- Email: [email protected]
Removal of a metallic foreign body embedded in the external nose via open rhinoplasty approach
Int. J. Oral Maxillofac. Surg. 2008; 37: 1148–1152 doi:10.1016/j.ijom.2008.09.010, available online at http://www.sciencedirect.com
Technical Note Trauma
Removal of a metallic foreign body embedded in the external nose via open rhinoplasty approach
C. H. Ryu, Y. J. Jang, J.-S. Kim, H. M. Song Department of Otolaryngology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
C. H. Ryu, Y. J. Jang, J. -S. Kim, H. M. Song: Removal of a metallic foreign body embedded in the external nose via open rhinoplasty approach. Int. J. Oral Maxillofac. Surg. 2008; 37: 1148–1152. # 2008 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. Most metallic foreign bodies are inert, but they can cause chronic inflammatory reactions and be a source of infection. Identification and removal of foreign bodies from wounds is often necessary. The present report describes two cases of a foreign body embedded in the external nose. Each case was successfully treated by an open rhinoplasty approach. This approach is an effective and safe method for removal of foreign bodies in the external nose. It provides a good surgical field and a better cosmetic outcome than a conventional incision.
Keywords: foreign body; open rhinoplasty approach; metal.
Facial foreign bodies (FBs) are relatively uncommon. FBs may be dormant and remain in the soft tissue for years without causing damage to adjacent structures7. They can also produce chronic inflammatory reactions and be a source of infection3,11. Their identification and removal from wounds is often necessary. FBs can be removed via a direct incision in the overlying skin, but this approach provides a limited surgical field that can result in damage to adjacent structures. Such an approach also leaves a visible scar on the face. An alternative approach for FB removal is open rhinoplasty, which provides good surgical exposure and less prominent scarring. The present report describes two cases in which an open rhinoplasty approach
was observed (Fig. 1A and B). No FB was palpable in the external nose. On endoscopic examination, the FB was not identifiable in the nasal cavity. A plain radiograph showed that the FB was located near the nasal tip, but the precise location was uncertain (Fig. 2A, B and C). An exploration of the FB using the open rhinoplasty approach was performed under local anesthesia. A transcolumellar incision was made, the overlying skin elevated from the cartilaginous and bony structures, and the entire external nasal framework was exposed. The FB was not visible at this stage. Based on information from the plain radiograph, an incision was made at the middle crus of the lower lateral cartilage. An ovoid, metallic FB (4 mm), embedded underneath the
0901-5027/1201148 + 05 $30.00/0
was successfully used in removing FBs embedded in the external nose.
Case reports Case 1
A 35-year-old male presented with a FB in the external nose. The patient worked as a welder and the FB had entered the nose after a minor explosive event at work 2 days before presentation. FB removal via a direct incision of the overlying skin, under local anesthesia, at a local clinic had been unsuccessful. The patient did not have any nasal symptoms, and there were no local inflammatory signs. On physical examination, the postoperative scar resulting from the previous incision on the external nose
Accepted for publication 30 September 2008 Available online 18 November 2008
# 2008 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Foreign body removal via open rhinoplasty approach
1149
Fig. 1. Preoperative photographs. Scarring due to a previous incision on the nasal tip (A and B) and mid-columellar (C and D) regions.
lower lateral cartilage and above the vestibular skin, was observed and easily removed (Fig. 3A and B). The lower lateral cartilage incision site was sutured using monocryl 5-0. The postoperative course was uneventful, and the patient was discharged on postoperative day 2 without any complaints. Case 2
A 43-year-old male presented with an FB embedded in the external nose. The patient worked as a welder, and the FB had entered the nose during work, 1 month before presentation. Removal of the FB using the open rhinoplasty approach, under local anesthesia, at the local hospital had been unsuccessful. The patient did not exhibit any nasal symptoms. On physical examination, the postoperative transcolumellar incision scar resulting from the previous open rhinoplasty approach was noted (Fig. 1C and D). There was no indication of a penetrating scar on the external nose. The FB was not
palpable in the external nose. Endoscopic examination of the nasal cavity did not detect the FB. A plain radiograph showed that the FB was located near the lower lateral cartilage of the right external nose (Fig. 2D, E and F). An open approach was performed under general anesthesia. After the overlying skin was raised from the cartilaginous and bony structures, the FB was probed. A small, round, metallic object (5 mm) was embedded in the soft tissue on the lateral portion of the lateral crus of the right lower lateral cartilage (Fig. 3C and D). The FB was easily removed. The patient was discharged on postoperative 2 day with no complications. Discussion
In children, FBs in the nose have generally been inserted by the children and include toys and toy parts (beads, marbles), food (corn, beans, peas, seeds, nuts, hamburger, gum), and other small items (paper wads, cotton, erasers, pebbles, screws, sponges,
button batteries)1. In adults, FBs in the nose are generally the result of trauma (assaults or accidents) that results in metallic or glass fragments, or nasal jewelry embedding in the nasal region2. FBs may also be inserted in the nose by adults with mental retardation or illnesses, such as schizophrenia10. The classical symptom of an intranasal FB is a unilateral nasal discharge. Most cases are asymptomatic, except for a history given by the caregiver or the child of a FB having being inserted in the nose18. A unilateral nasal discharge in children should be assumed to be caused by an intranasal FB until proven otherwise16. In adults, most cases of soft tissue FBs after trauma or accidents are asymptomatic. The discovery of an occult FB on routine dental radiography has been previously reported4,9,17. The FB left in situ for over 20 years could be asymptomatic16. Symptoms, if present, could be pain or discomfort, local swelling, and facial cellulitis. Most metallic FBs are inert and may cause no problems for
1150
Ryu et al.
Fig. 2. Preoperative radiological findings. The foreign body can be seen near the left nasal tip area (A, B and C) and the right alar cartilage (D, E and F).
several years in the absence of infection. However, some metallic materials (in particular iron, copper and lead) may cause a delayed reaction and damage to adjacent structures7,12,14. In general, identification and removal of FBs from wounds is essential, because of the risk of infection. In the present cases, while the patients had clear histories of facial trauma, the clinical examinations returned negative findings because the FBs were small and the overlying skin had healed. In this setting, detection of soft tissue FBs is a challenge. The localization of FBs is important so that adjacent structure injury can be avoided and the time of removal can be reduced. Various imaging modalities, including plain radiography, xerography, computed tomography (CT), and ultrasonography (US), have been advocated for detecting FBs6. Radiographs detected FBs generally considered radiopaque (gravel, glass, metal) in 98% of
cases, but do not detected radiolucent (wood, plastic, cactus spine) bodies. The false-negative and false-positive rates for radiography are 50% and 1.6%, respectively11. In the current cases, plain radiography showed the suspected location of metallic FBs, although their precise depths were not known. The authors were assured that the FBs were located in the superficial plane, so facial CT was not performed. If plain radiographs, history and clinical examination fail to reveal the presence of superficial FBs, US or CT can be used as an alternative method13. CT and especially US are suitable imaging methods for the detection of FBs in soft tissue13. Computed radiography-soft copy is the preferred imaging technique for the detection of wood and plastic FBs in soft tissue, regardless of their size6. Amalgam produces a metallic streaking artefact in CT, which visualizes wood as gas density, and
depicts all the other materials as similar hyperdense masses6. US is sensitive and specific in detecting FBs in soft tissue. The particles were better defined in form and size with CT and US than with plain radiography. Sonography is a useful tool in the localization and removal of soft tissue FBs5. The sensitivity of US in detecting gravel was 40%, metal was 45–48%, glass was 50–52%, cactus spine was 30%, wood was 50–55%, and plastic was 40–53%11,15. Various methods of removing intranasal FBs have been described1,2,8,10,16,18. The nature of the FB determines the method of removal. Most methods involve retrieval in the orthograde direction using nasal forceps, a hooked probe or instrument, Foley catheter or suction1,2,8,10,16,18. Removal of soft tissue FBs can be accomplished through aesthetic incisions via the overlying wound. Investigation of a suspected
Foreign body removal via open rhinoplasty approach
1151
Fig. 3. Operative findings. An ovoid metallic object (4 mm) was observed after an incision at the left alar cartilage (A and B). A round metallic object (5 mm) was observed after medial traction of the right alar cartilage (C and D).
FB via direct incision may provide a limited surgical field, which can increase the risk of damage to adjacent nerves and anatomical structures. This is particularly relevant when FBs are located within the external nose and are remote form the overlying wound as there is a risk of damaging the cartilage supporting the nasal framework. Such procedures can break nasal frameworks and cause external nose deformities. Exploration via direct incision leaves a visible scar. The open rhinoplasty approach provides a good surgical field and less prominent scarring. Complications associated with open rhinoplasty include nasal tip drooping, visible columellar scar, nostril asymmetry and wound infection. The advantage of this approach is that the surgeon can observe the whole framework of the external nose. The open rhinoplasty approach results in a potentially less perceptible scar. Although this approach provides good surgical exposure, FBs are sometimes not easily observed when they are deeply located with in the soft tissue. Thorough surgical exploration is
often required, and correlation with radiographs is always recommended during exploration.
7.
References 1. Baker MD. Foreign bodies of the ears and nose in childhood. Pediatr Emerg Care 1987: 3: 67–70. 2. De Carpentier JP, Flanagan P, Hargreaves SP, Timms MS. An unusual cause of facial pain. J Laryngol Otol 1996: 110: 796–798. 3. Ebner F, Tolly E, Tritthart H. Uncommon intraspinal space occupying lesion (foreign-body granuloma) in the lumbosacral region. Neuroradiology 1985: 27: 354–356. 4. Fagan T, Mathewson RJ. Unusual nasal foreign body detected by panoramic dental radiography: case report. Pediatr Dent 1990: 12: 43–44. 5. Friedman DI, Forti RJ, Wall SP, Crain EF. The utility of bedside ultrasound and patient perception in detecting soft tissue foreign bodies in children. Pediatr Emerg Care 2005: 21(8):487–492. 6. Ginsburg MJ, Ellis GL, Flom LL. Detection of soft-tissue foreign bodies by plain radiography, xerography, com-
8.
9.
10. 11.
12.
13.
puted tomography, and ultrasonography. Ann Emerg Med 1990: 19: 701– 703. Ho VH, Wilson MW, Fleming JC, Haik BG. Retained intraorbital metallic foreign bodies. Ophthal Plast Reconstr Surg 2004: 20: 232–236. Kadish HA, Corneli HM. Removal of nasal foreign bodies in the pediatric population. Am J Emerg Med 1997: 15: 54–56. Kirtle PE, Aaron GR, Jones HL, Duncan NO. Incidental finding of an intranasal foreign body discovered on routine dental examination: case report. Pediatr Dent 1991: 13: 49–51. Kuzy FD, Korbich M. Foreign body in nasal cavity. Oral Surg Oral Med Oral Pathol 1982: 54: 254. Manthey DE, Storrow AB, Milbourn JM, Wagner BJ. Ultrasound versus radiography in the detection of soft-tissue foreign bodies. Ann Emerg Med 1996: 28: 7–9. McKinney Jr RV, Brady GL, Singh BB. Metallic foreign body embedded in the cheek for 20 years. J Am Dent Assoc 1981: 102: 331–333. Oikarinen KS, Nieminen TM, Ma¨ka¨ra¨inen H, Pyhtinen J. Visibility of foreign bodies in soft tissue in plain
1152
Ryu et al.
radiographs, computed tomography, magnetic resonance imaging, and ultrasound. An in vitro study. Int J Oral Maxillofac Surg 1993: 22(2):119–124. 14. Paproski SM, Smith SL, Crawford RI. Ferruginous foreign body: a clinical simulant of melanoma with distinctive histologic features. Am J Dermatopathol 2002: 24: 396–398. 15. Shiels 2nd WE, Babcock DS, Wilson JL, Burch RA. Localization and guided removal of soft-tissue foreign bodies with sonography. AJR Am J Roentgenol 1990: 155(6):1277–1281.
16. Tay AB. Long-standing intranasal foreign body: an incidental finding on dental radiograph: a case report and literature review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000: 90(4):546–549. 17. Waldman LA, Nashua NH. Facial cellulitis caused by unrecognized foreign body. Oral Surg Oral Med Oral Pathol 1979: 48: 408–409. 18. Werman HA. Removal of foreign bodies of the nose. Emerg Med Clin North Am 1987: 5: 253–263.
Address: Yong Ju Jang Department of Otolaryngology Asan Medical Center University of Ulsan College of Medicine 388-1 Pungnap-dong Songpa-gu Seoul 138-736 Republic of Korea Tel: +82 2 3010 3710 Fax: +82 2 489 2773 E-mail: [email protected]
Technical Note Trauma
Removal of a metallic foreign body embedded in the external nose via open rhinoplasty approach
C. H. Ryu, Y. J. Jang, J.-S. Kim, H. M. Song Department of Otolaryngology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
C. H. Ryu, Y. J. Jang, J. -S. Kim, H. M. Song: Removal of a metallic foreign body embedded in the external nose via open rhinoplasty approach. Int. J. Oral Maxillofac. Surg. 2008; 37: 1148–1152. # 2008 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. Most metallic foreign bodies are inert, but they can cause chronic inflammatory reactions and be a source of infection. Identification and removal of foreign bodies from wounds is often necessary. The present report describes two cases of a foreign body embedded in the external nose. Each case was successfully treated by an open rhinoplasty approach. This approach is an effective and safe method for removal of foreign bodies in the external nose. It provides a good surgical field and a better cosmetic outcome than a conventional incision.
Keywords: foreign body; open rhinoplasty approach; metal.
Facial foreign bodies (FBs) are relatively uncommon. FBs may be dormant and remain in the soft tissue for years without causing damage to adjacent structures7. They can also produce chronic inflammatory reactions and be a source of infection3,11. Their identification and removal from wounds is often necessary. FBs can be removed via a direct incision in the overlying skin, but this approach provides a limited surgical field that can result in damage to adjacent structures. Such an approach also leaves a visible scar on the face. An alternative approach for FB removal is open rhinoplasty, which provides good surgical exposure and less prominent scarring. The present report describes two cases in which an open rhinoplasty approach
was observed (Fig. 1A and B). No FB was palpable in the external nose. On endoscopic examination, the FB was not identifiable in the nasal cavity. A plain radiograph showed that the FB was located near the nasal tip, but the precise location was uncertain (Fig. 2A, B and C). An exploration of the FB using the open rhinoplasty approach was performed under local anesthesia. A transcolumellar incision was made, the overlying skin elevated from the cartilaginous and bony structures, and the entire external nasal framework was exposed. The FB was not visible at this stage. Based on information from the plain radiograph, an incision was made at the middle crus of the lower lateral cartilage. An ovoid, metallic FB (4 mm), embedded underneath the
0901-5027/1201148 + 05 $30.00/0
was successfully used in removing FBs embedded in the external nose.
Case reports Case 1
A 35-year-old male presented with a FB in the external nose. The patient worked as a welder and the FB had entered the nose after a minor explosive event at work 2 days before presentation. FB removal via a direct incision of the overlying skin, under local anesthesia, at a local clinic had been unsuccessful. The patient did not have any nasal symptoms, and there were no local inflammatory signs. On physical examination, the postoperative scar resulting from the previous incision on the external nose
Accepted for publication 30 September 2008 Available online 18 November 2008
# 2008 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Foreign body removal via open rhinoplasty approach
1149
Fig. 1. Preoperative photographs. Scarring due to a previous incision on the nasal tip (A and B) and mid-columellar (C and D) regions.
lower lateral cartilage and above the vestibular skin, was observed and easily removed (Fig. 3A and B). The lower lateral cartilage incision site was sutured using monocryl 5-0. The postoperative course was uneventful, and the patient was discharged on postoperative day 2 without any complaints. Case 2
A 43-year-old male presented with an FB embedded in the external nose. The patient worked as a welder, and the FB had entered the nose during work, 1 month before presentation. Removal of the FB using the open rhinoplasty approach, under local anesthesia, at the local hospital had been unsuccessful. The patient did not exhibit any nasal symptoms. On physical examination, the postoperative transcolumellar incision scar resulting from the previous open rhinoplasty approach was noted (Fig. 1C and D). There was no indication of a penetrating scar on the external nose. The FB was not
palpable in the external nose. Endoscopic examination of the nasal cavity did not detect the FB. A plain radiograph showed that the FB was located near the lower lateral cartilage of the right external nose (Fig. 2D, E and F). An open approach was performed under general anesthesia. After the overlying skin was raised from the cartilaginous and bony structures, the FB was probed. A small, round, metallic object (5 mm) was embedded in the soft tissue on the lateral portion of the lateral crus of the right lower lateral cartilage (Fig. 3C and D). The FB was easily removed. The patient was discharged on postoperative 2 day with no complications. Discussion
In children, FBs in the nose have generally been inserted by the children and include toys and toy parts (beads, marbles), food (corn, beans, peas, seeds, nuts, hamburger, gum), and other small items (paper wads, cotton, erasers, pebbles, screws, sponges,
button batteries)1. In adults, FBs in the nose are generally the result of trauma (assaults or accidents) that results in metallic or glass fragments, or nasal jewelry embedding in the nasal region2. FBs may also be inserted in the nose by adults with mental retardation or illnesses, such as schizophrenia10. The classical symptom of an intranasal FB is a unilateral nasal discharge. Most cases are asymptomatic, except for a history given by the caregiver or the child of a FB having being inserted in the nose18. A unilateral nasal discharge in children should be assumed to be caused by an intranasal FB until proven otherwise16. In adults, most cases of soft tissue FBs after trauma or accidents are asymptomatic. The discovery of an occult FB on routine dental radiography has been previously reported4,9,17. The FB left in situ for over 20 years could be asymptomatic16. Symptoms, if present, could be pain or discomfort, local swelling, and facial cellulitis. Most metallic FBs are inert and may cause no problems for
1150
Ryu et al.
Fig. 2. Preoperative radiological findings. The foreign body can be seen near the left nasal tip area (A, B and C) and the right alar cartilage (D, E and F).
several years in the absence of infection. However, some metallic materials (in particular iron, copper and lead) may cause a delayed reaction and damage to adjacent structures7,12,14. In general, identification and removal of FBs from wounds is essential, because of the risk of infection. In the present cases, while the patients had clear histories of facial trauma, the clinical examinations returned negative findings because the FBs were small and the overlying skin had healed. In this setting, detection of soft tissue FBs is a challenge. The localization of FBs is important so that adjacent structure injury can be avoided and the time of removal can be reduced. Various imaging modalities, including plain radiography, xerography, computed tomography (CT), and ultrasonography (US), have been advocated for detecting FBs6. Radiographs detected FBs generally considered radiopaque (gravel, glass, metal) in 98% of
cases, but do not detected radiolucent (wood, plastic, cactus spine) bodies. The false-negative and false-positive rates for radiography are 50% and 1.6%, respectively11. In the current cases, plain radiography showed the suspected location of metallic FBs, although their precise depths were not known. The authors were assured that the FBs were located in the superficial plane, so facial CT was not performed. If plain radiographs, history and clinical examination fail to reveal the presence of superficial FBs, US or CT can be used as an alternative method13. CT and especially US are suitable imaging methods for the detection of FBs in soft tissue13. Computed radiography-soft copy is the preferred imaging technique for the detection of wood and plastic FBs in soft tissue, regardless of their size6. Amalgam produces a metallic streaking artefact in CT, which visualizes wood as gas density, and
depicts all the other materials as similar hyperdense masses6. US is sensitive and specific in detecting FBs in soft tissue. The particles were better defined in form and size with CT and US than with plain radiography. Sonography is a useful tool in the localization and removal of soft tissue FBs5. The sensitivity of US in detecting gravel was 40%, metal was 45–48%, glass was 50–52%, cactus spine was 30%, wood was 50–55%, and plastic was 40–53%11,15. Various methods of removing intranasal FBs have been described1,2,8,10,16,18. The nature of the FB determines the method of removal. Most methods involve retrieval in the orthograde direction using nasal forceps, a hooked probe or instrument, Foley catheter or suction1,2,8,10,16,18. Removal of soft tissue FBs can be accomplished through aesthetic incisions via the overlying wound. Investigation of a suspected
Foreign body removal via open rhinoplasty approach
1151
Fig. 3. Operative findings. An ovoid metallic object (4 mm) was observed after an incision at the left alar cartilage (A and B). A round metallic object (5 mm) was observed after medial traction of the right alar cartilage (C and D).
FB via direct incision may provide a limited surgical field, which can increase the risk of damage to adjacent nerves and anatomical structures. This is particularly relevant when FBs are located within the external nose and are remote form the overlying wound as there is a risk of damaging the cartilage supporting the nasal framework. Such procedures can break nasal frameworks and cause external nose deformities. Exploration via direct incision leaves a visible scar. The open rhinoplasty approach provides a good surgical field and less prominent scarring. Complications associated with open rhinoplasty include nasal tip drooping, visible columellar scar, nostril asymmetry and wound infection. The advantage of this approach is that the surgeon can observe the whole framework of the external nose. The open rhinoplasty approach results in a potentially less perceptible scar. Although this approach provides good surgical exposure, FBs are sometimes not easily observed when they are deeply located with in the soft tissue. Thorough surgical exploration is
often required, and correlation with radiographs is always recommended during exploration.
7.
References 1. Baker MD. Foreign bodies of the ears and nose in childhood. Pediatr Emerg Care 1987: 3: 67–70. 2. De Carpentier JP, Flanagan P, Hargreaves SP, Timms MS. An unusual cause of facial pain. J Laryngol Otol 1996: 110: 796–798. 3. Ebner F, Tolly E, Tritthart H. Uncommon intraspinal space occupying lesion (foreign-body granuloma) in the lumbosacral region. Neuroradiology 1985: 27: 354–356. 4. Fagan T, Mathewson RJ. Unusual nasal foreign body detected by panoramic dental radiography: case report. Pediatr Dent 1990: 12: 43–44. 5. Friedman DI, Forti RJ, Wall SP, Crain EF. The utility of bedside ultrasound and patient perception in detecting soft tissue foreign bodies in children. Pediatr Emerg Care 2005: 21(8):487–492. 6. Ginsburg MJ, Ellis GL, Flom LL. Detection of soft-tissue foreign bodies by plain radiography, xerography, com-
8.
9.
10. 11.
12.
13.
puted tomography, and ultrasonography. Ann Emerg Med 1990: 19: 701– 703. Ho VH, Wilson MW, Fleming JC, Haik BG. Retained intraorbital metallic foreign bodies. Ophthal Plast Reconstr Surg 2004: 20: 232–236. Kadish HA, Corneli HM. Removal of nasal foreign bodies in the pediatric population. Am J Emerg Med 1997: 15: 54–56. Kirtle PE, Aaron GR, Jones HL, Duncan NO. Incidental finding of an intranasal foreign body discovered on routine dental examination: case report. Pediatr Dent 1991: 13: 49–51. Kuzy FD, Korbich M. Foreign body in nasal cavity. Oral Surg Oral Med Oral Pathol 1982: 54: 254. Manthey DE, Storrow AB, Milbourn JM, Wagner BJ. Ultrasound versus radiography in the detection of soft-tissue foreign bodies. Ann Emerg Med 1996: 28: 7–9. McKinney Jr RV, Brady GL, Singh BB. Metallic foreign body embedded in the cheek for 20 years. J Am Dent Assoc 1981: 102: 331–333. Oikarinen KS, Nieminen TM, Ma¨ka¨ra¨inen H, Pyhtinen J. Visibility of foreign bodies in soft tissue in plain
1152
Ryu et al.
radiographs, computed tomography, magnetic resonance imaging, and ultrasound. An in vitro study. Int J Oral Maxillofac Surg 1993: 22(2):119–124. 14. Paproski SM, Smith SL, Crawford RI. Ferruginous foreign body: a clinical simulant of melanoma with distinctive histologic features. Am J Dermatopathol 2002: 24: 396–398. 15. Shiels 2nd WE, Babcock DS, Wilson JL, Burch RA. Localization and guided removal of soft-tissue foreign bodies with sonography. AJR Am J Roentgenol 1990: 155(6):1277–1281.
16. Tay AB. Long-standing intranasal foreign body: an incidental finding on dental radiograph: a case report and literature review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000: 90(4):546–549. 17. Waldman LA, Nashua NH. Facial cellulitis caused by unrecognized foreign body. Oral Surg Oral Med Oral Pathol 1979: 48: 408–409. 18. Werman HA. Removal of foreign bodies of the nose. Emerg Med Clin North Am 1987: 5: 253–263.
Address: Yong Ju Jang Department of Otolaryngology Asan Medical Center University of Ulsan College of Medicine 388-1 Pungnap-dong Songpa-gu Seoul 138-736 Republic of Korea Tel: +82 2 3010 3710 Fax: +82 2 489 2773 E-mail: [email protected]