Posterior migration of lumbar disc herniation: A case report

Posterior epidural migration of herniated lumbar disc fragments is a rare pathological entity. This can lead to major neurological deficits. Here, we present a rare case of sequestrated lumbar disc fragment migration into the epidural space. A 49-year-old-man presented with severe low back pain and weakness of the long extensor muscle of the hallux. MRI of the lumbar spine revealed posterior epidural lesion at the L4-L5 level. The disc fragment was isointense on T1 and T2-weighted Images (WI). The mass lesion was removed after decompressive laminectomy. Pathological investigation revealed an intervertebral disc fragment. The patient's condition improved postoperatively.

Surgical outcome and prognostic factors for 39 recurrent spinal hydatid cysts

Background

Cystic bone echinococcosis accounts for 0.5-4% of all reported cases, and 45% occur in the spine. Our aim was to review the clinical and radiological features, surgery, and outcomes for 39 patients with recurrent spinal hydatidosis.

Methods

Thirty-nine reports of patients with recurrent spinal hydatidosis (2011-2020) were followed for an average of 9.28 ± 5.60 months.

Results

Lesions occurred in descending order in the; lumbar (48.7%), thoracic (43.6%), and cervical spine (7.7%). Total cyst resection was achieved in 28 of 39 patients (71.8%). Intraoperative cyst rupture occurred in 13 patients (33.3%). The postoperative American Spinal Injury Association (ASIA) score was "good" in 82% of patients. Those with "poor" postoperative ASIA scores had a 41% incidence of recurrent thoracic hydatid cysts; further, they demonstrated significantly higher recurrence rates if cysts had ruptured intraoperatively (P = 0.001). In addition, laminectomy, subtotal original cyst resection (P < 0.007), and a thoracic location were all significantly associated with higher recurrence rates (P < 0.04).

Conclusion

The majority of patients demonstrated improvement following surgery for cervical hydatid cysts. Notably, those with poor outcomes typically experienced intraoperative ruptures of their thoracic hydatid cysts, contributing to high cyst recurrence rates.

Primary Ewing's sarcoma of the occipital bone: A case report and review of the literature

Background

Primary Ewing's sarcoma (ES) arising from cranial bones is an extremely rare entity that accounts for only 1-4% of all ES cases.

Case Description

A 21-year-old woman presented with ES of the skull affecting the occipital region. The patient underwent surgical excision following radiotherapy and chemotherapy. No recurrence or metastasis occurred over a 10-month follow-up.

Conclusion

ES reaches adolescents. The mainstay of treatment includes surgical removal of the tumor, followed by radio- and chemotherapy.

Accuracy and Safety of Fluoroscopy-Assisted Transpedicular Screw Insertion in Thoracolumbar Spine Surgery: Evaluation of 122 Screws

The objective of this study is to determine the accuracy and safety of trans-pedicular screws' insertion in the thoracolumbar spine using a fluoroscopy-assisted surgical technique. We retrospectively evaluated all patients who underwent a postoperative computed tomography scan to assess the location of the pedicular screws following thoracolumbar spinal surgery, at the Mohammed Vth Military Training Hospital-Rabat, from January 2020 to April 2022. We used Gertzbein's classification to grade pedicular cortex breaches. A screw penetration greater than 4 mm (grades D–E) was considered critical and one less than 4 mm was classified as noncritical (grades A–C). A total of 122 screws inserted in the T1 to L5 vertebrae were included from 25 patients. The average age was 46 years old. Pathologies included degenerative disorders (5 patients), tumors (8 patients), and trauma (12 patients). All screws were inserted using lateral and anteroposterior fluoroscopic guidance. A total of 11 transpedicular screws breaches were identified. The breaches incidence was significantly higher in thoracic pedicles (8 screws) than in lumbar pedicles (3 screws). Of these, three critical cases occurred in two patients and one of them required reintervention. The remaining eight exceedances were not critical and were closely monitored and followed up. Transpedicular screws fluoroscopy-assisted surgical fixation can be performed for the stabilization of the thoracolumbar spine with satisfactory safety and precision.

Positive outcome of nonoperative management of spinal cord compression by multiple myeloma: A case report

Background

Spinal cord compression (SCC) is a severe consequence of multiple myeloma (MM). Surgical management is appropriate when there are spinal instability and neurological function compromise. The reversibility of peripheral neuropathy during treatment of MM has been reported in some studies after a cycle of Bortezomib (Velcade), Thalidomide, and Dexamethasone (VTD), but very rare in myeloma patients with SCC.

Case Description

We report a case of a 58-year-old male tetraplegic secondary to cervical SCC by MM who completely recovered after 5 cycles of VTD chemotherapy without surgery.

Conclusion

Surgical spinal cord decompression by laminectomy is known as the gold standard for treating this condition. Nevertheless, some patients can completely recover from nervous insult without surgery.

Management and positive outcome of skull-base ossifying fibroma: a case report

The ossifying fibroma is a benign fibro-osseous tumor rarely affecting the skull base. The incidence of ossifying fibroma itself is uncommon. It is considered to be an aggressive and fast-growing bone lesion. Early detection and complete surgical removal are essential to deal with its aggressive nature and recurrence. We report a case of a 20-year-old man admitted for the management of ossifying fibroma of the orbital roof extending inside the orbit mimicking meningioma and revealed by a progressive proptosis and headache. The patient underwent surgery for the subtotal removal of the tumor with its frontal infiltration with a good outcome. All meningiomas like tumors are not meningiomas and other tumors such as ossifying fibroma might be mistaken for meningioma and even get confirmation from the pathological anatomy study. Need be for these tumors to be looked at more closely for better therapeutic decision-making.

Variation of Ventricular Size after Surgical Treatment of Chronic Subdural Hematoma

Background

Surgical removal is the treatment of choice for chronic subdural hematoma (CSDH). Despite clinical improvement after surgery, computed tomography (CT) scan control often showed residual collection, which may discuss the possibility of failed surgery. The aim of this study is the assessment of ventricular size before and after surgery and to study its relation with residual hematoma.

Methods

In this prospective study (2013-2016), 63 patients who had burr-hole drainage of CSDH were sequentially allocated to either two groups; Group 1 with CT scan control under the 3^rd day of surgery and Group 2 with delayed CT scan control (from 4^th to 7^th day). Linear measure of ventricular size was assessed by Evans' index. We reviewed and analyzed the data between both groups.

Results

There were 33 patients in Group 1 and 30 patients in Group 2. Preoperatively, the average thickness of hematoma was 20.5 mm in Group 1 versus 19.9 mm in Group 2 (P = 0.67); the mean midline shift was 8.5 mm in each group; Evans' index was 26.7% in Group 1 and 27% in Group 2 (P = 0.7). Postoperatively, the mean thickness of the residual hematoma was 7.7 mm in Group 1 and 8.4 mm in Group 2 (P = 0.57); the mean midline shift was 3.3 mm in Group 1 and 1.9 mm in Group 2 (P = 0.08); Evan's index was 28.5% in Group 1 and 32.1% in Group 2 (P = 0.002).

Conclusion

The adoption of Evans' index, for assessing the variation of ventricular size after surgery, by neurosurgeons appears to be a good and simple method for evaluation and following the success of surgical removal of CSDH, despite the observation of some residual collection in early CT scan control.

Comparison of inhaled versus intravenous anesthesia for laryngoscopy and laryngeal electromyography in a rat model

Background

Propofol and remifentanil intravenous combination is one popular form of total intravenous anesthesia (TIVA) in mainstream clinical practice, but it has rarely been applied to a rat model for laryngoscopy and laryngeal electromyography (LEMG). Our objective was to establish a safe and reproducible general anesthetic protocol for laryngoscopy and endoscopic LEMG in a rat model. Our hypothesis is that TIVA allows a minimally morbid, and feasible laryngoscopy and LEMG.

Methods

Sprague Dawley rats were subjected to either inhalational anesthesia (IA) (isoflurane) or TIVA (propofol and remifentanil) and underwent laryngoscopy and LEMG. The primary outcome was a complete minimally interrupted rigid laryngoscopy and obtaining reproducible motor unit potentials from the posterior cricoarytenoid muscles. The secondary outcome was morbidity and mortality.

Results

Seventeen out of twenty-two rats underwent both TIVA and IA. Only two underwent IA only. All nineteen rats that underwent IA had a successful experiment. Seventeen rats underwent TIVA, however, only nine completed a successful experiment due to difficulty achieving a surgical plane, and respiratory events. Upon comparing the success of the two anaesthetic regimens, IA was superior to TIVA (P = 0.0008). There was no statistical difference between the amplitudes (p = 0.1985) or motor units burst duration (p = 0.82605) of both methods. Three mortalities were encountered, one of which was due to lidocaine toxicity and two were during anesthetic induction. Respiratory related morbidity was encountered in two rats, all seen with TIVA.

Conclusions

TIVA is not an ideal anesthetic regimen for laryngeal endoscopy and LEMG in rat models. Contrary to our hypothesis, IA did not affect the quality of the LEMG and allowed a seamless rigid endoscopy.

Electronic supplementary material

The online version of this article (10.1186/s40463-018-0312-9) contains supplementary material, which is available to authorized users.

Correlation between gonial angle and dynamic tongue collapse in children with snoring/sleep disordered breathing - an exploratory pilot study

BACKGROUND

Drug induced sleep endoscopy (DISE) is hoped to identify reasons of failure of adenotonsillectomy (AT) in treating pediatric sleep disordered breathing (SDB). Maxillomandibular disproportion has been studied as another association which may explain alternative pathogenesis of SDB. We aimed to explore the relation between the size of the gonial angle and inclination of the epiglottis measured from cone beam CT (CBCT) and tongue base collapse based on DISE in children with SDB.

METHOD

A retrospective chart review was conducted at a tertiary pediatric center. Children (6-17 years old) assessed at a multi-disciplinary Upper Airway Clinic, diagnosed with SDB and maxillo-mandibular disproportion (MMD), and who underwent DISE were eligible. Variables obtained from the electronic medical records of the clinic and prospective database included demographics, comorbidities, surgeries performed, investigations, DISE findings and CBCT findings. The gonial angle of subjects with and without tongue base collapse (TBC) on SNP were compared.

RESULTS

In total 29 patients (13 male, 8 female) age 6-17 (median= 9) were eligible for the study from January 2009 - July 2016. We included 11 subjects, and 10 comparators. The mean gonial angle of the TBC group was 139.3°± 7.6°, while that of the comparison group was 129.4°±3.5 (mean difference -9.937, 95% CI of -15.454 to - 4.421, P = 0.001, power of test 0.95). Additionally, the mean inclination of the epiglottis had a mild positive correlation (r=0.32, p<0.05) with the gonial angle, in the whole cohort.

CONCLUSIONS

This pilot study suggests that TBC may be mediated by a wider gonial angle in children with SDB patients. The posterior tilt of the epiglottis on CBCT may be a surrogate sign of TBC.

Spontaneous Intraventricular Hemorrhage Caused by Sphenoid Meningioma

INTRODUCTION

 Benign sphenoid meningioma presenting with an acute intraventricular hemorrhage is extremely uncommon.

CASE REPORT

 We report a case of a 61-year-old man who was admitted after sudden onset of a severe headache. Brain computed tomography revealed a sphenoid meningioma with acute intraventricular hemorrhage.

DISCUSSION

 Intraventricular hemorrhage caused by Meningiomas is infrequent. Several hypotheses have been proposed to explain the cause of hemorrhage.

CONCLUSION

 The benignity of meningiomas is relative because these tumors can cause exceptional complications such as bleeding.

Paradoxical Tuberculomas Complicating Tuberculous Meningitis: About Two Cases

Paradoxical tuberculomas in patients with tuberculous meningitis during antituberculous chemotherapy is an unusual phenomenon. This reaction is due to the immune response of the host to antituberculous drugs. It is commonly seen in the intensive phase of chemotherapy. We report the cases of two patients with tuberculous meningitis who had developed tuberculomas during adequate and appropriate antitubercular therapy. Tuberculous meningitis requires the regular clinical and radiological follow-up to detect paradoxical response.

Bilateral Traumatic Thalamic Hemorrhage: A Rare Clinical Presentation

Bilateral traumatic thalamic hemorrhage is a very rare occurrence, especially after head trauma, and is limited to case reports. The authors present a 27-year-old man, admitted for head trauma causing bilateral thalamic bleeding. Posttraumatic intracerebral bleeding is caused by focal or diffuse axonal injury. Bilateral traumatic thalamic hemorrhage is a rare clinical and radiologic presentation.

Cystic Trigeminal Schwannoma. Case presentation

Trigeminal schwannoma is the second commonest intracranial schwannoma; they remain rare. A minority exhibit cystic changes, with even fewer an intracystic fluid level. We report a case of a 45-year-old man, presented with a progressive hearing loss, worsening right-sided facial spasms and facial numbness in the region of the right trigeminal nerve. Neurological examination revealed hypoesthesia in the right facial region and intermittent rights sided hemi-facial spasms, without signs of raised intracranial pressure or achieve the mixed nerves or neurological deficit. A Magnetic resonance imaging of the brain revealed a cystic mass in the right cerebello-pontine angle with extension forward towards the cavum meckel. The patient was operated by retro sigmoid approach, with a total resection of the tumor.

Intracranial cystic schwannomas constitute an uncommon subset of tumors with a distinct clinico-biological behavior. The presence of fluid–fluid levels within the tumors, although rare, confirms the cystic nature of the neoplasms. Cystic areas are usually secondary to the coalescence of mucinous or microcystic regions in Antoni B tissues. The treatment is surgical in the majority of cases and stereotactic radiosurgery has a clear role for adjuvant treatment of post-surgical recurrence of the tumor or residue.

Posterior epidural migration of lumbar intervertebral fragment: case report

Disc fragments are well known to migrate to superior, inferior, or lateral sites in the anterior epidural space, posterior epidural migrated lumbar disc fragments is an extremely rare disorder. Posterior epidural migrated lumbar disc fragments are often confused with other posterior epidural space-occupying lesions (cysts, abscesses, tumors, and hematomas). We reported the case of a 52- year-old man presented with progressive not systematizes bilateral radiculopathy complicated one week before admission a difficulty dorsiflexion prevents the start, and the stared to use crutches. Clinical examination revealed steppage gait and a strength score of 3/5 on dorsiflexion of feet. MR imaging of lumbar spine showed right posterolateral epidural mass that compressed the dural sac at the L3-4 level. Patient underwent surgery using posterior approach, an L3 laminectomy was performed, the extruded disk fragment was gently removed and L3-L4 interspace was explored. Histopathology confirmed the (PEMLIF). Postoperative course was uneventful.

Diagnosis and management challenge of a granular cell astrocytoma of the pineal region: case report

Granular cell astrocytoma (GCA) is a rare type of infiltrative brain tumor with most reported cases occurring in the suprasellar region. A pineal localization is extremely rare, with only 4 previously reported cases in the literature. The authors describe the case of a 16-year-old boy who developed signs of increased intracranial pressure and Parinaud syndrome. Cranial CT and MRI revealed a well-demarcated and enhanced mass in the pineal region accompanied by obstructive hydrocephalus. Subtotal resection was performed via a subtemporal approach. A histological diagnosis of GCA was made. Three years after surgery, the patient was alive and well without adjuvant therapy, and serial MRI showed no signs of progression of a small residual tumor. After a thorough review of the different epidemiological, clinical, and imaging features; treatments; and prognoses of GCAs in other intracranial localizations, the authors analyzed features of this tumor in the pineal region.

Pediatric intramedullary schwannoma without neurofibromatosis: case report

Pediatric intramedullary schwannoma without neurofibromatosis is extremely rare with only five cases reported so far. We present this rare finding in an 10-year-old boy who presented with a sudden onset of weakness in the lower limbs. An intraoperative diagnosis of schwannoma enabled us to carry out a total excision of the tumor, which resulted in near complete recovery at 10 months follow-up. Although rare, this diagnosis should be considered when a child presents with a solitary intramedullary tumor since its total resection can be achieved improving surgical outcome.

[Cryptococcal meningitis in a patient with a ventriculoperitoneal shunt and monitoring for pulmonary sarcoidosis]

The fungus Cryptococcus neoformans can cause common opportunistic infection in acquired immune deficiency syndrome (AIDS) patients. But other conditions can be associated with sarcoidosis. Meningoencephalitis is the most common manifestation of this disease. One of the most important neurological complications is the development of intracranial hypertension (ICH), which may result in high morbidity and mortality. We report the case of a patient harboring a ventriculoperitoneal shunt, and having contracted a cryptococcal meningitis as a risk factor for pulmonary sarcoidosis. Brain MRI showed arachnoiditis, with a mass in contact with the right frontal horn. Indian ink staining of the cerebrospinal fluid (CSF) showed positivity that was confirmed by the identification of Cryptococcus neoformans after culture. The evolution was favorable under medical treatment with removal of material. The relationship between sarcoidosis and cryptococcosis, described in the literature is not coincidental but is a rare complication of sarcoidosis of potential severity (40% of mortality). Sarcoidosis is a common systemic disease that may increase host susceptibility to CNS cryptococcal infection without any other signs or symptoms of host immunosuppression. The diagnosis of cryptococcosis should be evoked as a differential diagnosis of neuro-sarcoidosis.

Arachnoiditis ossificans of the cauda equina

A case of post-traumatic arachnoiditis ossificans of the cauda equina is reported. The lesion is a rare pathological entity usually confined to the thoracic and high lumbar regions that can cause progressive spinal cord and cauda equine compression. The pathophysiology and therapeutic strategy of this rare entity are still controversial.

[Neuroepithelial thalamo-mesencephalic cyst]

Thalamo-mesencephalic neuroepithelial cysts are rare lesions of the central nervous system. They are thought to arise from neuroectoderm and are also referred to as ependymal cysts due to their origin. It can remain asymptomatic throughout life or rarely can cause symptoms. We describe a 42-year-old woman who presented with thalamic syndrome due to a neuroepithelial cyst of the thalamo-midbrain. Differential diagnosis is made with other cystic lesions in the brain. However a good analysis of imaging feature led to diagnosis. When the lesion is symptomatic, mini-invasive procedure is indicated.

Dynamic CT scan of the craniovertebral junction: a role in the management of os odontoideum

Os odontoideum is an uncommon abnormality of the cranio-vertebral junction (CVJ) that exists as a separate ossicle apart from a hypoplastic dens. Its genesis and natural history have been debated, and its proper treatment remains uncertain. A 48-year-old woman complained of persistent upper neck pain and paraesthesia of her left side. Magnetic resonance imaging of the CVJ demonstrated an os odontoideum. Dynamic computed tomography scan of the CVJ showed a reduction of the space available for the spinal cord to 50% from extended to flexed position. The patient underwent posterior spinal fusion of C1-C2 using a sublaminar titanium hook and rods fixed in moderate extension. We discuss the usefulness of the dynamic computed tomography (CT) scan in the evaluation of atlantoaxial motion and the management of this pathology.

Multiple lytic lesions of the spine: a rare diagnosis of eosinophilic granuloma in an adult: a case report

Eosinophilic granuloma (EG) is a rare benign osteolytic lesion observed rarely in adults, with only some 18 cases of spinal location reported in the literature. We present an unusual variant of EG in a 23-year-old man with radiological features of multiple spinal lytic lesions which was evocated of metastatic processes. A surgically transpedicular biopsy of the thoracic collapsed vertebrae with posterior stabilization was made. Histological examination of the tissue showed features of eosinophilic granuloma. The clinical and radiological findings of EG present dilemmas of both diagnosis and treatment. The etiology is unclear and the therapeutic approach is still controversial.

Cavernous hemangioma of the skull: 3 case reports

BACKGROUND

Intraosseous cavernous hemangiomas of the bone are uncommon tumors, accounting for 0.7% to 1% of all bone neoplasms. The vertebral column is most often affected, followed by the skull. Calvarial cavernous hemangioma is rare, comprising about 0.2% of all benign neoplasms of the skull.

CASES REPORTS

We describe 3 patients with calvarial hemangiomas that were localized frontally (2 cases) and parietally. The diameter ranged from 2 to 3 cm. They presented with slowly growing mass, hard to pressure, with freely mobile skin above the cavernoma sites. Cranial CT scan showed osteolytic lesion with erosion of the tabula externa. Magnetic resonance imaging performed in one patient showed hypointense lesion on T1-weighted image and hyperintense on T2-weighted image. Resection and postoperative course were uneventful. Pathological examination revealed a cavernous hemangioma of the diploe.

CONCLUSION

Skull cavernous hemangiomas are rare benign tumors. The preferred treatment is complete tumor removal with normal bony margins. Sometimes, the classic radiographic appearances are not evident. Consequently, the diagnosis is most often made during surgical resection.

Posterior epidural migration of lumbar disk fragments: report of two cases and review of the literature

BACKGROUND

Posterior epidural migration of an extruded disk fragment is rare, and posterior migration of the free fragments causing cauda equina syndrome is exceptionally rare. The disk fragment must transgress through numerous anatomical restraints including the nerve roots in such cases.

METHODS

Two cases of migration of the sequestrated disk into the posterior epidural space are presented. The first patient complained, over the course of 1 month, of paresthesias and weakness of the lower limbs, with urinary retention. However, in the other case, there was steppage gait and strength score of 3/5 on dorsiflexion of left foot, without bladder or bowel disturbance.

RESULTS

Lumbar CT scan with sagittal reconstruction showed a posterior epidural mass, which was isodense to the disk. The preoperative differential diagnosis included epidural abscess, hematoma, and neoplasm. An urgent decompressive lumbar laminectomy was performed. At surgery, the lesion proved to be a massive extruded disk fragment.

CONCLUSION

Diagnosis of posterior epidural migration of the sequestrated disks may be difficult. It may present with subtle clinical features. Magnetic resonance images may mimic those of other more common posterior epidural lesions. Early surgery should be the first choice to prevent severe neurologic deficits.

Invasive Aspergillus terreus sinusitis with orbitocranial extension: case report

BACKGROUND

Aspergillosis of the paranasal sinuses is infrequent and usually involves the species Aspergillus fumigatus and A. flavus. The maxillary sinus is the most common sinus to be affected. Invasive cranio-orbital aspergillosis originating in the sphenoid sinus is rare and mostly occurs in immunocompromised patients with poor outcomes. We present a case of invasive A. terreus sphenoidal sinusitis with intraorbital and intracranial extension in an immunocompetent patient.

CASE DESCRIPTION

This 62-year-old man presented with a 2-month history of left retroorbital pain followed by rapid decreasing vision and 2 episodes of epistaxis. Ophthalmologic examination revealed no light perception left. Computed tomographic scan and MR images demonstrated an enhanced sphenoid lesion within the left sphenoid sinus with bone destruction and intraorbital and cavernous sinus extensions. A malignant tumor was suspected. The patient underwent a transphenoidal biopsy of the sphenoid mass. Histologic analysis revealed numerous Aspergillus hyphea, and the species A. terreus was isolated from fungal cultures of specimens. No systemic fungal infection was found, and the patient had no evidence of immunosuppression. After 3 months' administration of oral voriconazole, the patient became well, and the orbitocranial mass regressed in size. It was stabilized on the ninth postoperative month.

CONCLUSION

A. terreus sinusitis with orbitocranial extension had never been reported in the literature. Even in an immunocompetent host, ISOA is difficult to eradicate using surgical debridement combined with optimal antifungal agents because of the intracranial extension and the relative resistance of conventional antifungal therapy. Early diagnosis is important to prevent an unfavorable outcome of this emergent infection.

Sudden onset of paraplegia caused by hemorrhagic spinal epidural angiolipoma. A case report

Spinal epidural angiolipoma is a rare benign tumor containing vascular and mature adipose elements. A slow progressive clinical course was mostly presented and rarely a fluctuating course during pregnancy. The authors report the original case of spontaneous spinal epidural bleeding resulting from thoracic epidural angiolipoma who presented with hyperacute onset of paraplegia, simulating an extradural hematoma. The patient was admitted with sudden non-traumatic hyperacute paraplegia during a prolonged walk. Neurologic examination showed sensory loss below T6 and bladder disturbances. Spinal MRI revealed a non-enhanced heterogeneous thoracic epidural lesion, extending from T2 to T3. A bilateral T2-T4 laminectomy was performed to achieve resection of a lipomatous tumor containing area of spontaneous hemorrhage. The postoperative course was uneventful with complete neurologic recovery. Histologic examination revealed the tumor as an angiolipoma. Because the prognosis after rapid surgical management of this lesion is favorable, the diagnosis of spinal angiolipoma with bleeding should be considered in the differential diagnosis of hyperacute spinal cord compression.

Metallic foreign body in the sphenoid sinus after ballistic injury: a case report

Paranasal sinus injuries by foreign bodies have a lower incidence compared with facial injuries. Among them, penetrating maxillofacial injuries to the sphenoid sinus and skull base remain rare. We report the case of a 41-year-old man who presented with, after a missile-related maxillofacial injury, a metallic foreign body enclosed within the sphenoid sinus with carotid-canal fracture. Angiographic evaluation showed a mass in the right internal carotid artery. The foreign object was successfully extracted through a transmaxillary sublabial approach with a good outcome. We discuss the extensive preoperative evaluation and interdisciplinary management of this unusual injury.