, his injury did require the collaboration of ENT and Neurosurgery, which is most easily performed at a trauma center where those resources are generally rapidly available.

This patient was discharged home in good condition, on oral antibiotics for the frontal sinus injury. His outpatient follow up with both specialties revealed no adverse sequela.

https://insights.ovid.com/pubmed?pmid=19050539

http://emedicine.medscape.com/article/869430-overview#a4

Disclaimer

De-identificaiton is undertaken utilizing the Safe Harbor method described by the US Department of Health and Human Services. All remaining patient information required for teaching purposes has been altered to maintain this standard.

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