title: Transnasal Penetration of a Ballpoint Pen: Case Report and Review of Literature.
abstract: BACKGROUND
  Transnasal penetration by a nonmissile foreign body is a rare injury. Consequently, appropriate management remains controversial. We report a case of transnasal penetration by a ballpoint pen and review the literature. To our knowledge, this is the first living patient who sustained carotid artery damage from a transnasal penetrating intracranial injury.
  
  
  METHODS
  A 56-year-old female presented with a ballpoint pen lodged through her left nostril. She exhibited right cranial nerve palsies (III, IV, VI, and V1). A computed tomography (CT) scan of the head revealed a foreign body in the left nasal cavity traversing the ethmoid/sphenoid and likely through the right superior orbital fissure and cavernous sinus, with the distal tip adjacent to the right atrium. CT angiography revealed nonopacification of the right internal carotid artery (ICA) from the mid-petrous segment to the ophthalmic segment. Subsequently, she underwent coil embolization of the proximal right ICA, followed by a right frontotemporal craniotomy with anterior temporal lobectomy to skeletonize the pen and right distal ICA, and finally clipping of the ICA distal to the pen and prompt transnasal endoscopic removal of the pen. There were no hemorrhagic complications. She awoke at her neurologic preoperative baseline.
  
  
  CONCLUSIONS
  Injuries such as the one described here should be managed through a multidisciplinary approach. The trajectory of the foreign body should be delineated through CT imaging, along with vascular imaging if appropriate. If there are signs of vascular injury, then attempts to maintain proximal and distal control are prudent to avoid hemorrhagic complications. This combined endovascular-endoscopic-open craniotomy approach has not been reported previously in the literature.
authors.affiliation: Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA. Electronic address: hsnguyen@mcw.edu.
authors.forename: Ha Son
authors.initials: HS
authors.lastname: Nguyen
authors.affiliation: Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.
authors.forename: Akinwunmi
authors.initials: A
authors.lastname: Oni-Orisan
authors.affiliation: Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.
authors.forename: Ninh
authors.initials: N
authors.lastname: Doan
authors.affiliation: Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.
authors.forename: Wade
authors.initials: W
authors.lastname: Mueller
mesh_terms: D015901:Angiography, Digital Subtraction; D002343:Carotid Artery, Internal / Q000601:surgery*; D003399:Craniotomy; D004621:Embolization, Therapeutic; D004724:Endoscopy; D005260:Female; D005548:Foreign-Body Migration / Q000175:diagnosis* / Q000523:psychology / Q000601:surgery*; D006801:Humans; D033183:Interdisciplinary Communication; D000070516:Intersectoral Collaboration; D008875:Middle Aged; D009666:Nose / Q000293:injuries*; D016728:Self-Injurious Behavior / Q000175:diagnosis* / Q000523:psychology; D013702:Temporal Lobe / Q000601:surgery; D014057:Tomography, X-Ray Computed; D014951:Wounds, Stab / Q000175:diagnosis* / Q000523:psychology / Q000601:surgery*
keywords: Craniofacial trauma; Penetrating injury; Transnasal