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Gossypiboma in the Nasal Septum After Septorhinoplasty: A Case Study
J Oral Maxillofac Surg 71:e42-e44, 2013
Gossypiboma in the Nasal Septum After Septorhinoplasty: A Case Study Sung-Woo Cho, MD,* and Hong Ryul Jin, MD, PhD† This report describes a case of gossypiboma in the septum. A 31-year-old woman presented with nasal obstruction and crusting that started 2 years previously after she underwent rhinoseptoplasty in another private clinic. Physical examination disclosed remaining posterior septal deviation to the left side with septal mucosal erosion on the left side. Under general anesthesia, the septal flap was elevated on the left side of the nasal cavity. A gossypiboma was found around the perpendicular ethmoid plate and between the septal flaps. The perpendicular ethmoid plate was resected and the gossypiboma was removed under endoscopy. Because of severe adhesion between the gossypiboma and the septal mucosa, removal of the gossypiboma resulted in a defect on the left mucoperichondrial flap. Right inferior turbinate mucosa was harvested and grafted on the mucosal defect of the left side. Five months after the operation, the nasal cavity showed a straight septum with a well-healed mucosa without any nasal symptoms. This case is a reminder of the fundamental importance of absolute care at every step of rhinologic surgery. © 2013 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 71:e42-e44, 2013 fully treated with endoscopic assistance and includes a brief literature review.
Gossypiboma is a term used to describe a mass of cotton matrix that is left behind in a body cavity during an operation. Gossypibomas are found most commonly in the abdomen, followed by the pelvis and the thorax.1 Although its prevalence is known to be 1 in every 1,000 to 1,500 abdominal operations, the estimates suggest that the general incidence is likely higher considering the reluctance of those involved to report the occurrences.2 The incidence of gossypiboma in otorhinolaryngology/maxillofacial surgery is even lower than for intraabdominal gossypibomas.3 To the authors’ knowledge, there has been only 1 report of gossypiboma in the field of rhinology.4 Indeed, the authors believe this is the first report of gossypiboma in the nasal septum after rhinoseptoplasty. The present report describes a case of gossypiboma in the nasal septum that was success-
Report of Case This study was approved by the institutional review board of the Clinical Research Institute at the Boramae Medical Center. A 31-year-old woman presented at the authors’ hospital for nasal obstruction. Two years previously, the patient underwent augmentation rhinoplasty at another private clinic, where a silicone implant and septoplasty were used to correct her deviated nasal septum that was causing nasal obstruction. After that surgery, the patient’s nasal obstruction did not improve, and she complained of frequent crusting in the left nasal cavity. Physical examination disclosed a remaining posterior septal deviation to the left side with septal mucosal erosion anterior to the deviation (Fig 1). Because the patient was satisfied with the appearance of her nose, only a revision septoplasty was planned. While elevating the left septal mucoperichondrial flap, the mucosal flap at the site of the erosive lesion was lacerated. After further elevation of the entire mucosal flap, an inadequately resected, deviated perpendicular ethmoid plate (PEP) and a gossypiboma around the PEP were found (Fig 2A). The main mass of the gossypiboma was located between the right mucosal flap and the PEP. The PEP was further resected, and the gossypiboma was removed carefully and thoroughly under endoscopic view. Because of the severe adhesion of the gossypiboma to the septal mucosa, an additional laceration was made on the left side of the mucosal flap after complete removal. Mucosa was harvested from the medial side of the right inferior turbinate and grafted onto the left-side mucosal defect. After repositioning and closing the septal flap, a Silastic sheet (Dow Corning, Midland, MI) was applied, and both nasal cavities were packed with Merocel (Medtronic
Received from Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University College of Medicine, Boramae Medical Center, Seoul, Korea. *Resident. †Professor. Address correspondence and reprint requests to Dr Jin: Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University College of Medicine, Boramae Medical Center 39, Boramae-Gil, Dongjak-gu, Seoul 156-707, Korea; e-mail: hrjin@snu .ac.kr © 2013 American Association of Oral and Maxillofacial Surgeons
0278-2391/13/7101-0$36.00/0 http://dx.doi.org/10.1016/j.joms.2012.09.007
e42
e43
CHO AND JIN
FIGURE 1. Endoscopic photographs of the patient’s nasal cavities at presentation. A, The right side of the nasal cavity is clear, whereas B, the left side shows a focal, erosive lesion (arrow) with posterior septal deviation to the left. Cho and Jin. Gossypiboma After Septorhinoplasty. J Oral Maxillofac Surg 2013.
Xomed, Jackson, FL). The Merocel was removed 2 days after surgery and the Silastic sheet was kept in situ for 2 weeks. A biopsy of the mucosal tissue adhering to the gossypiboma showed fibrosis and giant cells around the cotton fibers (Fig 3), and a culture of the tissue showed no growth of bacteria. The patient’s nasal symptoms disappeared after surgery. A nasal cavity examination 5 months after surgery showed a straight septum and a well-healed mucosal defect (Fig 2B).
Discussion Cotton is an inert material and does not undergo decomposition.5 Gossypibomas cause 2 types of responses in the body—an exudative type of response, leading to abscess formation with or without bacterial superinfection, and an aseptic fibrous response that results in adhesion or encapsulation, leading to granuloma formation.6 Gossypibomas may present at any time, ranging from immediately postoperatively to several decades after the initial surgery.7 The authors believe this case was the latter presentation because fibrosis and giant cells were present in the pathologic
specimen, and there was no evidence of infection or bacterial growth. A chronic silent fibrous response may have resulted in erosion of the septal mucosa, causing recurrent crusting. Severe adhesion of the gossypiboma to the surrounding septal mucosal flap with fragile mucosa owing to the recurrent crusting caused a mucosal defect that required a free mucosal graft. Although the working space for a rhinoseptoplasty is very small, after surgery the external nose is easy to check for a remaining foreign body. Conversely, the septal cavity is truly a small, deep space with a restricted visual field. Without diligent care, it is easy to leave a foreign body inside the septum. The previous surgeon may have used a piece of small gauze inside the septum and did not remove it. Gauze packing with a substantial size (the authors use 4 ⫻ 1.5 cm2 cotton gauze) with tied black silk thread helps to identify the gauze more easily. A careful observation of the septal cavity before closure and an exact count of the gauze are necessary to prevent leaving a foreign
FIGURE 2. Endoscopic photographs taken during the operation and at 5 months after surgery. A, The gossypiboma (arrowhead) surrounds the incompletely removed and deviated perpendicular ethmoid plate (arrow) and is firmly adhered to the septal flap. Complete removal was accompanied by a mucosal laceration. B, At 5 months after surgery, a well-adapted mucosal free graft (arrow) is observed. Cho and Jin. Gossypiboma After Septorhinoplasty. J Oral Maxillofac Surg 2013.
e44
GOSSYPIBOMA AFTER SEPTORHINOPLASTY
body in the septal cavity. This case is a reminder of the fundamental importance of absolute care at every step of rhinologic surgery.
References
FIGURE 3. Histology of the specimen (hematoxylin and eosin stain; magnification, ⫻200) shows cotton fibers surrounded by fibrous tissue (arrow) and giant cells (arrowhead). Cho and Jin. Gossypiboma After Septorhinoplasty. J Oral Maxillofac Surg 2013.
1. Wan W, Le T, Riskin L, et al: Improving safety in the operating room: A systematic literature review of retained surgical sponges. Curr Opin Anaesthesiol 22:207, 2009 2. Irabor DO: Under-reporting of gossypiboma in a third-world country. A sociocultural view. Health 4:56, 2012 3. Lauwers PR, Van Hee RH: Intraperitoneal gossypibomas: The need to count sponges. World J Surg 24:521, 2000 4. Tan VE, Sethi DS: Gossypiboma: An unusual intracranial complication of endoscopic sinus surgery. Laryngoscope 121:879, 2011 5. Sturdy JH, Baird RM, Gerein AN: Surgical sponges: A cause of granuloma and adhesion formation. Ann Surg 165:128, 1967 6. Chorvat G, Kahn J, Camelot G, et al: [The fate of swabs forgotten in the abdomen (author’s transl)]. Ann Chir 30:643, 1976 7. Ribalta T, McCutcheon IE, Neto AG, et al: Textiloma (gossypiboma) mimicking recurrent intracranial tumor. Arch Pathol Lab Med 128:749, 2004
Gossypiboma in the Nasal Septum After Septorhinoplasty: A Case Study Sung-Woo Cho, MD,* and Hong Ryul Jin, MD, PhD† This report describes a case of gossypiboma in the septum. A 31-year-old woman presented with nasal obstruction and crusting that started 2 years previously after she underwent rhinoseptoplasty in another private clinic. Physical examination disclosed remaining posterior septal deviation to the left side with septal mucosal erosion on the left side. Under general anesthesia, the septal flap was elevated on the left side of the nasal cavity. A gossypiboma was found around the perpendicular ethmoid plate and between the septal flaps. The perpendicular ethmoid plate was resected and the gossypiboma was removed under endoscopy. Because of severe adhesion between the gossypiboma and the septal mucosa, removal of the gossypiboma resulted in a defect on the left mucoperichondrial flap. Right inferior turbinate mucosa was harvested and grafted on the mucosal defect of the left side. Five months after the operation, the nasal cavity showed a straight septum with a well-healed mucosa without any nasal symptoms. This case is a reminder of the fundamental importance of absolute care at every step of rhinologic surgery. © 2013 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 71:e42-e44, 2013 fully treated with endoscopic assistance and includes a brief literature review.
Gossypiboma is a term used to describe a mass of cotton matrix that is left behind in a body cavity during an operation. Gossypibomas are found most commonly in the abdomen, followed by the pelvis and the thorax.1 Although its prevalence is known to be 1 in every 1,000 to 1,500 abdominal operations, the estimates suggest that the general incidence is likely higher considering the reluctance of those involved to report the occurrences.2 The incidence of gossypiboma in otorhinolaryngology/maxillofacial surgery is even lower than for intraabdominal gossypibomas.3 To the authors’ knowledge, there has been only 1 report of gossypiboma in the field of rhinology.4 Indeed, the authors believe this is the first report of gossypiboma in the nasal septum after rhinoseptoplasty. The present report describes a case of gossypiboma in the nasal septum that was success-
Report of Case This study was approved by the institutional review board of the Clinical Research Institute at the Boramae Medical Center. A 31-year-old woman presented at the authors’ hospital for nasal obstruction. Two years previously, the patient underwent augmentation rhinoplasty at another private clinic, where a silicone implant and septoplasty were used to correct her deviated nasal septum that was causing nasal obstruction. After that surgery, the patient’s nasal obstruction did not improve, and she complained of frequent crusting in the left nasal cavity. Physical examination disclosed a remaining posterior septal deviation to the left side with septal mucosal erosion anterior to the deviation (Fig 1). Because the patient was satisfied with the appearance of her nose, only a revision septoplasty was planned. While elevating the left septal mucoperichondrial flap, the mucosal flap at the site of the erosive lesion was lacerated. After further elevation of the entire mucosal flap, an inadequately resected, deviated perpendicular ethmoid plate (PEP) and a gossypiboma around the PEP were found (Fig 2A). The main mass of the gossypiboma was located between the right mucosal flap and the PEP. The PEP was further resected, and the gossypiboma was removed carefully and thoroughly under endoscopic view. Because of the severe adhesion of the gossypiboma to the septal mucosa, an additional laceration was made on the left side of the mucosal flap after complete removal. Mucosa was harvested from the medial side of the right inferior turbinate and grafted onto the left-side mucosal defect. After repositioning and closing the septal flap, a Silastic sheet (Dow Corning, Midland, MI) was applied, and both nasal cavities were packed with Merocel (Medtronic
Received from Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University College of Medicine, Boramae Medical Center, Seoul, Korea. *Resident. †Professor. Address correspondence and reprint requests to Dr Jin: Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University College of Medicine, Boramae Medical Center 39, Boramae-Gil, Dongjak-gu, Seoul 156-707, Korea; e-mail: hrjin@snu .ac.kr © 2013 American Association of Oral and Maxillofacial Surgeons
0278-2391/13/7101-0$36.00/0 http://dx.doi.org/10.1016/j.joms.2012.09.007
e42
e43
CHO AND JIN
FIGURE 1. Endoscopic photographs of the patient’s nasal cavities at presentation. A, The right side of the nasal cavity is clear, whereas B, the left side shows a focal, erosive lesion (arrow) with posterior septal deviation to the left. Cho and Jin. Gossypiboma After Septorhinoplasty. J Oral Maxillofac Surg 2013.
Xomed, Jackson, FL). The Merocel was removed 2 days after surgery and the Silastic sheet was kept in situ for 2 weeks. A biopsy of the mucosal tissue adhering to the gossypiboma showed fibrosis and giant cells around the cotton fibers (Fig 3), and a culture of the tissue showed no growth of bacteria. The patient’s nasal symptoms disappeared after surgery. A nasal cavity examination 5 months after surgery showed a straight septum and a well-healed mucosal defect (Fig 2B).
Discussion Cotton is an inert material and does not undergo decomposition.5 Gossypibomas cause 2 types of responses in the body—an exudative type of response, leading to abscess formation with or without bacterial superinfection, and an aseptic fibrous response that results in adhesion or encapsulation, leading to granuloma formation.6 Gossypibomas may present at any time, ranging from immediately postoperatively to several decades after the initial surgery.7 The authors believe this case was the latter presentation because fibrosis and giant cells were present in the pathologic
specimen, and there was no evidence of infection or bacterial growth. A chronic silent fibrous response may have resulted in erosion of the septal mucosa, causing recurrent crusting. Severe adhesion of the gossypiboma to the surrounding septal mucosal flap with fragile mucosa owing to the recurrent crusting caused a mucosal defect that required a free mucosal graft. Although the working space for a rhinoseptoplasty is very small, after surgery the external nose is easy to check for a remaining foreign body. Conversely, the septal cavity is truly a small, deep space with a restricted visual field. Without diligent care, it is easy to leave a foreign body inside the septum. The previous surgeon may have used a piece of small gauze inside the septum and did not remove it. Gauze packing with a substantial size (the authors use 4 ⫻ 1.5 cm2 cotton gauze) with tied black silk thread helps to identify the gauze more easily. A careful observation of the septal cavity before closure and an exact count of the gauze are necessary to prevent leaving a foreign
FIGURE 2. Endoscopic photographs taken during the operation and at 5 months after surgery. A, The gossypiboma (arrowhead) surrounds the incompletely removed and deviated perpendicular ethmoid plate (arrow) and is firmly adhered to the septal flap. Complete removal was accompanied by a mucosal laceration. B, At 5 months after surgery, a well-adapted mucosal free graft (arrow) is observed. Cho and Jin. Gossypiboma After Septorhinoplasty. J Oral Maxillofac Surg 2013.
e44
GOSSYPIBOMA AFTER SEPTORHINOPLASTY
body in the septal cavity. This case is a reminder of the fundamental importance of absolute care at every step of rhinologic surgery.
References
FIGURE 3. Histology of the specimen (hematoxylin and eosin stain; magnification, ⫻200) shows cotton fibers surrounded by fibrous tissue (arrow) and giant cells (arrowhead). Cho and Jin. Gossypiboma After Septorhinoplasty. J Oral Maxillofac Surg 2013.
1. Wan W, Le T, Riskin L, et al: Improving safety in the operating room: A systematic literature review of retained surgical sponges. Curr Opin Anaesthesiol 22:207, 2009 2. Irabor DO: Under-reporting of gossypiboma in a third-world country. A sociocultural view. Health 4:56, 2012 3. Lauwers PR, Van Hee RH: Intraperitoneal gossypibomas: The need to count sponges. World J Surg 24:521, 2000 4. Tan VE, Sethi DS: Gossypiboma: An unusual intracranial complication of endoscopic sinus surgery. Laryngoscope 121:879, 2011 5. Sturdy JH, Baird RM, Gerein AN: Surgical sponges: A cause of granuloma and adhesion formation. Ann Surg 165:128, 1967 6. Chorvat G, Kahn J, Camelot G, et al: [The fate of swabs forgotten in the abdomen (author’s transl)]. Ann Chir 30:643, 1976 7. Ribalta T, McCutcheon IE, Neto AG, et al: Textiloma (gossypiboma) mimicking recurrent intracranial tumor. Arch Pathol Lab Med 128:749, 2004