Foreign Bodies in the Maxillofacial Region: Assessment With Multidetector Computed Tomography

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Maxillofacial region is an anatomically complex area, representing a crossroads of different systems and apparatus. It is defined as the anatomical region lying on the facial skeleton from the inferior outline of maxilla up to an ideal plane passing through the skull base and the inion point, posteriorly. In this area, the digestive and respiratory systems connect to themselves and open in the mouth and sino-nasal cavities. Even the orbits with the ocular globes and their surrounding tissues lie in the same area. Despite the little exposed surface, the chance of penetrating injuries to this site is at least similar to other regions of the body due to the “pivotal role” of the face in human relations. Moreover, the external openings of respiratory and digestive systems and the orbital cavities represent an easy way in for foreign bodies (FBs). Based on the access paths, it is possible to distinguish ingested, inhaled, penetrating, and iatrogenic (owing to surgery) FBs. FB may stop in oral and ocular cavities, or proceed deeply, reaching the surrounding soft tissues, the facial bones, or other cavities such as sino-nasal region, mouth, orbits, and further spaces of the head and neck region, like infratemporal fossa, parapharyngeal space, and sphenopalatine fossa. Furthermore, FBs accidentally introduced and lost in visceral cavities (mouth, ear, and nose), particularly in pediatric subjects, may be quickly removed during direct inspection.

Introduction

Maxillofacial region is an anatomically complex district, representing a complex crossroads of different systems and apparatus. Despite the little exposed surface, the chance of penetrating injuries to this site is at least similar to other regions of the body owing to the “pivotal role” of the face in human relations. Furthermore, in this area lie the external openings of the respiratory and digestive systems and the orbital cavities, which represent other ways through which foreign bodies (FBs) can penetrate both in the same cavities and across them in deep spaces of maxillofacial area.1, 2, 3 All external objects located in the human body are usually considered as FBs. They can be found not only in oral, nasal, or ocular cavities but also in the surrounding soft tissues, in the facial bones, and in other cavities of head and neck region, such as infratemporal fossa, parapharyngeal space, and sphenopalatine fossa. Furthermore, FB accidentally introduced and lost in visceral cavities (mouth, ear, and nose), particularly in pediatric subjects, may be quickly removed during direct inspection. Many emergency calls describe different accident scenarios with FB penetration, especially in case of motor vehicle accident where broken glasses, metal slivers, or rubbles may deeply penetrate the maxillofacial region via skin. The question is what is the role of imaging in patients with facial FB. The answer is that imaging is crucial to identify quickly the penetrating FB (PFB) and all the related pathologies, especially to rapidly address the patients with the correct therapy. Moreover, the complex anatomy of head and neck region and the different characteristics of the FB and its location require different diagnostic protocols. In particular, the presence of a crucial vascular and nervous network in this region requires at least vascular studies and mapping to define the 3-dimensional shape of FB and its relationship with the surrounding structures.4, 5, 6

Section snippets

Anatomy

The anatomy of the maxillofacial region is crucial to foresee correctly the location of any FB based on its doorway, thus predicting any life-threatening complication. In particular, vascular and nervous structures may be impaired by FBs, not only along its pathway inside the body during penetration but also in case of wrong handling of procedures during removal. Maxillofacial area may be defined as the anatomical region lying on the facial skeleton from the inferior outline of the maxilla up

Diagnostic Imaging in FBs

Based on the access paths, it is possible to distinguish ingested, inhaled, PFB, and iatrogenic (owing to surgery) FBs. Several imaging techniques may be used to detect and correctly characterize FBs. In particular, the choice of the appropriate technique is related to several factors: (1) doorway, (2) chemical composition, and (3) supposed location inside the body, such as the upper aerodigestive tract or other specific regions.15, 16, 17

Inhaled and Ingested FB

Accidental penetration of FB in the oral and nasal cavities is uncommon. Indeed, even in emergency such as a full-width frontal crash, conscious subjects tend to clamp their mouth to prevent penetration. In these cases, fractured teeth could accidentally penetrate into the mouth and even migrate to physiological shrinkages or anatomical cleft like Morgagni ventricle or pyriform sinuses.18, 19 In such cases, physical examination can successfully identify broken teeth, whereas radiographic

Penetrating Foreign Bodies

Accidental FB penetration in the maxillofacial region represents a dangerous condition often associated with polytrauma, and mostly occurring during road-traffic accidents or car crashes. Despite the little exposed surface, the chance of penetrating injuries to this site is high owing to the proximity of the face and the neck to the windscreen, whose fragments could easily reach skin or orbits and penetrate the underlying layers of the body. In case of low-energetic projection, slivers

Iatrogenic FBs

All the FBs accidentally penetrated during surgical procedures are defined as iatrogenic. A large number of reports describe the presence of FBs forgotten in the surgical field and retrieved only after long time in relation to the onset of specific set of symptoms. However, these reports are mainly focused on a specialist clinical setting (odontoiatric) and do not exhaustively carry out a critical review about how to adequately approach the patient to solve his problem. Because maxillofacial

Conclusions

FBs are a common finding in the maxillofacial region and may be encountered in different contexts. Mostly, in case of removal of ingested or inhaled FBs, no diagnostic procedure is needed in the decision making. High-energy PFBs often represent an emergency or potentially emergency condition, in which a correct depiction of penetration doorway and FB׳s exact shape and location is mandatory to assess the best surgical removal strategy. At present, iatrogenic FBs are the more common encountered

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