British Journal of Oral Surgery (Ig75), 13, 73-77
MAXILLARY
ANTROLITH:
A CASE
REPORT
JAMESEVANS,M.B., B.D.S., F.D.S.R.C.S.l Dental School, University Hospital of Wales, Cardiff
Summary. A case of a maxillary antrolith containing fibres from a gauze antral pack is reported, and the features and aetiology of antrolithiasis are discussed. INTRODUCTION A MAXILLARY autrolith results from the complete or partial calcareous encrustation of an antral foreign body, which constitutes its central nidus (Bowerman, 1969). Endogenous niduses are the commoner and frequently are of dental origin, although blood or pus cells, or mucus are suggested where no other cause is found. Less commonly the nidus is exogenous being usually inhaled, e.g. paper (Lord, 194.4) and snuff (Dutta, 1973). Whereas over three hundred cases of rhinolithiasis are recorded (Abu-Jaudeh, 1951), there are only 17 recorded cases of antrolithiasis. Two of these have been in the nasal and antral cavities and are thus termed antrorhinoliths (Brown & Allen, 1957; Dutta, 1973). The usual clinical features are facial pain, nasal obstruction, and purulent or blood-stained nasal discharge. The discharge may be often of long standing, lasting for 30 years in one case (Cunningham et al., 1945). The autroliths vary in consistency and colour, from being hard to friable and soft, and from black to grey or brown (Karges et al., 1971). They consist of mineral salts, especially calcium phosphate and carbonate, organic matter and water. CASE REPORT A do-year-old male opera singer was referred by his dental practitioner giving a d-day history of severe pain in the left maxilla, and of intermittent pain there, with occasional foul tasting intra-oral discharge, for over IO years. Fourteen years previously he had had a fracture of his left zygomatic complex elevated and an antral pack inserted via an intra-oral approach. His past medical history was otherwise unremarkable. Examination revealed a generally healthy man with slight swelling of the left cheek. An oro-antral fistula was present in a linear scar high in the left buccal sulcus, and a hard, dark grey mass was visible and palpable through the fistula. Radiographs demonstrated generalised opacity of the left antrum, and the presence of radio-opaque bodies (Fig. I). Using local analgesia the oro-antral fistula was enlarged and two separate hard, dark grey bodies about 1.5 cm in diameter were removed (Fig. 2). The antrum was chronically infected. Ten weeks later, the fistula still being patent, the patient was admitted to hospital for its closure. Under general anaesthesia and through a buccal approach, the fistulous tract was excised, the antrum cleared of polyps, and an intra-nasal antrostomy was performed allowing post-operative saline irrigation and antral drainage. Difficulty was encountered in the advancement of the buccal flap because of the fibrous tissue which Received 3.1.75.
Accepted 20.1.75
1 Present address: Department of Oral and Maxillo-Facial Surgery, Carmiesburn Hospital, Bearsden, Glasgow. 73
74
BRITISH
JOURNAL OF ORAL SURGERY
FIG. I Radiographs showing an opaque antrum (A), and radio-opaque bodies in it (B).
FIG.
2
Encrusted bodies removed from the antrum. had resulted from the chronic inflammation in the area. The parotid duct was not visualised and was presumably traumatised, for post-operatively the patient developed a discharge of saliva from the nose on eating. The fistula healed by first intention and the nasal salivary discharge ceased spontaneously, only to recur 3 weeks later. It finally resolved following surgical exploration of the area 4 months later, and the patient remains symptom free.
DISCUSSION Of the 17 cases of antrolithiasis already recorded in the literature written in English, 14have been associated with antral infection and from the records of the remaining 3 such infection cannot be excluded. Five of these 17 had associated oro-antral fistulae, and in 6 a central nidus was found (4 of the I 7 were not examined
MAXILLARY
Photomicrograph
75
ANTROLITH
FIG. 3, A of the sectioned antroliths taken with plain light ( x
IO).
histologically) (Bowerman, 1969; Karges et al., 1971; Crist & Johnson, 1972; Dutta, 1973). In other organs, the renal tract and salivary glands for example, stasis, change in pH, and cellular remnants due to infection are said to initiate In the antrum however, infection and poor drainage are comstone formation. mon. Antral foreign bodies have been reported frequently especially in the presence of oro-antral fistulae (Killey at al., 1971) but although they are associated with chronic infection they only rarely become encrusted. It is probable, therefore, that in addition to a nidus and a long history of infection, other hitherto unexplained factors are necessary for antrolith formation. Examination of the antroliths in this case showed laminations of a finely granular amorphous material containing phosphate. At the very centre were wellpreserved birefringent fibres, almost certainly of cotton cellulose from the original antral pack (Fig. 3). The cotton fibres were probably trapped by the bony spicules associated with the fractured antral walls, or by the edges of the lateral bony antrostomy. Some difficulty in removing antral packs is not unusual, and such entrapment of fibres must be fairly common. The enclosure of the pack in polythene, or the use of an inflatable urinary catheter balloon (Jackson et al., 1956) would prevent this.
76
BRITISH JOURNAL OF ORAL SURGERY
FIG. 3, B Photomicrograph of the sectioned antroliths taken with polarised light showing the laminated structure and a birefringent fibre running vertically in the centre of the figure ( x IO).
Because of the long history of antral infection and intra-oral discharge, it is probable that the oro-antral fistula arose because of failure of the buccal wound to heal rather than by ulceration of the antrolith through the mucosa. The fistula probably lead to the chronic antritis which contributed towards the antrolithiasis. The failure of healing of the buccal wound may have been due to its position high up overlying the lateral bony antrostomy where it would have been unsupported after pack withdrawal (Hopkins, 1971). Had the incision been placed at the mucogingival reflection over bone, the edges would have been supported and less likely to invert, and the tract from mouth to antrum would have been longer and less liable to rapid epithelialisation, even if kept patent by the presence of the end of the pack. This case demonstrates some further hazards of antral packing, and emphasises the need for careful placing of the buccal incision. ACKNOWLEDGEMENTS I should like to thank Mr Russell Hopkins. Consultant Oral Surgeon, for his help in the preparation of this paper andfor permission to report the case; Dr D. M. Walker and Mr R. T.
MAXILLARY
ANTROLITH
77
Allison for the histopathological examination of the specimens; Mr R. Starr and his colleagues in the Audio Visual Aids Unit, and Mrs Diana Twamley for her secretarial assistance. REFERENCES ABU-JAUDEH, C. N. (1951). Laryngoscope, 61, 271. BOWERMAN, J. E. (1969). Journal of Laryngology and Otology, 83, 873. BROWN, C. J. (Jr) & ALLEN, R. E. (1957). ‘journal Oral Surgery, 15, 153. GRIST, F. R. & JOHNSON, R. L. (1972). Journal of Oral Surgery, 30, 694. CUNNINGHAM, A. T., LORD, 0. C., MANLEY, C. H. & POLSON,C. J. (1945).
of
Journal of Laryngology and Otology, 60, 253. DUTTA, A. (1973). Journal of Oral Surgery, 31, 876. HOPKINS, R. (1971). Annals of the Royal College of Surgeons of England, 49, 403. JACKSON,V. R., ABBEY, J. A. & GLANZ, S. (1956). JournaZ of OraZ Surgery, 14, 14. Km~;,gh;~ A., EVERSOLE,L. R. & POINDEXTER,B. J. (Jr) (1971). Journal of Oral Surgery, KILLE;, H. C., SEWARD, G. R. & KAY, L. W. (1971). An Outline of Oral Surgery, Part II, 1st Ed., p. 244. Bristol: Wright. LORD, 0. C. (1944). Journal of Laryngology and Otology, 59, 218.
MAXILLARY
ANTROLITH:
A CASE
REPORT
JAMESEVANS,M.B., B.D.S., F.D.S.R.C.S.l Dental School, University Hospital of Wales, Cardiff
Summary. A case of a maxillary antrolith containing fibres from a gauze antral pack is reported, and the features and aetiology of antrolithiasis are discussed. INTRODUCTION A MAXILLARY autrolith results from the complete or partial calcareous encrustation of an antral foreign body, which constitutes its central nidus (Bowerman, 1969). Endogenous niduses are the commoner and frequently are of dental origin, although blood or pus cells, or mucus are suggested where no other cause is found. Less commonly the nidus is exogenous being usually inhaled, e.g. paper (Lord, 194.4) and snuff (Dutta, 1973). Whereas over three hundred cases of rhinolithiasis are recorded (Abu-Jaudeh, 1951), there are only 17 recorded cases of antrolithiasis. Two of these have been in the nasal and antral cavities and are thus termed antrorhinoliths (Brown & Allen, 1957; Dutta, 1973). The usual clinical features are facial pain, nasal obstruction, and purulent or blood-stained nasal discharge. The discharge may be often of long standing, lasting for 30 years in one case (Cunningham et al., 1945). The autroliths vary in consistency and colour, from being hard to friable and soft, and from black to grey or brown (Karges et al., 1971). They consist of mineral salts, especially calcium phosphate and carbonate, organic matter and water. CASE REPORT A do-year-old male opera singer was referred by his dental practitioner giving a d-day history of severe pain in the left maxilla, and of intermittent pain there, with occasional foul tasting intra-oral discharge, for over IO years. Fourteen years previously he had had a fracture of his left zygomatic complex elevated and an antral pack inserted via an intra-oral approach. His past medical history was otherwise unremarkable. Examination revealed a generally healthy man with slight swelling of the left cheek. An oro-antral fistula was present in a linear scar high in the left buccal sulcus, and a hard, dark grey mass was visible and palpable through the fistula. Radiographs demonstrated generalised opacity of the left antrum, and the presence of radio-opaque bodies (Fig. I). Using local analgesia the oro-antral fistula was enlarged and two separate hard, dark grey bodies about 1.5 cm in diameter were removed (Fig. 2). The antrum was chronically infected. Ten weeks later, the fistula still being patent, the patient was admitted to hospital for its closure. Under general anaesthesia and through a buccal approach, the fistulous tract was excised, the antrum cleared of polyps, and an intra-nasal antrostomy was performed allowing post-operative saline irrigation and antral drainage. Difficulty was encountered in the advancement of the buccal flap because of the fibrous tissue which Received 3.1.75.
Accepted 20.1.75
1 Present address: Department of Oral and Maxillo-Facial Surgery, Carmiesburn Hospital, Bearsden, Glasgow. 73
74
BRITISH
JOURNAL OF ORAL SURGERY
FIG. I Radiographs showing an opaque antrum (A), and radio-opaque bodies in it (B).
FIG.
2
Encrusted bodies removed from the antrum. had resulted from the chronic inflammation in the area. The parotid duct was not visualised and was presumably traumatised, for post-operatively the patient developed a discharge of saliva from the nose on eating. The fistula healed by first intention and the nasal salivary discharge ceased spontaneously, only to recur 3 weeks later. It finally resolved following surgical exploration of the area 4 months later, and the patient remains symptom free.
DISCUSSION Of the 17 cases of antrolithiasis already recorded in the literature written in English, 14have been associated with antral infection and from the records of the remaining 3 such infection cannot be excluded. Five of these 17 had associated oro-antral fistulae, and in 6 a central nidus was found (4 of the I 7 were not examined
MAXILLARY
Photomicrograph
75
ANTROLITH
FIG. 3, A of the sectioned antroliths taken with plain light ( x
IO).
histologically) (Bowerman, 1969; Karges et al., 1971; Crist & Johnson, 1972; Dutta, 1973). In other organs, the renal tract and salivary glands for example, stasis, change in pH, and cellular remnants due to infection are said to initiate In the antrum however, infection and poor drainage are comstone formation. mon. Antral foreign bodies have been reported frequently especially in the presence of oro-antral fistulae (Killey at al., 1971) but although they are associated with chronic infection they only rarely become encrusted. It is probable, therefore, that in addition to a nidus and a long history of infection, other hitherto unexplained factors are necessary for antrolith formation. Examination of the antroliths in this case showed laminations of a finely granular amorphous material containing phosphate. At the very centre were wellpreserved birefringent fibres, almost certainly of cotton cellulose from the original antral pack (Fig. 3). The cotton fibres were probably trapped by the bony spicules associated with the fractured antral walls, or by the edges of the lateral bony antrostomy. Some difficulty in removing antral packs is not unusual, and such entrapment of fibres must be fairly common. The enclosure of the pack in polythene, or the use of an inflatable urinary catheter balloon (Jackson et al., 1956) would prevent this.
76
BRITISH JOURNAL OF ORAL SURGERY
FIG. 3, B Photomicrograph of the sectioned antroliths taken with polarised light showing the laminated structure and a birefringent fibre running vertically in the centre of the figure ( x IO).
Because of the long history of antral infection and intra-oral discharge, it is probable that the oro-antral fistula arose because of failure of the buccal wound to heal rather than by ulceration of the antrolith through the mucosa. The fistula probably lead to the chronic antritis which contributed towards the antrolithiasis. The failure of healing of the buccal wound may have been due to its position high up overlying the lateral bony antrostomy where it would have been unsupported after pack withdrawal (Hopkins, 1971). Had the incision been placed at the mucogingival reflection over bone, the edges would have been supported and less likely to invert, and the tract from mouth to antrum would have been longer and less liable to rapid epithelialisation, even if kept patent by the presence of the end of the pack. This case demonstrates some further hazards of antral packing, and emphasises the need for careful placing of the buccal incision. ACKNOWLEDGEMENTS I should like to thank Mr Russell Hopkins. Consultant Oral Surgeon, for his help in the preparation of this paper andfor permission to report the case; Dr D. M. Walker and Mr R. T.
MAXILLARY
ANTROLITH
77
Allison for the histopathological examination of the specimens; Mr R. Starr and his colleagues in the Audio Visual Aids Unit, and Mrs Diana Twamley for her secretarial assistance. REFERENCES ABU-JAUDEH, C. N. (1951). Laryngoscope, 61, 271. BOWERMAN, J. E. (1969). Journal of Laryngology and Otology, 83, 873. BROWN, C. J. (Jr) & ALLEN, R. E. (1957). ‘journal Oral Surgery, 15, 153. GRIST, F. R. & JOHNSON, R. L. (1972). Journal of Oral Surgery, 30, 694. CUNNINGHAM, A. T., LORD, 0. C., MANLEY, C. H. & POLSON,C. J. (1945).
of
Journal of Laryngology and Otology, 60, 253. DUTTA, A. (1973). Journal of Oral Surgery, 31, 876. HOPKINS, R. (1971). Annals of the Royal College of Surgeons of England, 49, 403. JACKSON,V. R., ABBEY, J. A. & GLANZ, S. (1956). JournaZ of OraZ Surgery, 14, 14. Km~;,gh;~ A., EVERSOLE,L. R. & POINDEXTER,B. J. (Jr) (1971). Journal of Oral Surgery, KILLE;, H. C., SEWARD, G. R. & KAY, L. W. (1971). An Outline of Oral Surgery, Part II, 1st Ed., p. 244. Bristol: Wright. LORD, 0. C. (1944). Journal of Laryngology and Otology, 59, 218.
