Brushed Aside: Unusual Lodgment of a Toothbrush in the Infraorbital Region - A Case Report

Introduction

Foreign objects can enter the soft tissues through open wounds and lacerations during the accidents. In instances of injuries to orofacial tissues caused by impact to the head, such as being struck by an object like a bottle, hitting a car windshield, or falling to the ground, the presence of foreign bodies can hinder the healing process when unnoticed and not promptly removed from the soft tissues.^1-4 Removing some of these foreign objects may cause more harm than good and therefore, are left in situ. However, most of these objects are removed before infection or any other complications occur.¹ Diagnosing and promptly identifying foreign bodies typically rely on the patient's medical history and clinical examination. However, various imaging techniques, both in vivo and in vitro have been explored to locate foreign bodies. Examples of these methods include plain radiographs, xeroradiographs, computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound (US).¹

The term ‘Jael syndrome’ is used in cases of intentional damage to the craniofacial area caused by a knife. This term was used in literature based on the Biblical story of the murder of Sisera by Jael (Jude IV: 21). McKenney mentioned that the first case of this syndrome was reported in 1968 by Jefferson, whose 16-year-old adolescent boy sustained a severe accidental wound near the temple. Tissues affected by changes from gunshot wounds and scarring can result from Safer surgery, during which an iatrogenic foreign body was accidentally introduced. The approach to this type of injury should be continuous and interdisciplinary, beginning with the trauma department ensuring airway maintenance and hemodynamic stabilization, and followed by neurological, ophthalmological, and vascular examinations as needed.⁵

Treatment must be initiated at the earliest. Stabilization of the patient must be prioritized. Upper airway assessment and maintenance, followed by hemodynamic control and neurological evaluation are to be carried out. Following the primary stabilization, the foreign body should be carefully removed, preferably under general anaesthesia. In the imaging, if the object is identified superficially and not located near a major blood vessel, object removal can be performed under local anesthesia.⁵

Case Presentation

A 28-year-old female reported to the Department of Oral and Maxillofacial Surgery, Karnataka Institute of Medical Sciences and Hospital, Hubli, Karnataka with a blunt injury and history of assault with a toothbrush involving the left infraorbital region. The patient complained of pain and swelling in the said region. On clinical examination, we noted posterior orbital edema of the left eye, subconjunctival hemorrhage, paraesthesia of the infraorbital region on the affected side, and a localized rise in temperature. No evidence of facial fractures was noted and the mouth opening was found normal. On examination, vision was normal and tetanus prophylaxis was already administered. Immediate CT scans were performed, which revealed a rectangular radiolucent image in the left zygoma region (Figure 1).

The procedure for removal was done electively under general anesthesia. The case was approached through a subciliary incision, with a total operating time of three hours (Figure 2).

The foreign body, a 7 cm long broken piece of toothbrush, was removed successfully without any vessel injury (Figure 3). There was no damage to other surrounding tissues and muscles. Further exploration revealed no lodgment of any other foreign body. The wound was irrigated thoroughly, and the incision was closed with layered suturing using 3-0 Vicryl, followed by 4-0 nylon. Post-surgical follow-up was done once every week for three months. The patient made a full recovery and the parasthesia was resolved after the surgery.

Discussion

Foreign bodies can penetrate deep into soft and hard tissues through open wounds and lacerations formed during trauma. If left undetected, these foreign bodies within the tissues can cause severe complications within days, months, or even years after the initial trauma.⁶

In case of non-healing wounds from penetrating injuries with persistent purulent discharge, pain, or the development of chronic sinuses, the possible presence of a residual foreign body should be suspected.⁷

Removing foreign bodies in the head and neck proves challenging due to their proximity to vital structures or difficult access.⁸ The presence of a foreign body can alter the anatomy. Diagnostic imaging is essential for treatment planning, enabling the identification and precise localization of the lodged foreign body while ensuring the preservation of surrounding vital structures. The diagnostic tools that aid in confirming the presence, location, size, and shape of foreign bodies include plain radiographs, computed tomography (CT) scans, ultrasonography, and magnetic resonance imaging (MRI).³

The following steps were performed: access, foreign body removal, wound inspection, cleaning and suturing, tetanus prophylaxis, and antibiotic use. In our case, the diagnosis was made based on clinical examination and CT scans. The treatment initially prioritized the patient’s primary stability with clinical and neurologic evaluation. It was decided to perform the procedure under general anesthesia, resulting in successful removal of the foreign body and adequate functional restoration.^8-11

Injuries to the jaw or face caused by foreign objects can lead to life-threatening situations. Hence, a proper protocol involving a multidisciplinary team should be followed to diagnose and treat the same. This increases the survival chance and post-treatment quality of life of the patient. Removal of post-trauma/assault lodgment of foreign bodies depends on the site and depth of penetration. The potential for benefit over harm in the removal procedure should always be considered, based on the proximity and involvement of vital structures. In many cases, the foreign body, if not causing any harm, is left as it is. However, in the present case, there was evidence of inflammatory reaction and infraorbital nerve compression which justified the need for the procedure.

Acknowledgments And Disclosure Statements

• No funds, grants, or other support was received.
• The authors have no relevant financial or non-financial interests to disclose.
• The authors report no conflicts of interest related to this study.