Seizure Caused by Intraparenchymal Hemorrhage from Migration of Mandibular Dental Wire through Foramen Ovale in a Child: A Case Report

Introduction: The foramen ovale is a structure formed from neural crest-derived mesenchyme located on the greater wing of the sphenoid bone. It allows for the extracranial passage of multiple significant intracranial structures including the mandibular branch of the trigeminal nerve (CN V3). This branch supplies sensation to the lower face, jaw, and anterior tongue, plus motor input to the muscles of mastication. The foramen ovale is also close to other foramina and their associated structures. Here we describe the case of an orthodontic wire traversing the left foramen ovale with termination in the inferior left temporal lobe.

Case Presentation: Here we report the case of a 12-year-old male who presented to the emergency department (ED) with a 2-day history of nausea and emesis and a one-day history of altered mental status. He recently had problems related to his braces and they had to be readjusted. Prior to presentation, he started speaking Spanish, which was unusual because he primarily speaks English, and he was showing signs of absence seizures. Upon arrival to the ED, an X-ray demonstrated a foreign metallic body entering his skull which was determined to be his orthodontic wire from his braces. The patient was started on broad-spectrum antibiotics due to his high risk of infection. He was sedated, and then sent for computed tomography angiography of his head and neck. Imaging confirmed an orthodontic wire entering the skull through the foramen ovale and terminating within the inferior temporal lobe. Associated with the wire was an intraparenchymal hemorrhage measuring 2.4 × 1.6 cm and showing early signs of vasogenic edema ([Figs. 1], [2], [3]). Imaging indicated the sparing of the internal carotid artery and its major branches, suggesting the hemorrhage was likely venous in nature. The wire was then safely removed with no complications. A same-day neurological exam showed no indications of cranial nerve deficits, and the patient was discharged on hospital day 4. At his most recent follow-up 2 weeks post discharge, magnetic resonance imaging showed evolving residual blood product within the left temporal lobe ([Fig. 4]) and a cranial nerve exam at his baseline; however, he continues to have focal seizures despite taking levetiracetam.

Discussion/Conclusion: The foramen ovale has important contents within and is surrounded by important structures. This includes the internal carotid artery as it leaves the carotid canal and the maxillary branch of the trigeminal nerve (CN V2) as it enters the foramen rotundum. Due to the curvature of the wire, the trajectory was likely kept superior rather than traveling posterior or to either side. This most likely caused it to stay anterior to CN V3 and the internal carotid artery and lateral to CN V4. We believe this process occurred over multiple days of chewing with the loose dental wire slowly pushing it up into the skull. As his residual hematoma continues to regress, seizure activity may also be diminished. This is the first case described in the literature in which a foreign object penetrated the skull floor through the foramen ovale.

 

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No conflict of interest has been declared by the author(s).

Publication History

Article published online:
01 February 2023