Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Case Report
Chronic Maxillary Sinusitis Associated with
an Unusual Foreign Body: A Case Report
Yunus Feyyat Sahin,1 Togay Muderris,2 Sami Bercin,2 Ergun Sevil,2 and Muzaffer Krs2
1 Division of Otolaryngology, Batman Sifa Hospital, 72070 Batman, Turkey
2 Department of Otolaryngology, Head and Neck Surgery, Ataturk Education and Research Hospital, Bilkent, 06800 Ankara, Turkey
Copyright 2012 Yunus Feyyat Sahin et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
Foreign bodies in maxillary sinuses are unusual clinical conditions, and they can cause chronic sinusitis by mucosal irritation. Most
cases of foreign bodies in maxillary sinus are related to iatrogenic dental manipulation and only a few cases with non-dental origin
are reported. Oroantral fistulas secondary to dental procedures are the most common way of insertion. Treatment is surgical
removal of the foreign body either endoscopically or with a combined approach, with Caldwell-Luc procedure if endoscopic
approach is inadequate for visualisation. In this case, we present a 24-year-old male patient with unilateral chronic maxillary
sinusitis due to a wooden toothpick in left maxillary sinus. The patient had a history of upper second premolar tooth extraction.
CT scan revealed sinus opacification with presence of a foreign body in left maxillary sinus extending from the floor of the sinus
to the orbital base. The foreign body, a wooden toothpick, was removed with Caldwell-Luc procedure since it was impossible
to remove the toothpick endoscopically. There was no obvious oroantral fistula in the time of surgery, but the position of the
toothpick made us to think that it was inserted through a previously healed fistula, willingly or accidentally.
Right Left
Figure 1: CT scan showing the foreign body in the left maxillary sinus.
therapy for sinusitis three times, but his complaints persisted. the orbital base. (Figure 1) There was also a discontinuity in
On physical examination, he had a mild septal deviation to the bony segment of the sinus floor, but there was no sign of
left, his left inferior turbinate was hypertrophic, and he had fistula since the connection between maxillary sinus and oral
purulent and foul-smelling discharge from his left nostril. cavity was interrupted by soft tissues. Shape and position of
Nasal endoscopy revealed polyps and purulent secretion on the foreign body made us think that it had been inserted from
left middle meatus. In his oral examination, there was no a previously healed oroantral fistula, where the second upper
obvious dental problem (cavities, mobility, etc.), but his molar tooth had been extracted. But we could not find out
left upper second molar tooth was absent due to extraction if it had been inserted willingly or accidentally, because the
for root abscess three years ago, yet there was no sign of patient could not remember such an incident.
oroantral fistula. He had no history of surgery for nasal or Endoscopic surgery was planned to take the foreign
sinus pathologies, and he had no chronic medical condition. body out; left uncinectomy and middle meatal antrostomy
A computed tomography scan of the paranasal sinuses were performed under general anesthesia. We saw the
was done prior to medical treatment because his sinusitis was foreign body, a wooden toothpick, through the sinus ostium,
unilateral and resistant to medical therapy. CT scan revealed and we realised that it was not possible to take out the
sinus opacification with the presence of a foreign body in the toothpick endoscopically. So we turned the operation to
left maxillary sinus extending from the floor of the sinus to an external approach using the Caldwell-Luc procedure for
Case Reports in Otolaryngology 3
better visualization of the antrum. Toothpick was removed position and direction of the toothpick made us think that
with the help of a forceps. (Figures 2(a)2(f)) We checked it had been inserted through an oroantral fistula, which
oral cavity again for an oroantral fistula during surgery, but probably occurred secondary to a tooth extraction and
still there was no interruption in the oral mucosa which may healed after insertion of the toothpick without any surgical
suggest a fistula. intervention. This case points out once more that it is very
The patient was given antibiotics and topical deconges- important to recognize and fix an oroantral communication
tants for a week following surgery. The patient improved occurred during a dental procedure immediately to prevent
dramatically from the symptoms, and he was discharged the complications. Oroantral communications should be treated
day after surgery without any complications. At the 1-year by establishing a physical barrier between oral cavity and
followup, the patients physical examination and radiological maxillary sinus, and numerous surgical techniques have been
investigations were normal. introduced for repair, including rotating or advancing local
tissues such as the buccal or palatal mucosa, buccal fat pad,
3. Discussion submucosal tissue, or tongue tissue [9].
In conclusion, foreign bodies in the maxillary sinus
Foreign bodies in the maxillary sinus, whatever their origin, are rare issues, and oroantral fistulas, which are usually
are rare entities, but they are an integral part of the dieren- secondary to dental procedures, are the most common way of
tial diagnosis for rhinosinusitis, mainly when sinusitis occurs insertion. Whatever the foreign body is, it must be removed
unilaterally. It is dicult to estimate their frequency because to prevent chronic infections even if it is asymptomatic.
of the rarity of the entity, and because of the small numbers Endoscopic sinonasal surgery shall be the choice of treat-
of series published. Although the exact mechanism of how ment, since it is minimally invasive, but combined approach
foreign bodies cause sinusitis remains unknown, it has been with Caldwell-Luc procedure can also be used especially if
suggested that foreign bodies produce chronic physical and endoscopic approach is inadequate.
chemical irritation of the mucosa, leading to a degree of
ciliary insuciency and secondary infection [8].
Maxillary sinus foreign bodies usually have a dental
References
origin in relation to manipulation, or they may show up [1] W. Fokkens, V. Lund, and J. Mullol, European Position Paper
secondary to an oroantral fistula, as mentioned before. on Rhinosinusitis and Nasal polyps Group. European paper
Oroantral communications occur most frequently following on rhinosinusitis and nasal polyps 2007, Rhinology, vol. 20,
maxillary molar or premolar extraction. The surgeon should pp. 1136, 2007.
be extremely careful for inspecting oroantral communica- [2] B. K. Kapila and J. Lata, A rare foreign body impaction: a case
tions especially after maxillary molar and premolar tooth report, Quintessence International, vol. 29, no. 9, pp. 583584,
extraction or endodontic surgery performed on maxillary 1998.
teeth which may result in sinus perforation that may develop [3] A. A. P. Connolly and P. White, How I do it: transantral
into oroantral communication more than into oroantral endoscopic removal of maxillary sinus foreign body, Journal
fistula [9, 10]. In this case, probably the oroantral com- of Otolaryngology, vol. 24, no. 1, pp. 7374, 1995.
munication which developed after maxillary premolar tooth [4] P. N. Liston and R. F. Walters, Foreign bodies in the maxillary
extraction was very small, and the surgeon could not be able antrum: a case report, Australian Dental Journal, vol. 47, no.
to recognize it during surgery. Then, after the insertion of the 4, pp. 344346, 2002.
toothpick into the maxillary sinus willingly or accidentally, [5] M. M. Lima, C. A. Moreira, V. C. Da Silva, and M. R.
the communication is closed after a while with granulation De Freitas, 34 Self-inflicted foreign bodies in the maxillary
tissue which occurred due to chronic irritation of the sinus, Brazilian Journal of Otorhinolaryngology, vol. 74, no. 6,
p. 948, 2008.
toothpick.
Because foreign bodies can cause irritation of the mucosa [6] J. Punwutikorn, Clinically significant oroantral communica-
tionsa study of incidence and site, International Journal of
that can be concluded to sinusitis, the removal of all foreign
Oral and Maxillofacial Surgery, vol. 23, no. 1, pp. 1921, 1994.
bodies is generally recommended, even when they do not
[7] R. Haas, G. Watzak, M. Baron, G. Tepper, G. Mailath, and G.
produce symptoms [11]. A foreign body can be removed
Watzek, A preliminary study of monocortical bone grafts for
with dierent techniques depending on the size and location
oroantral fistula closure, Oral Surgery, Oral Medicine, Oral
of it. The most common technique is endoscopic sinonasal Pathology, Oral Radiology, and Endodontics, vol. 96, no. 3, pp.
surgery allowing the removal of most foreign bodies via a 263266, 2003.
wide endonasal meatotomy [12]. When extraction is not pos- [8] F. Pagella, E. Emanuelli, and P. Castelnuovo, Endoscopic
sible by the endonasal approach, it can be conducted through extraction of a metal foreign body from the maxillary sinus,
an external approach by oral antrostomy or a combined Laryngoscope, vol. 109, no. 2, pp. 339342, 1999.
approach of endonasal meatotomy and oral antrostomy [13]. [9] A. Scattarella, A. Ballini, F. R. Grassi et al., Treatment of
In this case, we used the combined technique because the size oroantral fistula with autologous bone graft and application
and position of the toothpick did not allow us to remove it of a non-reabsorbable membrane, International Journal of
from endonasal meatotomy. Medical Sciences, vol. 7, no. 5, pp. 267271, 2010.
This case is unusual and interesting for two reasons; [10] C. H. J. Hauman, N. P. Chandler, and D. C. Tong, Endodontic
first, the foreign body itself, a whole wooden toothpick, implications of the maxillary sinus: a review, International
is the first in the literature to our knowledge; second, the Endodontic Journal, vol. 35, no. 2, pp. 127141, 2002.
4 Case Reports in Otolaryngology
INFLAMMATION
BioMed
PPAR Research
Hindawi Publishing Corporation
Research International
Hindawi Publishing Corporation
http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014
Journal of
Obesity
Evidence-Based
Journal of Stem Cells Complementary and Journal of
Ophthalmology
Hindawi Publishing Corporation
International
Hindawi Publishing Corporation
Alternative Medicine
Hindawi Publishing Corporation Hindawi Publishing Corporation
Oncology
Hindawi Publishing Corporation
http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014
Parkinsons
Disease
Computational and
Mathematical Methods
in Medicine
Behavioural
Neurology
AIDS
Research and Treatment
Oxidative Medicine and
Cellular Longevity
Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation
http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014