title: Wooden Foreign Body in the Skull Base: How Did We Miss It?
abstract: BACKGROUND
  Timely detection of intraorbital and skull base wooden foreign bodies is crucial. Wooden foreign bodies are difficult to detect on imaging. The radiologist may fail to identify wooden foreign bodies on two thirds of initial scans and can miss them in almost one third of total cases.
  
  
  METHODS
  A 66-year-old woman sustained a penetrating injury through the left upper eyelid with a small tree branch. The branch was immediately removed in the field, and she was provided with prompt medical care at a local hospital. Initial computed tomography (CT) scan diagnosis was "posttraumatic sinusitis," and this was treated empirically with vancomycin and piperacillin/tazobactam. On the eighth day after injury, she developed progressive swelling and pain of her eyelid with left trigeminal/supraorbital numbness and complete left ophthalmoplegia. A new CT scan showed an open "track" from the region of the left upper orbit/superior rectus to the contralateral sphenoid sinus, which raised suspicion for a retained foreign body. Further imaging confirmed the suspicion. Endoscopic sinus surgery was performed with extraction of the wooden object and evacuation of the left orbital infection.
  
  
  CONCLUSIONS
  This case indicates that intraorbital and skull base wooden foreign bodies are elusive, demanding a high index of suspicion from both clinicians and radiologists to identify retained material in the setting of ocular or sinus trauma. For better identification of wooden foreign bodies, bone windows on CT should have a width of -1000 Hounsfield units with a soft tissue window level of -500 Hounsfield units.
authors.affiliation: Department of Neurosurgery, Neurotrauma, University of Miami Miller School of Medicine, Miami, Florida, USA.
authors.forename: Ignacio
authors.initials: I
authors.lastname: Jusué-Torres
authors.affiliation: Department of Neurosurgery, Neurotrauma, University of Miami Miller School of Medicine, Miami, Florida, USA.
authors.forename: S Shelby
authors.initials: SS
authors.lastname: Burks
authors.affiliation: Department of Otolaryngology, University of Miami Miller School of Medicine, Miami, Florida, USA.
authors.forename: Corinna G
authors.initials: CG
authors.lastname: Levine
authors.affiliation: Department of Diagnostic Radiology, Division of Neuroradiology, University of Miami Miller School of Medicine, Miami, Florida, USA.
authors.forename: Rita G
authors.initials: RG
authors.lastname: Bhatia
authors.affiliation: Department of Otolaryngology, University of Miami Miller School of Medicine, Miami, Florida, USA.
authors.forename: Roy
authors.initials: R
authors.lastname: Casiano
authors.affiliation: Department of Neurosurgery, Neurotrauma, University of Miami Miller School of Medicine, Miami, Florida, USA. Electronic address: rbullock@med.miami.edu.
authors.forename: Ross
authors.initials: R
authors.lastname: Bullock
mesh_terms: D000368:Aged; D003951:Diagnostic Errors; D019723:Endoscopes; D015807:Eye Injuries, Penetrating / Q000150:complications* / Q000000981:diagnostic imaging / Q000601:surgery*; D005260:Female; D005547:Foreign Bodies / Q000150:complications* / Q000000981:diagnostic imaging / Q000601:surgery; D006801:Humans; D008279:Magnetic Resonance Imaging; D019291:Skull Base / Q000000981:diagnostic imaging / Q000601:surgery; D015898:Tomography Scanners, X-Ray Computed
keywords: Air mimicking; CT; Intraorbital wooden foreign body; MRI; Skull base