An unusual case of trismus and epistaxis

Educational Objectives: At the conclusion of this presentation, the participants should be able to explain the clinical presentation of an infratemporal fossa (ITF) foreign body and discuss the various surgical approaches for removal. Objective: Head and neck foreign bodies have a variety of distinct clinical presentations. We present an unusual case of an ITF foreign body requiring operative removal and discuss surgical approaches to this space. Study design: A case report and review of the literature. Methods: Case report and Medline search of the terms "infratemporal fossa" and "foreign body." Results: A 64 year old male sustained a laceration to his right cheek after a window pane shattered over his head. Plain film x-rays were unremarkable and the laceration was closed primarily. He developed mid-right face weakness, progressive trismus to 1.5 cm and salivary-like drainage from his cheek wound. He also developed intermittent right-sided epistaxis that was exacerbated with chewing. After referral to several dentists and an oral surgeon a CT scan revealed a 5 cm foreign body extending through the superior parotid gland into the ITF terminating in the middle turbinate. Through a modified Blair approach to the parotid gland two glass fragments were removed. Nasal endoscopy was used to visualize the glass imbedded in the middle turbinate. At three months follow up he had no trismus and facial nerve function was normal. A review of the literature identified several reports of displaced maxillary molars and traumatic foreign bodies of the ITF. This case is unique in its surgical approach and the concomitant presentation of trismus and epistaxis. Conclusions: ITF foreign bodies may present a diagnostic and therapeutic challenge. The surgical approach to removal is dictated by the nature of the injury.