ARTICLE IN PRESS
YBJOM-4252; No. of Pages 2
Available online at www.sciencedirect.com
British Journal of Oral and Maxillofacial Surgery xxx (2014) xxx–xxx
Short communication
Unilateral otitis media with effusion caused by retained surgical gauze as an unintended iatrogenic complication of orthognathic surgery: case report Chang Mook Park a , Kang Young Choi b , Sung Jae Heo a , Jung-Soo Kim a,∗ a b
Department of Otorhinolaryngology-Head and Neck Surgery Plastic and Reconstructive Surgery, School of Medicine, Kyungpook National University Hospital, Daegu, Korea
Received 14 November 2013; accepted 23 April 2014
Abstract Inadvertent retention of surgical gauze during an operation can have disastrous consequences for both the patient and the surgeon. Several cases have been reported, particularly after abdominal surgery. However, it has never to our knowledge been reported as a leading cause of dysfunction of the Eustachian tube after orthognathic surgery. We recently encountered a patient in whom it presented with unilateral otitis media with an effusion after orthognathic surgery. All surgeons involved with orthognathic surgery should be aware that remnants of surgical gauze after orthognathic surgery can compromise the Eustachian tube and cause otitis media with an effusion. © 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: Retained surgical gauze; Orthognathic surgery; Eustachian tube; Otitis media with effusion
Introduction Le Fort I osteotomy has been widely used since advancements in instrumentation and anaesthesia. However, it can be associated with considerable intraoperative bleeding because of the proximity of the site to the maxillary artery, its branches, and the pterygoid plexus. This bleeding is often controlled by packing the site with surgical gauze. Although cases involving retained remnants of gauze are rare, the number is lower than the actual number of cases because of the medicolegal implications. 1
∗ Corresponding author at: Department of Otorhinolaryngology-Head and Neck Surgery, Kyungpook National University, School of Medicine, Samduck-Dong 2ga, Jung-Gu, Daegu 700-712, Republic of Korea. Tel.: +82 53 420 5785; fax: +82 53 423 4524. E-mail addresses: [email protected], [email protected] (J.-S. Kim).
We present what is to our knowledge a previously unreported complication caused by retained surgical gauze during orthognathic surgery, which resulted in unilateral otitis media with an effusion after migration of the gauze to the pharyngeal opening of the Eustachian tube.
Case Report A 20-year-old woman presented with an 8-month history of unilateral fullness of the ear. She had already had 5 myringotomies at 2 local ENT clinics. Otoscopic examination showed a greyish effusion behind the left tympanic membrane, and nasopharyngeal endoscopic examination showed a foreign body resembling gauze in the opening of the left Eustachian tube (Fig. 1). When a more thorough history was taken we found that 8 months’ previously the patient had had an orthognathic operation
http://dx.doi.org/10.1016/j.bjoms.2014.04.014 0266-4356/© 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Park CM, et al. Unilateral otitis media with effusion caused by retained surgical gauze as an unintended iatrogenic complication of orthognathic surgery: case report. Br J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.bjoms.2014.04.014
YBJOM-4252; No. of Pages 2
2
ARTICLE IN PRESS C.M. Park et al. / British Journal of Oral and Maxillofacial Surgery xxx (2014) xxx–xxx
Discussion
Fig. 1. Nasopharyngeal endoscopy at presentation showed gauze-like material in the nasopharynx that seemed to originate from the left Eustachian tube. *=left torus tubarius.
Several cases of retained foreign body have been reported, particularly after abdominal surgery.1 However, those related to oromaxillofacial surgery, including orthognathic surgery, are extremely rare.2–4 According to one report, 5 the body responds to a foreign body by developing a fistula into a hollow viscus or, as in this case, the retained surgical gauze might partially migrate into the Eustachian tube. After we had investigated previous cases involving transmural migration of a foreign body we have come to the conclusion that this is the first report of a foreign body migrating into the Eustachian tube after orthognathic surgery. The MR images of foreign bodies characteristically show a row of dots within the mass, which results from the presence of air trapped between the synthetic fibres of the gauze.6 This can be helpful in differentiating a retained foreign body from other organic swellings. In adult patients who have unilateral otitis media with an effusion, a nasopharyngeal examination must be made to identify any extrinsic obstruction (such as a tumour) that may be compromising the ventilatory function of the Eustachian tube. Regrettably, the previous surgeon and local clinicians may have overlooked this. All surgeons who are involved with orthognathic surgery should be aware that a remnant of surgical gauze can compromise the Eustachian tube and cause otitis media with an effusion. According to the WHO surgical safety check list, constant vigilance during the operation, including taking an exact count of surgical gauzes, is essential to prevent the potentially disastrous consequences of a retained foreign body.
References
Fig. 2. Magnetic resonance scan (gadolinium-enhanced T1 weighted image) shows the retained foreign body with several black dots (small white arrow) indicating the presence of trapped air. The foreign body has migrated into the nasopharynx (large white arrow), corresponding to the endoscopic finding.
(including a Le Fort 1 osteotomy) for aesthetic reasons at a popular plastic surgery clinic. A magnetic resonance (MR) scan showed a 22 × 20 mm mass lesion that was consistent with a retained foreign body. The mass seemed to have migrated into the nasopharynx through the pharyngeal opening of the Eustachian tube (Fig. 2). She was treated by transnasal endoscopic removal of the foreign body under general anaesthesia. The retained surgical gauze was tightly adherent to the adjacent tissue, but was totally removed.
1. Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner MJ. Risk factors for retained instruments and sponges after surgery. N Engl J Med 2003;348:229–35. 2. Song SY, Hong JW, Yoo WM, Tark KC. Gossypiboma after mandibular contouring surgery. J Craniofac Surg 2009;20:1607–10. 3. Cho SW, Jin HR. Gossypiboma in the nasal septum after septorhinoplasty: a case study. J Oral Maxillofac Surg 2013;71:e42–4. 4. Sigron GR, Locher MC. A gossypiboma (foreign body granuloma) mimicking a residual odontogenic cyst in the mandible: a case report. J Med Case Rep 2011;28:211. 5. Sozutek A, Yormaz S, Kupeli H, Saban B. Transgastric migration of gossypiboma remedied with endoscopic removal: a case report. BMC Res Notes 2013;6:413. 6. Shiraev T, Bonar SF, Stalley P, Anderson SE. MRI “row of dots sign” in gossypiboma: an enlarging mass 8 months after sarcoma resection. Skeletal Radiol 2013;42:1017–9.
Please cite this article in press as: Park CM, et al. Unilateral otitis media with effusion caused by retained surgical gauze as an unintended iatrogenic complication of orthognathic surgery: case report. Br J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.bjoms.2014.04.014
YBJOM-4252; No. of Pages 2
Available online at www.sciencedirect.com
British Journal of Oral and Maxillofacial Surgery xxx (2014) xxx–xxx
Short communication
Unilateral otitis media with effusion caused by retained surgical gauze as an unintended iatrogenic complication of orthognathic surgery: case report Chang Mook Park a , Kang Young Choi b , Sung Jae Heo a , Jung-Soo Kim a,∗ a b
Department of Otorhinolaryngology-Head and Neck Surgery Plastic and Reconstructive Surgery, School of Medicine, Kyungpook National University Hospital, Daegu, Korea
Received 14 November 2013; accepted 23 April 2014
Abstract Inadvertent retention of surgical gauze during an operation can have disastrous consequences for both the patient and the surgeon. Several cases have been reported, particularly after abdominal surgery. However, it has never to our knowledge been reported as a leading cause of dysfunction of the Eustachian tube after orthognathic surgery. We recently encountered a patient in whom it presented with unilateral otitis media with an effusion after orthognathic surgery. All surgeons involved with orthognathic surgery should be aware that remnants of surgical gauze after orthognathic surgery can compromise the Eustachian tube and cause otitis media with an effusion. © 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: Retained surgical gauze; Orthognathic surgery; Eustachian tube; Otitis media with effusion
Introduction Le Fort I osteotomy has been widely used since advancements in instrumentation and anaesthesia. However, it can be associated with considerable intraoperative bleeding because of the proximity of the site to the maxillary artery, its branches, and the pterygoid plexus. This bleeding is often controlled by packing the site with surgical gauze. Although cases involving retained remnants of gauze are rare, the number is lower than the actual number of cases because of the medicolegal implications. 1
∗ Corresponding author at: Department of Otorhinolaryngology-Head and Neck Surgery, Kyungpook National University, School of Medicine, Samduck-Dong 2ga, Jung-Gu, Daegu 700-712, Republic of Korea. Tel.: +82 53 420 5785; fax: +82 53 423 4524. E-mail addresses: [email protected], [email protected] (J.-S. Kim).
We present what is to our knowledge a previously unreported complication caused by retained surgical gauze during orthognathic surgery, which resulted in unilateral otitis media with an effusion after migration of the gauze to the pharyngeal opening of the Eustachian tube.
Case Report A 20-year-old woman presented with an 8-month history of unilateral fullness of the ear. She had already had 5 myringotomies at 2 local ENT clinics. Otoscopic examination showed a greyish effusion behind the left tympanic membrane, and nasopharyngeal endoscopic examination showed a foreign body resembling gauze in the opening of the left Eustachian tube (Fig. 1). When a more thorough history was taken we found that 8 months’ previously the patient had had an orthognathic operation
http://dx.doi.org/10.1016/j.bjoms.2014.04.014 0266-4356/© 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Park CM, et al. Unilateral otitis media with effusion caused by retained surgical gauze as an unintended iatrogenic complication of orthognathic surgery: case report. Br J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.bjoms.2014.04.014
YBJOM-4252; No. of Pages 2
2
ARTICLE IN PRESS C.M. Park et al. / British Journal of Oral and Maxillofacial Surgery xxx (2014) xxx–xxx
Discussion
Fig. 1. Nasopharyngeal endoscopy at presentation showed gauze-like material in the nasopharynx that seemed to originate from the left Eustachian tube. *=left torus tubarius.
Several cases of retained foreign body have been reported, particularly after abdominal surgery.1 However, those related to oromaxillofacial surgery, including orthognathic surgery, are extremely rare.2–4 According to one report, 5 the body responds to a foreign body by developing a fistula into a hollow viscus or, as in this case, the retained surgical gauze might partially migrate into the Eustachian tube. After we had investigated previous cases involving transmural migration of a foreign body we have come to the conclusion that this is the first report of a foreign body migrating into the Eustachian tube after orthognathic surgery. The MR images of foreign bodies characteristically show a row of dots within the mass, which results from the presence of air trapped between the synthetic fibres of the gauze.6 This can be helpful in differentiating a retained foreign body from other organic swellings. In adult patients who have unilateral otitis media with an effusion, a nasopharyngeal examination must be made to identify any extrinsic obstruction (such as a tumour) that may be compromising the ventilatory function of the Eustachian tube. Regrettably, the previous surgeon and local clinicians may have overlooked this. All surgeons who are involved with orthognathic surgery should be aware that a remnant of surgical gauze can compromise the Eustachian tube and cause otitis media with an effusion. According to the WHO surgical safety check list, constant vigilance during the operation, including taking an exact count of surgical gauzes, is essential to prevent the potentially disastrous consequences of a retained foreign body.
References
Fig. 2. Magnetic resonance scan (gadolinium-enhanced T1 weighted image) shows the retained foreign body with several black dots (small white arrow) indicating the presence of trapped air. The foreign body has migrated into the nasopharynx (large white arrow), corresponding to the endoscopic finding.
(including a Le Fort 1 osteotomy) for aesthetic reasons at a popular plastic surgery clinic. A magnetic resonance (MR) scan showed a 22 × 20 mm mass lesion that was consistent with a retained foreign body. The mass seemed to have migrated into the nasopharynx through the pharyngeal opening of the Eustachian tube (Fig. 2). She was treated by transnasal endoscopic removal of the foreign body under general anaesthesia. The retained surgical gauze was tightly adherent to the adjacent tissue, but was totally removed.
1. Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner MJ. Risk factors for retained instruments and sponges after surgery. N Engl J Med 2003;348:229–35. 2. Song SY, Hong JW, Yoo WM, Tark KC. Gossypiboma after mandibular contouring surgery. J Craniofac Surg 2009;20:1607–10. 3. Cho SW, Jin HR. Gossypiboma in the nasal septum after septorhinoplasty: a case study. J Oral Maxillofac Surg 2013;71:e42–4. 4. Sigron GR, Locher MC. A gossypiboma (foreign body granuloma) mimicking a residual odontogenic cyst in the mandible: a case report. J Med Case Rep 2011;28:211. 5. Sozutek A, Yormaz S, Kupeli H, Saban B. Transgastric migration of gossypiboma remedied with endoscopic removal: a case report. BMC Res Notes 2013;6:413. 6. Shiraev T, Bonar SF, Stalley P, Anderson SE. MRI “row of dots sign” in gossypiboma: an enlarging mass 8 months after sarcoma resection. Skeletal Radiol 2013;42:1017–9.
Please cite this article in press as: Park CM, et al. Unilateral otitis media with effusion caused by retained surgical gauze as an unintended iatrogenic complication of orthognathic surgery: case report. Br J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.bjoms.2014.04.014
