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Endoscopic removal of a foreign body in the ethmoidal region, four years after a penetration injury
International Journal of Pediatric Otorhinolaryngology Extra (2006) 1, 81—84
www.elsevier.com/locate/ijporl
CASE REPORT
Endoscopic removal of a foreign body in the ethmoidal region, four years after a penetration injury German Fajardo a, Rogelio Chavolla b, Hugo Loza b, ´s Solorio a Antonio Ysunza a,*, Jesu a b
Department of Otolaryngology, Hospital Gea Gonzalez, 4800 Calzada Tlalpan, Mexico City, Mexico ´xico, Mexico City, Mexico Department of Otolaryngology, Hospital General de Me
Received 15 November 2005; received in revised form 16 January 2006; accepted 17 January 2006
KEYWORDS Endoscopy; Foreign body; Ethmoid and sphenoid sinuses; Penetrating injury
Summary The case of a 14-year-old patient with a foreign body in the ethmoidal region is presented. The patient had a penetrating injury 4 years before the initial clinical evaluation. On examination, the patient showed facial asymmetry with a swelling area on the upper left eyelid at the level of the inner cantus. A CT scan showed partial absence of ethmoidal cell lamellae and the anterior wall of the sphenoidal sinus. The maxillary sinus was partially occupied by an ovoid density projecting over its floor. An endoscopic resection of a foreign body was performed. The object was a pencil point of approximately 4 cm. There were no postoperative complications. The patient was discharged from the hospital 2 days after the surgery. The patient was followed for 8 months; there were no further complications. # 2006 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Children with foreign bodies in the upper respiratory tract are a common cause of ENT consultations. The most common location is the nose. Anatomically, foreign objects can be found in any portion of the nasal cavity and paranasal sinuses. Usually they are located on the floor below the inferior turbinate or immediately anterior to the middle turbinate. Most objects can be removed in the emergency room with little or no sedation. However, in some cases they can present a significant challenge * Corresponding author. E-mail address: [email protected] (A. Ysunza).
for the pediatric otolaryngologist. In some cases, a surgical removal is necessary, depending on the type, size, location and friability of the object [1,2]. Foreign bodies of the nose can be divided into those remaining within the nasal cavity proper, and those that penetrate into the paranasal sinuses. Foreign bodies that remain within the nasal cavity can usually be removed through the nose; external incisions are necessary only on selected cases. Foreign bodies that involve the sinuses present a particular challenge because of the close proximity of other vital structures such as the brain, orbit, the anterior and posterior ethmoidal arteries, the sphenopalatine artery, and the internal carotid artery [3,4].
1871-4048/$ — see front matter # 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pedex.2006.01.004
82 Foreign bodies in the nasal cavity and paranasal sinuses should be removed for several reasons. They often cause discomfort and can become the source of infections [5]. The most common removal technique for nasal foreign bodies is direct instrumentation. The use of alligator forceps, long bayonette forceps, straight forceps, mosquito clamps, and hemostat clams have been reported [6]. These instruments have been reported as particularly useful for solid objects placed in the anterior region of the nasal cavity. However, when the sinuses are involved, the use of the endoscope has significantly improved the diagnostic and therapeutic options [2,7]. The purpose of this paper is to present the case of a 14-year-old boy with a foreign object on the ethmoidal area. The patient was initially evaluated 4 years after the penetration injury in which the object was inserted through the nose. Clinical and imaging findings, as well as the endoscopic removal of the foreign body are described. Finally, a brief revision and discussion of the literature are included.
2. Case report A 14-year-old boy was examined as an out-patient in the ENT office. The patient referred that 4 years prior to the examination, a classmate had accidentally introduced a pencil through the nose. Two months after the injury, the patient started to show a volume increase on the ipsilateral inner cantus with an increase of local temperature and painful hyperemia of the surrounding skin area; the patient did not receive any treatment at that point. Six months after the incident the patient started to show an occasional purulent nasal discharge. Finally the patient looked for medical attention twice in 4 years, at a first level medical center. A family physician prescribed penicillin and trimetroprim; after this treatment no changes were noticed in his condition. Hence, the patient was referred to the ENT Department. On physical examination the patient was conscious and oriented. There was a clear facial asymmetry. Swelling of the upper left eyelid at the level of the inner cantus with fibrous consistency was evident. There was approximately 5 mm in diameter. Ipsilateral proptosis was also observed (see Fig. 1). Pupils reflexes were normal. Ocular movement was preserved. The nose had a normal appearance with a central pyramid, regular dorsum and straight nasolabial angle. An anterior rhinoscopy showed mucosal membrane with normal hydratation and color. A central
G. Fajardo et al.
Fig. 1 Clinical photograph of the patient prior to surgery. Swelling at the internal cantus can be observed.
nasal septum and normal turbinates were observed on both nasal passages. The rest of the examination was unremarkable. A CT scan of the nose and paranasal sinuses was performed. Partial absence of ethmoidal cell lamellae and the anterior wall of the ipsilateral sphenoidal sinus were observed. The left frontal sinus and a posterior ethmoidal cell were partially occupied by an accumulation of soft tissue that could correspond to secretion or mucosa. The ipsilateral maxillary sinus was partially occupied by an ovoid density projecting over its floor. This finding was referred as a possible retention cyst or polyp. The rest of the cavities showed adequate development and pneumatization (see Fig. 2). An endoscopic examination of the nose and sinuses was performed. The left ethmoidal infundibulum was opened. Anterior ethmoidal cells and
Fig. 2 A coronal CT scan is displayed at the ostiomeatal unit level. The foreign object can be seen in the left side at the anterior ethmoid.
Endoscopic removal of a foreign body in the ethmoidal region
83
3. Discussion
Fig. 3 Coronal CT scan. Posterior view of the foreign object, at the sphenoid sinus level.
middle fundamental lamellae of nasal concha were resected. A foreign object was revealed, lodged at the level of the posterior cells. The object was yellow, tubular and looked like a pencil. The object was identified and located entirely, it was extending to the sphenoidal sinus (see Fig. 3). The object was removed with a curved angular hook. In order to extract the object, it was necessary to cut it in several pieces. The object was completely extracted in four pieces (see Fig. 4). The surrounding thickened mucosa was removed and gauze packing was applied. The surgical procedure was completed without incidents or complications, and the patient was discharged from the hospital 2 days after surgery. Postoperatively the patient was treated with nasal irrigations with normal saline solution for 3 weeks. He was subjected to frequent endoscopic examinations during the following 2 months. In his last appointment the ethmoidal cavity was lined with normal mucosa.
Fig. 4 The foreign body cut in four pieces is displayed after surgical resection.
A search in the literature showed only a limited amount of information concerning the removal of foreign bodies by an endoscopic approach. It has been reported that special attention should be paid to the removal of a foreign body from the paranasal sinuses. After some time, a foreign body can trigger severe inflammation processes, infections and malignant changes have also been reported [8]. It is useful to separate inanimate and animate nasal and sinus foreign bodies. Both types may present with signs and symptoms of unilateral nasal obstruction, rhinorrhea or sinusitis. In the animate group, there have been reported maggots, leeches, intestinal worms and insects in the nasal cavity. They should be removed from the nasal cavity, but in special cases like parasitic infestation the treatment should be with systemic mebendazole. The inanimate foreign bodies are encountered more frequently, they may be iatrogenic or traumatic in origin. Iatrogenic foreign bodies include nasal packs, splints, cotton, needles and pieces of instruments. Trauma may cause nasal foreign bodies such as bone, cartilage fragments, or teeth. An exogenous foreign body may lodge in the nasal cavity, especially with blast injuries. Rhinoliths are unusual, they are formed by encrustation of a nasal foreign body with calcium and magnesium salts. In most cases rhinolith may be removed anteriorly, rarely a lateral rhinotomy may be needed [9,10]. When the sinuses are involved, the use of the endoscope has significantly improved the diagnostic and therapeutic options [2,4]. Mladina [6] reported a case of a metallic projectile lodged at the sphenoethmoid junction. This foreign body was successfully removed with an endoscopic approach. Another case of a foreign body in the ethmoid sinus causing neuralgia was reported by donald and Gadre [5]. This object was also removed successfully through an endoscopic approach. The introduction of sinus endoscopes has improved and facilitated the quality of detailed intranasal examination. Endoscopic examination has demonstrated to be a safe and reliable procedure for examinations of the sinuses through intranasal ethmoidectomy and esphenoidectomy. The endoscope allows an accurate recognition of the depth of the penetration of a foreign body, which in turn allows for a safer removal. The endoscope also allows the immediate recognition of key surrounding structures during a removal procedure [11,12].
84 The endoscopic approach was ideal for the case reported herein. The pencil did not penetrate any critical structures and it could be broken and manipulated to be extracted through the nasal passages. From this case report, it can be demonstrated that an intrasinus foreign body that has not traverse any critical structures, can be safely and reliably removed through sinus endoscopy. Moreover, the morbidity of an endoscopic approach has been reported as minor, as compared to an external approach.
References [1] H.A. Werman, Removal of foreign bodies of the nose, Emerg. Med. Clin. North Am. 5 (1987) 253—263. [2] H.A. Kadish, H.M. Corneli, Removal of nasal foreign bodies in the pediatric population, Am. J. Emerg. Med. 15 (1997) 54—56.
G. Fajardo et al. [3] E. Guazo, Removal of foreign bodies from the nose, N. Engl. J. Med. 312 (1985) 725. [4] N. Bhattacharyya, R. Wenokur, Endoscopic management of a chronic ethmoid and sphenoid sinus foreign body, Otolaryngol. Head and Neck Surg. 118 (1998) 5. [5] P. Donald, A. Gadre, Neuralgia like symptoms in a patient with an airgun pellet in the ethmoid sinus: case report, J. Laryngol. Otol. 109 (1995) 646—649. [6] R. Mladina, Endoscopic sinus surgery: a metallic foreign body at the sphenoethmoidal junction, J. Laryngol. Otol. 106 (1992) 998—999. [7] P. Murthy, J. Sahota, D. Nayak, R. Balakrishnan, P. Hazarika, Foreign body in the ethmoid sinus, Int. J. Oral. Maxillofac. Surg. 23 (1994) 74—75. [8] R.A. Uwadia, D. Maniar, M. Acharya, A transethmoid transorbital foreign body, J. Laryngol. Otol. 108 (1994) 411—412. [9] C.W. Cummings, J.M. Fredrickson, L.A. Harker, C.J. Krause, Otolaryngology Head and Neck Surg., third ed., vol. 2, Mosby, pp. 864—866. [10] Rice, Endoscopic Paranasal Sinus Surg., third ed., LWW, p. 136. [11] S.K. Das, Aetiological evaluation of foreign bodies in the ear and nose, J. Laryngol. Otol. 98 (1984) 989—991. [12] A.Q. Forrest, A large foreign body in the nose, J. Laryngol. Otol. 101 (1987) 1280—1282.
www.elsevier.com/locate/ijporl
CASE REPORT
Endoscopic removal of a foreign body in the ethmoidal region, four years after a penetration injury German Fajardo a, Rogelio Chavolla b, Hugo Loza b, ´s Solorio a Antonio Ysunza a,*, Jesu a b
Department of Otolaryngology, Hospital Gea Gonzalez, 4800 Calzada Tlalpan, Mexico City, Mexico ´xico, Mexico City, Mexico Department of Otolaryngology, Hospital General de Me
Received 15 November 2005; received in revised form 16 January 2006; accepted 17 January 2006
KEYWORDS Endoscopy; Foreign body; Ethmoid and sphenoid sinuses; Penetrating injury
Summary The case of a 14-year-old patient with a foreign body in the ethmoidal region is presented. The patient had a penetrating injury 4 years before the initial clinical evaluation. On examination, the patient showed facial asymmetry with a swelling area on the upper left eyelid at the level of the inner cantus. A CT scan showed partial absence of ethmoidal cell lamellae and the anterior wall of the sphenoidal sinus. The maxillary sinus was partially occupied by an ovoid density projecting over its floor. An endoscopic resection of a foreign body was performed. The object was a pencil point of approximately 4 cm. There were no postoperative complications. The patient was discharged from the hospital 2 days after the surgery. The patient was followed for 8 months; there were no further complications. # 2006 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Children with foreign bodies in the upper respiratory tract are a common cause of ENT consultations. The most common location is the nose. Anatomically, foreign objects can be found in any portion of the nasal cavity and paranasal sinuses. Usually they are located on the floor below the inferior turbinate or immediately anterior to the middle turbinate. Most objects can be removed in the emergency room with little or no sedation. However, in some cases they can present a significant challenge * Corresponding author. E-mail address: [email protected] (A. Ysunza).
for the pediatric otolaryngologist. In some cases, a surgical removal is necessary, depending on the type, size, location and friability of the object [1,2]. Foreign bodies of the nose can be divided into those remaining within the nasal cavity proper, and those that penetrate into the paranasal sinuses. Foreign bodies that remain within the nasal cavity can usually be removed through the nose; external incisions are necessary only on selected cases. Foreign bodies that involve the sinuses present a particular challenge because of the close proximity of other vital structures such as the brain, orbit, the anterior and posterior ethmoidal arteries, the sphenopalatine artery, and the internal carotid artery [3,4].
1871-4048/$ — see front matter # 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pedex.2006.01.004
82 Foreign bodies in the nasal cavity and paranasal sinuses should be removed for several reasons. They often cause discomfort and can become the source of infections [5]. The most common removal technique for nasal foreign bodies is direct instrumentation. The use of alligator forceps, long bayonette forceps, straight forceps, mosquito clamps, and hemostat clams have been reported [6]. These instruments have been reported as particularly useful for solid objects placed in the anterior region of the nasal cavity. However, when the sinuses are involved, the use of the endoscope has significantly improved the diagnostic and therapeutic options [2,7]. The purpose of this paper is to present the case of a 14-year-old boy with a foreign object on the ethmoidal area. The patient was initially evaluated 4 years after the penetration injury in which the object was inserted through the nose. Clinical and imaging findings, as well as the endoscopic removal of the foreign body are described. Finally, a brief revision and discussion of the literature are included.
2. Case report A 14-year-old boy was examined as an out-patient in the ENT office. The patient referred that 4 years prior to the examination, a classmate had accidentally introduced a pencil through the nose. Two months after the injury, the patient started to show a volume increase on the ipsilateral inner cantus with an increase of local temperature and painful hyperemia of the surrounding skin area; the patient did not receive any treatment at that point. Six months after the incident the patient started to show an occasional purulent nasal discharge. Finally the patient looked for medical attention twice in 4 years, at a first level medical center. A family physician prescribed penicillin and trimetroprim; after this treatment no changes were noticed in his condition. Hence, the patient was referred to the ENT Department. On physical examination the patient was conscious and oriented. There was a clear facial asymmetry. Swelling of the upper left eyelid at the level of the inner cantus with fibrous consistency was evident. There was approximately 5 mm in diameter. Ipsilateral proptosis was also observed (see Fig. 1). Pupils reflexes were normal. Ocular movement was preserved. The nose had a normal appearance with a central pyramid, regular dorsum and straight nasolabial angle. An anterior rhinoscopy showed mucosal membrane with normal hydratation and color. A central
G. Fajardo et al.
Fig. 1 Clinical photograph of the patient prior to surgery. Swelling at the internal cantus can be observed.
nasal septum and normal turbinates were observed on both nasal passages. The rest of the examination was unremarkable. A CT scan of the nose and paranasal sinuses was performed. Partial absence of ethmoidal cell lamellae and the anterior wall of the ipsilateral sphenoidal sinus were observed. The left frontal sinus and a posterior ethmoidal cell were partially occupied by an accumulation of soft tissue that could correspond to secretion or mucosa. The ipsilateral maxillary sinus was partially occupied by an ovoid density projecting over its floor. This finding was referred as a possible retention cyst or polyp. The rest of the cavities showed adequate development and pneumatization (see Fig. 2). An endoscopic examination of the nose and sinuses was performed. The left ethmoidal infundibulum was opened. Anterior ethmoidal cells and
Fig. 2 A coronal CT scan is displayed at the ostiomeatal unit level. The foreign object can be seen in the left side at the anterior ethmoid.
Endoscopic removal of a foreign body in the ethmoidal region
83
3. Discussion
Fig. 3 Coronal CT scan. Posterior view of the foreign object, at the sphenoid sinus level.
middle fundamental lamellae of nasal concha were resected. A foreign object was revealed, lodged at the level of the posterior cells. The object was yellow, tubular and looked like a pencil. The object was identified and located entirely, it was extending to the sphenoidal sinus (see Fig. 3). The object was removed with a curved angular hook. In order to extract the object, it was necessary to cut it in several pieces. The object was completely extracted in four pieces (see Fig. 4). The surrounding thickened mucosa was removed and gauze packing was applied. The surgical procedure was completed without incidents or complications, and the patient was discharged from the hospital 2 days after surgery. Postoperatively the patient was treated with nasal irrigations with normal saline solution for 3 weeks. He was subjected to frequent endoscopic examinations during the following 2 months. In his last appointment the ethmoidal cavity was lined with normal mucosa.
Fig. 4 The foreign body cut in four pieces is displayed after surgical resection.
A search in the literature showed only a limited amount of information concerning the removal of foreign bodies by an endoscopic approach. It has been reported that special attention should be paid to the removal of a foreign body from the paranasal sinuses. After some time, a foreign body can trigger severe inflammation processes, infections and malignant changes have also been reported [8]. It is useful to separate inanimate and animate nasal and sinus foreign bodies. Both types may present with signs and symptoms of unilateral nasal obstruction, rhinorrhea or sinusitis. In the animate group, there have been reported maggots, leeches, intestinal worms and insects in the nasal cavity. They should be removed from the nasal cavity, but in special cases like parasitic infestation the treatment should be with systemic mebendazole. The inanimate foreign bodies are encountered more frequently, they may be iatrogenic or traumatic in origin. Iatrogenic foreign bodies include nasal packs, splints, cotton, needles and pieces of instruments. Trauma may cause nasal foreign bodies such as bone, cartilage fragments, or teeth. An exogenous foreign body may lodge in the nasal cavity, especially with blast injuries. Rhinoliths are unusual, they are formed by encrustation of a nasal foreign body with calcium and magnesium salts. In most cases rhinolith may be removed anteriorly, rarely a lateral rhinotomy may be needed [9,10]. When the sinuses are involved, the use of the endoscope has significantly improved the diagnostic and therapeutic options [2,4]. Mladina [6] reported a case of a metallic projectile lodged at the sphenoethmoid junction. This foreign body was successfully removed with an endoscopic approach. Another case of a foreign body in the ethmoid sinus causing neuralgia was reported by donald and Gadre [5]. This object was also removed successfully through an endoscopic approach. The introduction of sinus endoscopes has improved and facilitated the quality of detailed intranasal examination. Endoscopic examination has demonstrated to be a safe and reliable procedure for examinations of the sinuses through intranasal ethmoidectomy and esphenoidectomy. The endoscope allows an accurate recognition of the depth of the penetration of a foreign body, which in turn allows for a safer removal. The endoscope also allows the immediate recognition of key surrounding structures during a removal procedure [11,12].
84 The endoscopic approach was ideal for the case reported herein. The pencil did not penetrate any critical structures and it could be broken and manipulated to be extracted through the nasal passages. From this case report, it can be demonstrated that an intrasinus foreign body that has not traverse any critical structures, can be safely and reliably removed through sinus endoscopy. Moreover, the morbidity of an endoscopic approach has been reported as minor, as compared to an external approach.
References [1] H.A. Werman, Removal of foreign bodies of the nose, Emerg. Med. Clin. North Am. 5 (1987) 253—263. [2] H.A. Kadish, H.M. Corneli, Removal of nasal foreign bodies in the pediatric population, Am. J. Emerg. Med. 15 (1997) 54—56.
G. Fajardo et al. [3] E. Guazo, Removal of foreign bodies from the nose, N. Engl. J. Med. 312 (1985) 725. [4] N. Bhattacharyya, R. Wenokur, Endoscopic management of a chronic ethmoid and sphenoid sinus foreign body, Otolaryngol. Head and Neck Surg. 118 (1998) 5. [5] P. Donald, A. Gadre, Neuralgia like symptoms in a patient with an airgun pellet in the ethmoid sinus: case report, J. Laryngol. Otol. 109 (1995) 646—649. [6] R. Mladina, Endoscopic sinus surgery: a metallic foreign body at the sphenoethmoidal junction, J. Laryngol. Otol. 106 (1992) 998—999. [7] P. Murthy, J. Sahota, D. Nayak, R. Balakrishnan, P. Hazarika, Foreign body in the ethmoid sinus, Int. J. Oral. Maxillofac. Surg. 23 (1994) 74—75. [8] R.A. Uwadia, D. Maniar, M. Acharya, A transethmoid transorbital foreign body, J. Laryngol. Otol. 108 (1994) 411—412. [9] C.W. Cummings, J.M. Fredrickson, L.A. Harker, C.J. Krause, Otolaryngology Head and Neck Surg., third ed., vol. 2, Mosby, pp. 864—866. [10] Rice, Endoscopic Paranasal Sinus Surg., third ed., LWW, p. 136. [11] S.K. Das, Aetiological evaluation of foreign bodies in the ear and nose, J. Laryngol. Otol. 98 (1984) 989—991. [12] A.Q. Forrest, A large foreign body in the nose, J. Laryngol. Otol. 101 (1987) 1280—1282.