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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 12  |  Issue : 2  |  Page : 99-104

Unusual foreign body in the maxillary sinus following extraction of the maxillary molar


Department of Oral and Maxillofacial Surgery, Dr. R Ahmed Dental College and Hospital, Kolkata, West Bengal, India

Date of Submission27-Sep-2022
Date of Acceptance07-Oct-2022
Date of Web Publication19-Dec-2022

Correspondence Address:
Dr. Monideepa Mitra
Department of Oral and Maxillofacial Surgery, Dr. R Ahmed Dental College and Hospital, Kolkata - 700 014, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijohs.ijohs_25_22

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  Abstract 


Displacement of tooth root into the maxillary sinus and formation of oroantral communication is common complications during extraction of maxillary molars. Herein, we present a unique case of a patient who came with complaints of heaviness over the antrum area which was later found to be due to the presence of zinc oxide-eugenol restorative material in the sinus and was retrieved by direct exploration through existing communication.

Keywords: Dental extraction, foreign body, maxillary antrum, oroantral communication, oroantral fistula


How to cite this article:
Rana V, Mitra M, Chattopadhyay A, Chatterjee A. Unusual foreign body in the maxillary sinus following extraction of the maxillary molar. Int J Oral Health Sci 2022;12:99-104

How to cite this URL:
Rana V, Mitra M, Chattopadhyay A, Chatterjee A. Unusual foreign body in the maxillary sinus following extraction of the maxillary molar. Int J Oral Health Sci [serial online] 2022 [cited 2023 Feb 1];12:99-104. Available from: https://www.ijohsjournal.org/text.asp?2022/12/2/99/364222




  Introduction Top


Oroantral communication following extraction of maxillary molars could be purely iatrogenic or due to preexisting periapical pathology, osteomyelitis of the maxilla, malignancy involving the sinus, and extensive fractures of the facial region.

Presenting features for such patients can be nasal regurgitation, unilateral epistaxis, changes in vocal resonance, and pain over the involved region.

Cone-beam computed tomography scan should be carried out in all suspected cases as a part of the routine radiographic examination as it provides a better method of visualization in suspected oroantral communication as well as to localize foreign bodies in three dimensions in cases like the ones reported here.

Retrieval of the foreign body can be achieved by the Caldwell-Luc procedure, functional endoscopic sinus surgery, or by direct exploration through existing communication.


  Case Report Top


A 40-year-old male patient came to the oral and maxillofacial surgery outpatient department with a chief complaint of heaviness over the left cheek for the past 4 days. He had no history of nasal regurgitation, epistaxis, or change in vocal resonance.

Significant surgical history revealed the fact that he had undergone extraction of 26 at an outside center, 2 weeks back and the dentist had mentioned the formation of an oroantral communication, which was managed with a zinc oxide-eugenol pack.

On examination, an unhealed extraction socket with an oroantral fistula was found with respect to 26.

There was tenderness over the left maxillary antrum region.

On intraoral examination, an unhealed socket with an oroantral fistula was found with respect to 26 region [Figure 1]. A zinc oxide-eugenol pack could be seen placed in the socket without any gauze on exploration.
Figure 1: Preoperative photograph of the oroantral fistula

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Subsequent radiographic investigation with cone-beam computed tomography revealed the presence of a radiopaque foreign body present between the oral cavity and maxillary antrum and diffuse opacification of the antrum. There was evidence of generalized thickening of the mucosal lining [Figure 2].
Figure 2: Preoperative radiograph

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The patient was advised antibiotics with anaerobic coverage, steam inhalation with mucolytic agents, nasal decongestants, and anti-inflammatory medications on the first appointment.

The first phase of treatment was planned with antral lavage and debridement of the extraction socket.

On the subsequent appointment, it was found the foreign body had dislodged from its previous position. Cone-beam computed tomography of the same patient shows the radiopaque foreign body near the floor of the orbit [Figure 3].
Figure 3: Preoperative radiograph taken in between appointments

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For the next 7 days, antral lavage was done with normal saline through the existing oroantral fistula of about 1.5 cm in diameter.

The foreign body could now be visualized intraorally through the fistula [Figure 4].
Figure 4: Foreign body inside the oroantral fistula

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Antral lavage was repeated till clear fluid was obtained.

The infected mucosal lining was removed along with the foreign body [Figure 5] Debridement of all remaining infected tissues was carried out.
Figure 5: Zinc oxide-eugenol pack as retrieved from the maxillary sinus

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The foreign body could be identified as the zinc oxide-eugenol pack without any gauze that was placed in the oroantral communication by the dentist who attempted the extraction of the tooth.

The wound was primarily closed with a 3-0 silk suture and the patient was advised to follow-up after 7 days.

The patient was again advised antibiotics with anaerobic coverage, nasal decongestant, and steam inhalation for the management of his chief complaints.

Suture removal was done after 7 days. Areas of wound dehiscence were noted in the area that was primarily opposed [Figure 6].
Figure 6: Wound dehiscence following primary closure

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The patient had no presenting symptoms of nasal regurgitation, epistaxis, or tenderness.

All the remaining infected lining of the antrum was removed followed by copious irrigation and lavage with normal saline.

The second phase of the treatment was planned with definitive closure by the buccal pad of fat.

The area surrounding the fistula was anesthetized and all the remaining infected lining and granulation tissue were removed.

Alveolar bone height was reduced with bone rongeurs.

An incision was made posterior to the communication, above tooth 27 up to the depth of the buccal vestibule.

A vertical releasing incision was made in the mucosa posterior to the involved area in the area of the zygomatic buttress followed by a periosteal incision. Dissecting scissors and curved artery forceps were used to expose the buccal pad of fat and it was gently mobilized by nontoothed forceps. A buccal pad of fat was harvested [Figure 7].
Figure 7: Harvesting buccal pad of fat

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It was advanced along the bony defect and sutured in the palatal margin with 3-0 Vicryl [Figure 8].
Figure 8: Suturing of the buccal pad of fat

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The patient was prescribed antibiotics, antihistamines, anti-inflammatory, and nasal decongestants for 5 days. He was advised to do a warm saline mouth rinse and steam inhalation and follow-up after 7 days. All deleterious oral habits were advised to be discontinued immediately from the day of surgery.

Follow-up was done after 1 week, 3 weeks, 3 months and 6 months [Figure 9],[Figure 10],[Figure 11],[Figure 12] from the date of surgery and showed complete uneventful healing of the surgical site. The patient faced no complications during the entire period and has no presenting complaints on the day of follow-up.
Figure 9: Follow-up after 1 week

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Figure 10: Follow-up after 3 weeks

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Figure 11: Follow-up after 3 months

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Figure 12: Follow-up after 6 months showing complete healing of the surgical site

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  Discussion Top


“Maxillary sinus is the pneumatic space that is lodged inside the body of the maxilla and that communicates with the environment by the way of the middle meatus and nasal vestibule.”[1]

The maxillary sinus is the first of the paranasal sinuses to develop.[2] It starts as a shallow groove on the medial surface of the maxilla during the 4th month of intrauterine life.[2] It is pyramidal in shape and is the largest of the paranasal sinuses.[2]

The anterior wall of the maxillary sinus is formed by the facial surface of the maxilla.[3] The posterior wall is formed by the infratemporal surface of the maxilla.[3] It forms the anterior border of the pterygopalatine fossa. The superior wall is formed by the fragile, triangular orbit floor, with the infraorbital groove running through it.[3] Its medial wall separates the sinus from the nasal cavity.[3]

The creation of oroantral communication following the extraction of maxillary molars is a common complication of dental extraction procedures. The palatal root of the first maxillary molar is often involved in such cases.

If the communication is <2 mm in diameter, it does not need any intervention.

If it is 2–5 mm, only suturing and tight closure would suffice.[4]

In cases, like discussed here, where the communication is of more than 7 mm, we need to manage it by raising a soft-tissue flap. The soft tissue can be local or distant in origin.

Locally, it can be acquired buccally, palatally, or from the buccal pad of fat.

Distant origin soft tissue can be sourced from the tongue or temporalis.

Closure can be also done with a bone graft of autogenous or alloplastic origin.

In our case, we harvested it from the buccal pad of fat due to the favorable location and easy access.

The buccal fat pad is a mass of specialized fatty tissue called syssarcosis, a fat that enhances muscular motion.[4] It is distinct from the subcutaneous fat and shows marked similarity to the orbital fat.[4] It can easily cover small-to-medium-sized defects of about 4 cm in diameter.[4]

The presence of a foreign body in the antrum is not a rare situation. In most cases, they are of odontogenic origin. The gold standard treatment modality for their removal is the Caldwell-Luc procedure. In recent years, functional endoscopic sinus surgery has gained popularity because it is a minimally invasive technique that can be used for drainage and restoring sinus ventilation.

The peculiarity of this case lies in the fact that the foreign body recovered here was a pack of zinc oxide-eugenol restorative cement without gauze. It was incorrectly used to manage the oroantral communication created during the extraction, by the dentist consulted by the patient before reporting at our hospital. Its presence caused inflammation of the antrum causing pain and heaviness over the involved area.


  Conclusion Top


Oroantral communication immediately after extraction of maxillary posterior teeth can be encountered in our day-to-day practice. If the dentist places any sedative dressing, for example, zinc oxide eugenol, Bismuth Iodoform Paraffin pack, etc., it must be explained to the patient and mentioned in clinical notes to facilitate further definitive treatment at a different clinic or institute.[5]

Foreign bodies in the paranasal sinus should be removed even when they are asymptomatic to prevent tissue reaction and chronic irritation of mucosa, leading to a degree of ciliary insufficiency.

A case in which carcinoma of the maxillary sinus developed in a patient with a metal foreign body in the antrum for 48 years has been reported.[6],[7]

The choice of surgical approach depends on the location and size of the foreign body. In this case, the endoscopic approach was not feasible and access through oroantral under direct vision yielded excellent outcomes.

Consent

The patient's written and informed consent has been collected and preserved by the author(s).

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Wendler D. Nathanael Highmore (1613-1685) and the maxillary sinus. Anat Anz 1986;162:375-80.  Back to cited text no. 1
    
2.
Balaji SM, Balaji PP. Textbook of Oral & Maxillofacial Surgery. 3rd ed. India: Elsevier; 2018.  Back to cited text no. 2
    
3.
Standring S. Gray's Anatomy: The Anatomical Basis of Clinical Practice. 41st ed. London: Elsevier Health Sciences; 2015.  Back to cited text no. 3
    
4.
Bonanthaya K, Panneerselvam E, Manuel S, Kumar VV, Rai A. Oral and Maxillofacial Surgery for the Clinician. 1st edition, Springer Nature; 2021.  Back to cited text no. 4
    
5.
Dhiman NK, Jaiswara C, Kumar N, Verma V, Vishwakarma AK. Post extraction zinc oxide eugenol pack mimicking tooth like structure in oro- antral fistula. Indian J Res 2015:9;78-82.  Back to cited text no. 5
    
6.
Basturk FB, Turkaydin D, Aktop S, Ovecoglu HS. An iatrogenic foreign body in the maxillary sinus: Report of an unusual case. J Otolaryngol Rhinol 2019;5:054.  Back to cited text no. 6
    
7.
G Birnmeyer, “On late sequelae of metallic foreign bodies in the region of the paranasal sinuses” Zeitschrift fur Laryngologie, Rhinologie, Otologie und ihre Grenzgebiete 42, 778-785, 1963 PMID: 14108947  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]



 

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  Introduction
  Case Report
  Discussion
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