Paediatric facial trauma without obvious external signs can conceal serious underlying pathology, including chronic infections and retained foreign bodies. This case highlights the diagnostic challenges of occult injuries and the critical role of advanced imaging in both diagnosis and intraoperative planning.
Case Description:
A four-year-old boy fell into a flower bed in March 2024, appearing to sustain only a minor facial injury without skin breach. He developed left zygomatic swelling and was admitted under Paediatric Surgery with a presumed infected hematoma. Oral Augmentin was prescribed, and he was discharged. Recurrent swelling occurred in April and May, managed in the community with repeated antibiotics.
In July, the patient presented with left periorbital swelling and was referred to ENT following ophthalmology review. CT imaging in August and MRI in September revealed chronic osteomyelitis of the left zygoma and arch, extensive inflammatory changes in the temporal and infratemporal fossa, and two areas of non-enhancement suggesting retained foreign bodies.
Surgical exploration in September confirmed the presence of multiple foreign bodies within the left temporal fossa and orbital rim, surrounded by inflamed tissue and periosteitis. The presumed trajectory suggested intraoral penetration with migration to the infratemporal region. Intraoperative ultrasound facilitated foreign body localization and removal. Postoperatively, the patient was treated with a six-week course of antibiotics in coordination with the Infectious Diseases team.
Discussion:
This case emphasizes the potential for retained foreign bodies and delayed infection following seemingly minor facial trauma. The absence of an entry wound can obscure diagnosis, highlighting the importance of repeat imaging and multidisciplinary assessment. Timely surgical intervention, supported by intraoperative imaging, was critical to source control and resolution.
Conclusion:
Occult paediatric facial trauma can result in significant morbidity. Persistent or recurrent swelling warrants escalation and imaging. Early surgical intervention remains key in managing retained foreign bodies and associated infection.