Injury to the Temporal Lobe via Medial Transorbital Entry of a Toothbrush

Background and Importance: Intracranial penetration by foreign bodies entering via the orbit represents an unusual form of traumatic brain injury. Nevertheless, much is at stake with high risk for cranial nerve and neurovascular injury. We present a case where the bristled end of a toothbrush entered the brain as a projectile via the superior orbital fissure and discuss important considerations for surgical management including modern skull base techniques. Clinical Presentation: A 35-year-old woman suffered a periorbital injury after her husband threw an electric toothbrush at a wall and the head of the toothbrush became a missile that projected through her superior orbital fissure, fracturing her greater sphenoid wing, and into her right temporal lobe. She complained of headache and incomplete vision loss in the affected eye. Intervention: After obtaining a cerebrovascular angiogram, we proceeded with emergent orbital decompression and anterograde extraction of the foreign body via a modified frontotemporal orbitozygomatic approach (two-piece supraorbital modified approach) with drilling of the skull base allowing for en bloc removal of the toothbrush. Conclusion: The patient recovered well with improvement in her vision and with stable partial third and sixth nerve palsies. This case report illustrates a unique mechanism of injury with a novel intracranial foreign body resulting in a superior orbital fissure syndrome. We review the neurosurgeon’s need for prompt management with an approach customized to the structure of the offending object, the damaged elements, and the surrounding cranial nerve and vascular anatomy.