|SPECIAL REPORT: OTORHINOLARYNGOLOGY
|Year : 2014 | Volume
| Issue : 2 | Page : 89-92
Foreign bodies in maxillary sinus: Causes and management
Shilpi Agarwal, Sanjeev Kumar
Department of Otorhinolaryngology, University College of Medical Sciences, GTB Hospital, Delhi, India
|Date of Web Publication||31-Jul-2014|
Dr. Shilpi Agarwal
J-3/183 Rajouri Garden, New Delhi - 110 027
Source of Support: None, Conflict of Interest: None
Foreign bodies in maxillary sinus, whatever their origin or nature, are unusual. However unilateral unexplained chronic rhinosinusitis should arouse clinical suscipicion. The diagnosis is based on radiological findings. The range of such foreign bodies is wide; those of dental origin such as tooth roots, burs, dental impression material, root-filling materials, dental implants, and needles take precedence over all others, but rarely, they may relate to blast injuries and penetrating objects. This special report highlights the unusual case of a pressure cooker nozzle lodged in maxillary sinus of a 28-year-old female who suffered a facial injury caused by explosion of a pressure cooker at home. The acuteness of the event and the flight of the foreign body were such that neither the casualty felt the ingress of foreign body nor was the diagnosis entertained by the surgeon who first examined her. Each blast injury therefore must be thoroughly evaluated for such possibility. While a radiological examination can clinch the diagnosis, treatment lies in endoscopic or surgical foreign body removal, with Caldwell luc procedure being a preferred technique.
Keywords: Foreign body, maxillary sinus, blast injury
|How to cite this article:|
Agarwal S, Kumar S. Foreign bodies in maxillary sinus: Causes and management. Astrocyte 2014;1:89-92
| Introduction|| |
Blast injuries can be a common cause of facial trauma. Such injuries can occur in industrial accidents, vehicular crashes, and domestic mishaps. Blasts of pressure cooker and liquefied petroleum gas cylinder in the kitchen are the two most common cause of accidental blast injury in Indian households. Such accidents can produce ingress of foreign bodies in paranasal sinuses. However, the larger percentage of paranasal sinus foreign bodies are iatrogenic (60%), while only about 25% occur following accidents.  Maxillary sinus is most commonly involved (80%).  Foreign bodies of iatrogenic origin are most commonly after dental procedures like implants, titanium plate, gutta percha. , In accidental type, various foreign bodies have been found like wooden sticks and tooth picks , [Table 1]. These foreign bodies are generally detected only when a patient presents with chronic sinusitis, or the discovery is purely incidental during a radiological examination.
Ammunition injuries like bomb blasts, gun shots, and knife injuries also involve the maxillary sinus but are associated with other facial injuries. ,,, Pellets may reside in the sinus and can cause problems later in life.
There are four stages described for a blast injury and are especially seen in warfare. , The first is the primary blast effect resulting from an explosive that leads to increased pressure, density, and high temperatures and known as a 'shock front'. The second is the secondary blast effect, which causes injury due to different kinds and shapes of objects ranging from shell fragments, sand, rocks, pebbles to parts of things in vicinity of blast and may cause penetrating injuries. A secondary blast injury is much more common than the primary blast. Third is the tertiary blast effect, which results from propelling of the body against walls or objects leading to various type of injuries. Finally, the quaternary blast injury causes asphyxia due to inhalation of toxic fumes, high temperature, and low oxygen condition.
| Case Report|| |
A 28-year-old female presented to emergency with facial trauma and was referred to an otorhinolaryngologist. On inspection, there was upper lip split and laceration of upper gingivobuccal sulcus with active bleeding. In addition there was bilateral cheek swelling without any periorbital swelling and loss of upper lateral two incisors and upper lateral canine. She was mildly sedated but responding to verbal commands and her vitals were stable. Her vision was normal with bilateral reactive pupillary reflexes.
On taking history from her husband, it was determined that there was pressure cooker blast injury in the kitchen after which she fell unconscious.
Initially, hemorrhage was controlled using 1:100 adrenaline packs and ligating the bleeding vessel. On further examination on anterior rhinoscopy there was septal fracture, blood clots but lateral nasal wall and floor were normal. There was laceration of upper gingivobuccal sulcus of approximately 5 cm extending from right upper first premolar to left upper canine. The palate was intact.
After control of bleeding, the next step would have been to close the laceration in at least two layers, but on inserting a ball point probe through the gingivobuccal sulcus opening, a hard object was felt indicating the possible presence of a foreign body. On gentle manipulation with a long toothed forceps, the foreign body was taken out [Figure 1]. It turned out to be a pressure cooker nozzle, which had found its way into the maxillary sinus during the blast. The patient could not recollect such an event even on a direct question. The maxillary sinus was gently flushed and the laceration was closed in two layers using 3-0 vicryl and 3-0 nylon sutures.
|Figure 1: Surgical removal of the pressure cooker nozzle which had entered into the right maxillary sinus following a blast injury.|
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| Discussion|| |
On review of literature, various accidental foreign bodies have been reported but majority of them are preceded by history of a dental procedure. Various dental materials are easily liable to reach maxillary sinus through the oroantral fistula created after dental extraction. Furthermore, overtime these fistulas close and diagnosis of foreign body becomes extremely difficult. In fact they are found incidentally when patient presents with nasal complaints which may vary from simple nasal discharge, headache to facial swelling. One case reported nasal regurgitation, which was examined to be diagnosed as foreign body maxilla with palatal fistula. Foreign bodies must be a differential diagnosis in cases of unexplained rhinosinusitis and to reach to a diagnosis, proper history is indispensable as a time gap for as much as 3 years has been reported between the probable cause of foreign body and presentation of symptoms. In a report, there was migration of bone cement toward the natural maxillary ostium leading to sinusitis after 3 years of dental procedure. This mechanism of mucociliary movement of foreign body explains the gap in between the causative procedure and symptoms.  In nonmigrated foreign body, it has been proposed that local inflammation of maxillary sinus due to constant irritation leads to sinusitis.
Endoscopic examination should be a part of work up of patients. In the cited case, the congestion in middle meatus pointed towards sinusitis, which on further radiological investigation, was diagnosed as foreign body in the maxillary sinus.  Prior dental procedure points toward the probable site of oroantral fistula and this forms the route of passage of foreign bodies; which may be self-inflicted. Though a complete history and examination is a prerequisite, the definite diagnosis is made by radiological investigations; noncontrast computed tomography (CT) scan of paranasal sinuses yields good information.
It can assess the size, type, and exact location of the foreign body. It is of utmost importance for choosing the operative technique. The gold standard operative technique has been Caldwell Luc operation, wherein osteotomy is done above canine fossa and maxillary sinus can be properly visualized.  Preferably, this is combined with nasal endoscopy, especially when the foreign bodies lie near the medial wall of sinus. It provides good illumination and visualization. Some surgeons prefer a Caldwell Luc approach even after endoscopic removal to properly visualize and irrigate the maxillary sinus, In total removal of large foreign body necessitates this approach.  foreign body remove from maxillary sinus must be carefully assessed for persistent oroantral fistula and repaired in the same sitting. Location of foreign body may require a variation in operative technique; lateral-based Caldwell luc with osteotomy over premolar is described to remove foreign bodys lodged near the lateral wall of sinus.  Foreign body entering sinus through the orbital cavity may be missed until diagnosed radiologically. The approach to such foreign bodies may vary with the duration of foreign body or the condition of orbit. in one such reported case the forign body was removed by giving infraorbital incision to gain access through the anterior wall of maxilla near its roof.  Patients with penetrating and blast injuries to eye must be evaluated by an otorhinolaryngologist to assess the sinuses and rule out foreign body hidden in the sinuses.
Patients coming in the emergency with blast injuries and penetrating trauma should undergo radiological investigation before discharge as cases have been reported wherein part of foreign body was missed and presented with symptoms of sinusitis after 12 years.  They may be missed as usually these cases are operated in emergency and wound exploration alone may remove only a part of the foreign body. Other plausible reason is that small foreign bodies may not be seen radiologically initially due to edema and hematomas.
The management of blast injuries with maxillary sinus foreign bodies requires a Caldwell luc approach to thoroughly irrigate the sinus and inspect it with endoscope. Additionally, whitehead varnish or iodoform pack maybe placed in sinus to stabilize the walls.  Stereotactic surgery has been carried out in multiple pellets or fragments embedded in paranasal sinuses to prevent damage to nearby vessels. 
Pressure cooker is a common utensil in an Indian household kitchen. On reviewing the literature, only two cases have been reported due to blast injury with pressure cooker, both leading to ocular trauma. , Hence the maxillary sinus can be attributed as the hidden area for impaction of foreign body, which may reach through alveolus, lateral wall of nose or palate.
There is a case report of similar trajectory of foreign body introduction in the maxillary sinus as in our case, where a snooker cue rested. In an accident, the snooker cue rested in the sinus through laceration in gingivibuccal sulcus, which was removed at the time of presentation. The patient was treated only to return with persistent episodes of sinusitis and rhinorrhoea after a month of injury wherein a piece was found to be present in sinus, which was removed one month later.  In this case, there was definite history of accident due to snooker cue, whereas in our case blast injury made it difficult to predict that the nozzle was embedded inside.
Oroantral fistula has been regarded as an important complication of maxillary sinus foreign body.  In large percentage, it is preceded by a dental procedure but can also be formed when the trajectory of a fast moving foreign body is through palate or alveolar bone. These cases must be repaired and followed up to look for proper healing.
| Conclusion|| |
Patients with unexplained maxillary sinusitis must be evaluated for history of prior dental procedure, oroantral fistula, alongwith radiological investigation to rule out a foreign body. Endoscopic approach is the preferred initial technique, it is further combined with Caldwell luc to increase access and to remove large foreign bodies.
Blast injuries must be evaluated thoroughly by detailed history, examination, and imaging because the sequence of events in blast type of injury is rapid and foreign bodies maybe be missed in these emergency cases. Even when patient has to be taken for surgery in emergency bases, postsurgical evaluation must be done radiologically. Also for a patient with chronic unilateral sinusitis or rhinorrhea, foreign body, though a rare cause, should be kept in mind as differential diagnosis. A proper past history may expose the possibility of foreign body.
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