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We share an interesting case of a child whom we saw with a low-grade inflammatory infraorbital mass secondary to a foreign body that localized to the infratemporal fossa. There are several unanswered questions about the ultimate source of the foreign body. However, this case stresses the importance of a broad differential diagnosis and the choice of imaging modality in children.
A 7-year-old girl was seen with a 2-month history of increased prominence and erythema of her left zygomatic arch and surrounding tissues. The family recalled minor, blunt trauma that occurred several weeks prior to the change in the child's appearance. The patient was in good health and medical history was otherwise unremarkable.
On examination, the patient was afebrile and in no distress. Visual acuity was 20/20 OU without correction. There was no globe malposition subjectively or by exophthalmometry. There was a firm, minimally tender immobile mass that was continuous with the left zygoma by palpation. The skin medial to the lesion had a violet discoloration (Figure 1). The subacute presentation without constitutional signs increased our suspicion of a primary malignant neoplasm of either the bone or soft tissue, as opposed to a noninfectious inflammatory process.
Facial asymmetry as noted by narrowed left palpebral fissure, erythematous infraorbital skin, and fullness of the inferolateral left orbital rim.
A computed tomographic scan of the head and orbit was obtained. It revealed a soft tissue lesion surrounding the left lateral orbit with extension into the infratemporal fossa. Additionally, there was hyperostosis of the left frontozygomatic arch (Figure 2, top). Within the infratemporal fossa extending to the superior alveolar ridge, there was a high-density foreign body that was contiguous with the soft tissue density (Figure 2, bottom). Subsequent examination of the oral cavity demonstrated a pyogenic granuloma in the buccal sulcus at the left level of the first upper molar. (Figure 3).
Top, Axial computed tomographic scan demonstrating the soft tissue mass to the level of the orbital rim. More posteriorly, a high-density material (arrow) is without an immediately adjacent soft tissue reaction. Bottom, Coronal computed tomographic scan showing bone window, localizing foreign body to the infratemporal fossa.
Glistening pyogenic granuloma in the buccal sulcus (arrow).
The patient underwent a left anterior orbitotomy to explore the region of the inferolateral orbital rim corresponding to the region of clinical involvement and to further evaluate the abnormality seen on the computed tomographic scan. A fibrous soft tissue mass overlying the orbital rim was removed. Incision into the mass produced a scant exudate. The underlying periosteum of the zygoma was thickened. Through intraoral blunt dissection of the pyogenic granuloma and reflection of the periosteum of the maxilla, a 24-mm, metallic, cylindrical foreign body was located on the anterolateral face of the maxilla and removed (Figure 4). The cavity was copiously irrigated and a Penrose drain was temporarily left in place exiting into the mouth. Intraoperatively, cefazolin was administered intravenously and followed with a postoperative course of oral amoxicillin. Review of the frozen and permanent pathological specimens revealed fibrotic tissue with chronic inflammation and reactive woven bone formation.
Retrieved 24-mm-long metallic foreign body.
The postoperative course was uneventful. At 5 months, there was no suggestion of recurrence and the mouth was well healed. Further questioning of the child and family did not glean insight into the source of the foreign body. The case social worker and pediatrician found no evidence of child abuse.
To our knowledge, this case represents the first report of an infratemporal foreign body presenting as an inferior orbital mass. There are several cases of foreign bodies in this region presenting with trismus and acute inflammation.1 However, these cases have been associated with a known direct injury (ie, broken pen tip from stabbing). We speculate that entry to the infratemporal fossa was via the buccal sulcus.
Despite a thorough multidisciplinary inquiry, the exact mechanism of injury could not be ascertained. Without invoking alien intervention, our best working hypothesis is that this pinlike foreign body may have become imbedded in the child's face during a lacerating sledding accident 2 years prior to presentation. The foreign body may have been lodged within the epicenter of the perizygomatic mass seen on computed tomography. The relatively minor trauma sustained 2 months prior to presentation may have dislodged the foreign body. Disruption of the reactive fibrous capsule may have permitted leakage of its contents, resulting in the low-grade inflammatory picture seen on presentation.
This case is instructive on several levels. Foreign bodies should be considered in the differential of all orbital and periorbital mass lesions, especially in children, who are notoriously poor historians. Accordingly, the choice of initial radiological imaging should attempt to rule out the existence of such material.2,3 Also, in very rare cases, oral examination may provide insight into the origin of lesions presenting in the periorbital region.
Corresponding author: Peter A. D. Rubin, Department of Ophthalmology, Ophthalmic Plastics, Orbital and Cosmetic Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, 243 Charles St, Boston, MA 02114.
Grant CA, Rubin PAD. An Infratemporal Fossa Foreign Body Presents as an Infraorbital Mass. Arch Ophthalmol. 2000;118(7):993-995. doi: