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A forgotten gauze pack in the nasopharynx: an unfortunate complication of adenotonsillectomy
American Journal of Otolaryngology–Head and Neck Medicine and Surgery 28 (2007) 191 – 193 www.elsevier.com/locate/amjoto
A forgotten gauze pack in the nasopharynx: an unfortunate complication of adenotonsillectomy Cem Ozera,4, Fulya Ozera, Mesut Senerb, Haluk Yavuza a
Department of Otorhinolaryngology Head and Neck Surgery, Baskent University Faculty of Medicine, Ankara, Turkey b Department of Anesthesiology and Reanimation, Baskent University Faculty of Medicine, Ankara, Turkey Received 9 June 2006
Abstract
A case of a foreign body lodged in the nasopharynx for a long time as a complication of adenotonsillectomy is presented. The patient was an 11-year-old boy admitted with nasal obstruction and bilateral foul-smelling purulent rhinorrhea. The diagnosis was confirmed with nasal endoscopy. Immediate removal of foreign body in the nasopharynx was performed under general anesthesia. Although foreign bodies lodged into the nasopharynx are rare, they may cause serious and even fatal complications. A high index of suspicion, particularly for persistent symptoms, is essential and necessitates further investigation before diagnosis of a case of rhinosinusitis or empirically prescribing antibiotics. D 2007 Elsevier Inc. All rights reserved.
1. Introduction
2. Case report
Adenotonsillectomy is one of the most commonly performed surgical procedures in otorhinolaryngology. Despite its simplicity, it has many possible complications, of which the most common ones include bleeding and anesthetic problems. Other less common complications include infection, pulmonary edema, velopharyngeal insufficiency, nasopharyngeal stenosis, Eagle’s syndrome, atlantoaxial subluxation, and taste disturbance [1]. Johnson et al [2] classified the complications of adenotonsillectomy as intraoperative, immediate postoperative ( b 24 hours), delayed (b 2 weeks), and long-term (weeks to months) complications according to their time of occurrence rather than their relative frequency. Early recognition of these complications is essential to prevent potential devastating consequences. In this article, we present a case of a nasopharyngeal foreign body lodged for a long time in an 11-year-old boy as an unusual complication of adenotonsillar surgery.
An 11-year-old boy presented with the complaint of purulent rhinorrhea, nasal obstruction, halitosis, and mouth breathing. No history of fever or epistaxis was reported. Six months ago, adenotonsillectomy was performed in another medical center because of recurrent tonsillitis and mouth breathing. Parents stated that his obstructive complaints increased after surgery. Several courses of antibiotics and decongestants were given empirically to the patient for a long period without significant improvement. The finding from physical examination of the patient revealed foulsmelling mouth breathing, postnasal purulent discharge, and bilateral mucopurulent nasal secretion. Otoscopic examination was normal. Endoscopic examination of the nasal cavity showed no foreign body in nasal cavities; however, a postnasal gauze pack was seen deeply in the nasopharynx obstructing the choanae bilaterally (Figs. 1 and 2). The patient’s complete blood count was normal. No radiologic examination was needed for diagnosis. A contact with the primary medical institution was established to inform about the patient and to provide feedback on the complication. Then, removal of the gauze pack in the nasopharynx under general anesthesia was immediately performed. During surgery, examination of the nasopharynx revealed secondary inflamed mucosa with purulent secretions. The patient was
4 Corresponding author. Department of Otorhinolaryngology Head and Neck Surgery, Baskent University Faculty of Medicine, Adana Teaching and Research Center, Seyhan 01110, Adana-Turkey. Tel.: +90 322 458 6868; fax: +90 322 459 9197. E-mail address: [email protected] (C. Ozer). 0196-0709/$ – see front matter D 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.amjoto.2006.07.009
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C. Ozer et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 28 (2007) 191–193
Fig. 1. Left nasal cavity viewed through a rigid endoscope. Black arrow indicates foreign body; ns, nasal septum; ic, inferior concha.
discharged on the following day with empiric antibiotic treatment. Complete recovery of patient’s symptoms and findings of the nasopharynx was noted on the follow-up examination. 3. Discussion Foreign bodies within the aerodigestive tract are quite common in children [3]. The clinical presentation of a foreign body impaction varies greatly according to the object’s location, composition, and depth of penetration. In most cases, the physician makes the diagnosis easily in the presence of typical symptoms with a suspicious history. However, impaction of a foreign body in an unusual anatomical area may cause atypical symptoms and may result in delay in diagnosis [4,5]. Nasopharynx is one of the uncommon anatomical sites for foreign body impaction. In the literature, there are few reports of foreign body impaction into the nasopharynx including coins, small pieces of toys, teeth, leech, and even a fish [5-9]. The impaction of a foreign body into the nasopharynx can occur via several ways. The dislocation of a nasal foreign body into the nasopharynx during removal process, upward migration of a pharyngeal or esophageal object after forceful emesis or coughing, traumatic penetration, and iatrogenic impaction as in our case are known possible routes [9]. Nasal foreign bodies usually present with unilateral purulent secretion and nasal obstruction, which makes the diagnosis easier in most cases [4]. However, clinical presentation of nasopharyngeal foreign bodies may mimic other common pediatric conditions such as adenoid hypertrophy or rhinosinusitis [6]. The most common complaints of the patients include bilateral purulent rhinorrhea and nasal obstruction. Otitis media with or without effusion, epistaxis, recurrent rhinosinusitis, and halitosis may accompany the problem in cases with nasopharyngeal foreign bodies lodged for a long time [9].
A complete head and neck examination must be done for every patient with a suspicious history of foreign body aspiration. Most nasal and nasopharyngeal objects can be detected during anterior rhinoscopy. Endoscopic assessment of the nasal cavity and the nasopharynx with rigid or flexible fiberoptic endoscopes under topical anesthesia is sufficient for diagnosis in almost all cases. Routine radiologic examination of the nose and nasopharynx via lateral radiographs is controversial. Although radiographs have a great value in identifying radiopaque foreign bodies, they will cause unnecessary radiation exposure in cases of radiolucent foreign bodies [9,10]. A potentially fatal complication of a foreign body in the nasopharynx is sudden airway obstruction due to descend of the object into the lower respiratory tract. This may happen spontaneously or during removal process [10]. Despite its long duration, no significant local complication was noted in our patient. This may be due to repeated treatment of the patient with antibiotics. In our case, foreign body impaction into the nasopharynx was iatrogenic. The surgeon had used temporary packing with a gauze to control bleeding after curettage adenoidectomy. Unfortunately, the gauze pack was forgotten during the operation. Although the complaints of the patient became much more prominent after the surgery the foreign body could not be detected. Initially, the surgeon might think that the complaints of the patient were related to postoperative edema. Later, bilateral rhinorrhea with nasal obstruction might lead the surgeon to think of rhinosinusitis rather than a forgotten foreign body. A careful examination of the nasal cavities and nasopharynx must be done in patients with a suspicious history of foreign body aspiration before the diagnosis of a case of sinusitis or empirically prescribing antibiotics [4]. In this regard, nasal endoscopy is a safe and reliable method for the evaluation of patients [11]. Immediate removal of foreign body under direct or indirect visualization is sufficient for the cure of the patient. Care should be taken to protect
Fig. 2. The photograph shows the gauze pack after removal.
C. Ozer et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 28 (2007) 191–193
airway during removal procedure especially when performed under local anesthesia to prevent possible airway complications [9].
4. Conclusion An iatrogenic foreign body in the nasopharynx is a rare entity. A high index of suspicion is essential for the diagnosis in the event that symptoms persist. Our case emphasizes a salutary but fundamental lesson for surgeons to check instruments and swabs at the end of every surgery.
References [1] Reilly MJ, Milmoe G, Pena M. Three extraordinary complications of adenotonsillectomy. Int J Pediatr Otorhinolaryngol 2006;70:941 - 6. [2] Johnson LB, Elluru RG, Myer CM. Complications of adenotonsillectomy. Laryngoscope 2002;112:35 - 6.
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[3] Hsu W, Sheen T, Lin C, et al. Clinical experiences of removing foreign bodies in the airway and esophagus with a rigid endoscope: a series of 3217 cases from 1970 to 1996. Otolaryngol Head Neck Surg 2000;122:450 - 4. [4] Francois M, Hamrioui R, Narcy P. Nasal foreign bodies in children. Eur Arch Otorhinolaryngol 1998;255:132 - 4. [5] Ogut F, Bereketoglu M, Bilgen C, et al. A metal ring that had been lodged in a childTs nasopharynx for 4 years. Ear Nose Throat J 2001;80:520 - 1. [6] Eghtedari F. Long lasting nasopharyngeal foreign body. Otolaryngol Head Neck Surg 2003;129:293 - 4. [7] Mahmood S, Lello GE. Tooth in the nasopharynx. Br J Oral Maxillofac Surg 2002;40:448 - 9. [8] Bilgen C, Karci B, Uluoz U. A nasopharyngeal mass: leech in the nasopharynx. Int J Pediatr Otorhinolaryngol 2002;64:73 - 6. [9] Briggs RD, Pou AM, Friedman NR. An unusual catch in the nasopharynx. Am J Otolaryngol 2001;22:354 - 7. [10] Oysu C, Yilmaz HB, Sahin AA, et al. Marble impaction in the nasopharynx following oral ingestion. Eur Arch Otorhinolaryngol 2003;260:522 - 3. [11] Kubba H, Phil M, Bingham BJG. Endoscopy in the assessment of children with nasal obstruction. J Laryngol Otol 2001;115:380 - 4.
A forgotten gauze pack in the nasopharynx: an unfortunate complication of adenotonsillectomy Cem Ozera,4, Fulya Ozera, Mesut Senerb, Haluk Yavuza a
Department of Otorhinolaryngology Head and Neck Surgery, Baskent University Faculty of Medicine, Ankara, Turkey b Department of Anesthesiology and Reanimation, Baskent University Faculty of Medicine, Ankara, Turkey Received 9 June 2006
Abstract
A case of a foreign body lodged in the nasopharynx for a long time as a complication of adenotonsillectomy is presented. The patient was an 11-year-old boy admitted with nasal obstruction and bilateral foul-smelling purulent rhinorrhea. The diagnosis was confirmed with nasal endoscopy. Immediate removal of foreign body in the nasopharynx was performed under general anesthesia. Although foreign bodies lodged into the nasopharynx are rare, they may cause serious and even fatal complications. A high index of suspicion, particularly for persistent symptoms, is essential and necessitates further investigation before diagnosis of a case of rhinosinusitis or empirically prescribing antibiotics. D 2007 Elsevier Inc. All rights reserved.
1. Introduction
2. Case report
Adenotonsillectomy is one of the most commonly performed surgical procedures in otorhinolaryngology. Despite its simplicity, it has many possible complications, of which the most common ones include bleeding and anesthetic problems. Other less common complications include infection, pulmonary edema, velopharyngeal insufficiency, nasopharyngeal stenosis, Eagle’s syndrome, atlantoaxial subluxation, and taste disturbance [1]. Johnson et al [2] classified the complications of adenotonsillectomy as intraoperative, immediate postoperative ( b 24 hours), delayed (b 2 weeks), and long-term (weeks to months) complications according to their time of occurrence rather than their relative frequency. Early recognition of these complications is essential to prevent potential devastating consequences. In this article, we present a case of a nasopharyngeal foreign body lodged for a long time in an 11-year-old boy as an unusual complication of adenotonsillar surgery.
An 11-year-old boy presented with the complaint of purulent rhinorrhea, nasal obstruction, halitosis, and mouth breathing. No history of fever or epistaxis was reported. Six months ago, adenotonsillectomy was performed in another medical center because of recurrent tonsillitis and mouth breathing. Parents stated that his obstructive complaints increased after surgery. Several courses of antibiotics and decongestants were given empirically to the patient for a long period without significant improvement. The finding from physical examination of the patient revealed foulsmelling mouth breathing, postnasal purulent discharge, and bilateral mucopurulent nasal secretion. Otoscopic examination was normal. Endoscopic examination of the nasal cavity showed no foreign body in nasal cavities; however, a postnasal gauze pack was seen deeply in the nasopharynx obstructing the choanae bilaterally (Figs. 1 and 2). The patient’s complete blood count was normal. No radiologic examination was needed for diagnosis. A contact with the primary medical institution was established to inform about the patient and to provide feedback on the complication. Then, removal of the gauze pack in the nasopharynx under general anesthesia was immediately performed. During surgery, examination of the nasopharynx revealed secondary inflamed mucosa with purulent secretions. The patient was
4 Corresponding author. Department of Otorhinolaryngology Head and Neck Surgery, Baskent University Faculty of Medicine, Adana Teaching and Research Center, Seyhan 01110, Adana-Turkey. Tel.: +90 322 458 6868; fax: +90 322 459 9197. E-mail address: [email protected] (C. Ozer). 0196-0709/$ – see front matter D 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.amjoto.2006.07.009
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C. Ozer et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 28 (2007) 191–193
Fig. 1. Left nasal cavity viewed through a rigid endoscope. Black arrow indicates foreign body; ns, nasal septum; ic, inferior concha.
discharged on the following day with empiric antibiotic treatment. Complete recovery of patient’s symptoms and findings of the nasopharynx was noted on the follow-up examination. 3. Discussion Foreign bodies within the aerodigestive tract are quite common in children [3]. The clinical presentation of a foreign body impaction varies greatly according to the object’s location, composition, and depth of penetration. In most cases, the physician makes the diagnosis easily in the presence of typical symptoms with a suspicious history. However, impaction of a foreign body in an unusual anatomical area may cause atypical symptoms and may result in delay in diagnosis [4,5]. Nasopharynx is one of the uncommon anatomical sites for foreign body impaction. In the literature, there are few reports of foreign body impaction into the nasopharynx including coins, small pieces of toys, teeth, leech, and even a fish [5-9]. The impaction of a foreign body into the nasopharynx can occur via several ways. The dislocation of a nasal foreign body into the nasopharynx during removal process, upward migration of a pharyngeal or esophageal object after forceful emesis or coughing, traumatic penetration, and iatrogenic impaction as in our case are known possible routes [9]. Nasal foreign bodies usually present with unilateral purulent secretion and nasal obstruction, which makes the diagnosis easier in most cases [4]. However, clinical presentation of nasopharyngeal foreign bodies may mimic other common pediatric conditions such as adenoid hypertrophy or rhinosinusitis [6]. The most common complaints of the patients include bilateral purulent rhinorrhea and nasal obstruction. Otitis media with or without effusion, epistaxis, recurrent rhinosinusitis, and halitosis may accompany the problem in cases with nasopharyngeal foreign bodies lodged for a long time [9].
A complete head and neck examination must be done for every patient with a suspicious history of foreign body aspiration. Most nasal and nasopharyngeal objects can be detected during anterior rhinoscopy. Endoscopic assessment of the nasal cavity and the nasopharynx with rigid or flexible fiberoptic endoscopes under topical anesthesia is sufficient for diagnosis in almost all cases. Routine radiologic examination of the nose and nasopharynx via lateral radiographs is controversial. Although radiographs have a great value in identifying radiopaque foreign bodies, they will cause unnecessary radiation exposure in cases of radiolucent foreign bodies [9,10]. A potentially fatal complication of a foreign body in the nasopharynx is sudden airway obstruction due to descend of the object into the lower respiratory tract. This may happen spontaneously or during removal process [10]. Despite its long duration, no significant local complication was noted in our patient. This may be due to repeated treatment of the patient with antibiotics. In our case, foreign body impaction into the nasopharynx was iatrogenic. The surgeon had used temporary packing with a gauze to control bleeding after curettage adenoidectomy. Unfortunately, the gauze pack was forgotten during the operation. Although the complaints of the patient became much more prominent after the surgery the foreign body could not be detected. Initially, the surgeon might think that the complaints of the patient were related to postoperative edema. Later, bilateral rhinorrhea with nasal obstruction might lead the surgeon to think of rhinosinusitis rather than a forgotten foreign body. A careful examination of the nasal cavities and nasopharynx must be done in patients with a suspicious history of foreign body aspiration before the diagnosis of a case of sinusitis or empirically prescribing antibiotics [4]. In this regard, nasal endoscopy is a safe and reliable method for the evaluation of patients [11]. Immediate removal of foreign body under direct or indirect visualization is sufficient for the cure of the patient. Care should be taken to protect
Fig. 2. The photograph shows the gauze pack after removal.
C. Ozer et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 28 (2007) 191–193
airway during removal procedure especially when performed under local anesthesia to prevent possible airway complications [9].
4. Conclusion An iatrogenic foreign body in the nasopharynx is a rare entity. A high index of suspicion is essential for the diagnosis in the event that symptoms persist. Our case emphasizes a salutary but fundamental lesson for surgeons to check instruments and swabs at the end of every surgery.
References [1] Reilly MJ, Milmoe G, Pena M. Three extraordinary complications of adenotonsillectomy. Int J Pediatr Otorhinolaryngol 2006;70:941 - 6. [2] Johnson LB, Elluru RG, Myer CM. Complications of adenotonsillectomy. Laryngoscope 2002;112:35 - 6.
193
[3] Hsu W, Sheen T, Lin C, et al. Clinical experiences of removing foreign bodies in the airway and esophagus with a rigid endoscope: a series of 3217 cases from 1970 to 1996. Otolaryngol Head Neck Surg 2000;122:450 - 4. [4] Francois M, Hamrioui R, Narcy P. Nasal foreign bodies in children. Eur Arch Otorhinolaryngol 1998;255:132 - 4. [5] Ogut F, Bereketoglu M, Bilgen C, et al. A metal ring that had been lodged in a childTs nasopharynx for 4 years. Ear Nose Throat J 2001;80:520 - 1. [6] Eghtedari F. Long lasting nasopharyngeal foreign body. Otolaryngol Head Neck Surg 2003;129:293 - 4. [7] Mahmood S, Lello GE. Tooth in the nasopharynx. Br J Oral Maxillofac Surg 2002;40:448 - 9. [8] Bilgen C, Karci B, Uluoz U. A nasopharyngeal mass: leech in the nasopharynx. Int J Pediatr Otorhinolaryngol 2002;64:73 - 6. [9] Briggs RD, Pou AM, Friedman NR. An unusual catch in the nasopharynx. Am J Otolaryngol 2001;22:354 - 7. [10] Oysu C, Yilmaz HB, Sahin AA, et al. Marble impaction in the nasopharynx following oral ingestion. Eur Arch Otorhinolaryngol 2003;260:522 - 3. [11] Kubba H, Phil M, Bingham BJG. Endoscopy in the assessment of children with nasal obstruction. J Laryngol Otol 2001;115:380 - 4.