Endoscopic Extraction of a Foreign Body from the Maxillary Sinus

1. Natsuki Sugiura, MD1,2 2. Kentaro Ochi, MD1,2 3. Yasushi Komatsuzaki, MD1,2

1. 2.

Kanagawa City, Kanagawa, Japan 2Department of Otolaryngology, St Marianna University School of Medicine.
1

1. Reprint requests: Kentaro Ochi, MD, Department of Otolaryngology, St Marianna University Toyoko Hospital, 3-435, Kosugi-cho, Nakahara-ku, Kawasaki City, Japan 211-0063; e-mail, k2ochi@marianna-u.ac.jp. A foreign body in the maxillary sinus is a rare finding. Possible causes are injury or accident and dental procedures.1 Classically, the Caldwell-Luc procedure, which involves opening the anterior wall of the maxillary sinus, has been performed to extract the maxillary foreign body. Recent developments in diagnostic and surgical techniques using nasal and sinus endoscopy have provided much less invasive methods for visualization of the internal structure of the sinuses. We report the case of the foreign body of the maxillary sinus that was successfully extracted through the inferior meatal window under endoscopic observation via a small hole at the canine fossa.

CASE REPORT
A 33-year-old man presented to the outpatient clinic of the St Marianna University Toyoko Hospital with a 2- to 3-year history of an occasional heavy feeling on his left cheek. He had a history of dental treatment in his youth. Plain sinus films demonstrated a radiodense, loop-shaped foreign

Management of a maxillary sinus foreign body (dental bur).

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Abstract Metal foreign bodies are occasionally found in the paranasal sinuses. Often they result from the escape of material through an oroantral fistula or from trauma. Rarely, they occur as a complication of a dental procedure. A literature review revealed only four other reports of iatrogenic dental bur lodgment in the maxillary sinus, all of which are in the dental literature. Otolaryngologists, who might be required to deal with this complication, must be knowledgeable about its management. In this article we describe a patient who was referred to our otolaryngology department for management of a retained dental bur in the maxillary sinus. We also review two treatment options--an endoscopic and an open surgical approach--for the removal of sinus foreign bodies.

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Introduction Foreign bodies in the maxillary sinus are not common. (1) Causes include the escape of teeth and dental impression material through an oroantral fistula, penetrating trauma, and iatrogenic causes. (2) Because antral perforation is frequently associated with dental procedures involving apical surgery of the maxillary molar teeth, (3) these procedures often create a pathway for foreign bodies to enter the maxillary sinus. Fortunately, displaced dental instruments in the maxillary sinus are rare. A literature search revealed only two British (3,4) and two Japanese (5,6) published reports of dental burs displaced into the maxillary antrum; all four of these cases are published in the dental literature. Patients with this complication would likely be referred to an otolaryngologist for treatment. Therefore, it is important to be familiar with this complication and its management.

Case report A 28-year-old woman underwent the extraction of tooth 14 for a periapical abscess that was unresponsive to antibiotics. During the extraction procedure, the tooth roots were fractured. While a power dental tool was being used to extract the roots, the patient heard a snap, and it was noted that the dental tool broke. After the dentist failed to complete the tooth extraction, the patient was sent to the emergency room at Upstate Medical University for an otolaryngologic evaluation. Our examination revealed that the patient was anxious but otherwise healthy. Fractured tooth roots were visualized in tooth socket 14, but no obvious oroantral fistula was seen. No bleeding or discharge from the socket was noted. The patient had no sinus tenderness or nasal discharge. Anteroposterior and lateral radiographs of the sinuses (figure 1) revealed a foreign body in the left maxillary sinus. The patient was started on clindamycin and taken to the operating room, where we performed a left Caldwell-Luc procedure. No fistula was visible intraoperatively, but the foreign body, a dental bur, was found and removed from the left maxillary sinus (figure 2). The patient was discharged from the hospital the following day, and her tooth extraction--with closure of the oroantral fistula--was completed 2 days later at her dentist's office. She has recovered completely from both procedures. Discussion The natural history of foreign bodies in the paranasal sinuses is only anecdotal and is not truly known. (7) Reported sequelae include chronic sinusitis, cutaneous fistula, rhinolith formation, and chronic pain. (7) Likewise, metallic foreign bodies have been associated with malignancy, (8) and when the metal is lead, there is concern for an increased risk of lead poisoning, particularly in children. (7) For these reasons, removal of metallic foreign bodies is indicated. (9) The classical surgical technique for removal of foreign bodies in the maxillary sinus is the Caldwell-Luc procedure, (9) which involves opening the anterior wall of the maxillary sinus. Recently, technologic advances have made possible the use of an endoscopic approach for the removal of these foreign bodies. (1,7,9) Reported advantages of the endoscopic approach, when compared with the Caldwell-Luc procedure, include less invasiveness and decreased associated morbidity, decreased risk of tooth root injury, and the ability to fully visualize the sinus. (1,7,9) Despite these advantages, open approaches are better suited for the removal of larger objects or those located anteriorly in the sinus. (7) In our case, we chose the open approach because of the size of the retained dental bur. [FIGURE 1 OMITTED] Sinus foreign bodies are not common findings. When they are discovered, however, their removal is indicated. Often, otolaryngologists are called upon to remove them. Because foreign bodies in the paranasal sinuses vary in size and location, otolaryngologists must be familiar with the different approaches for properly removing them. [FIGURE 2 OMITTED] References (1.) Connolly AA, White P. How I do it: Transantral endoscopic removal of maxillary sinus foreign body. J Otolaryngol 1995;24(1):73-4.

(2.) Gupta AC, Murthy DE Putotu ML. Unusual type of foreign body in the maxillary sinus. J Laryngol Otol 1990;104(9):718-19. (3.) Donlon WC. Reamer in the maxillary antrum: A complication of periapical surgery. Oral Surg Oral Med Oral Pathol 1989;68(1): 122-3. (4.) Abe K, Beppu K, Shinohara M, Oka M. An iatrogenic foreign body (dental bur) in the maxillary antrum: A report of two cases. Br Dent J 1992;173(2):63-5. (5.) Murata H, Kida S, Miura K, et al. A foreign body in the maxillary sinus; report of three cases. Jpn J Oral Surg 1987;33:1024. (6.) Kanda T, Ono K, Mizuki H, et al. Two cases of a foreign body in the maxillary sinus. Jpn J Oral Surg 1983;29:1956-60. (7.) Brinson GM, Senior BA, Yarbrough WG. Endoscopic management of retained airgun projectiles in the paranasat sinuses. Otolaryngol Head Neck Surg 2004;130(1):25-30. (8.) Birnmeyer G. [On late sequelae of metallic foreign bodies in the region of the paranasal sinuses.] Z Laryngol Rhinol Otol 1963; 42:778-85. (9.) Pagella F, Emanuelli E, Castelnuovo E Endoscopic extraction of a metal foreign body from the maxillary sinus. Laryngoscope 1999; 109(2 Pt 1):339-42. Joseph L. Smith II, MD; Precha Emko, MD, FACS From ENT Associates of Chester County, Exton. Pennsylvania (Dr. Smith), and the Department of Otolaryngology and Communication Sciences, Upstate Medical University, Syracuse, New York (Dr. Emko). Reprint requests: Joseph L. Smith II, MD, ENT Associates of Chester County, 80 W. Welsh Pool Rd., Suite 103, Exton, PA 19341. Phone: (610) 363-2532; fax: (610) 363-0210; e-mail: jlsmithii@ yahoo.com