Endoscopic Extraction of a Metal Foreign Body From the Maxillary Sinus

Abstract

Metal foreign bodies are occasionally found in the sinuses. The literature reports cases in which the foreign body was of dental origin or the result of a war injury or accident.1-6 The problem has grown since the middle of the 1980s because of the development of techniques using osteointegrated implants to treat edentulousness; one of the complications of this form of treatment is the malpositioning of metal fixtures within the maxillary sinus. The classic surgical technique for their removal is the Cald-well-Luc procedure, which involves opening the anterior wall of the maxillary sinus. The development of diagnostic and surgical techniques using nasal and sinus endoscopy has provided a much less invasive method for direct visualization of the internal structure of the sinuses. The first endoscopically controlled removal of a foreign body from the maxillary sinus was reported as long ago as 1904 by Binder7; Imhoffer8 subsequently reported a similar case in 1910. Mladina has reported three cases of projectiles lodged in the ethmoidal and sphenoidal sinuses that were removed by means of endoscopic techniques.9 Connolly and White10 extracted a projectile from the maxillary sinus using endoscopically controlled inferior meatotomy. In this article we describe the removal of metal implant fixtures from the maxillary sinus by means of sinus endoscopy through the canine fossa. All patients underwent endoscopic sinus surgery via the canine fossa under local anesthesia. Topical anesthesia was used in all cases, in the form of a lidocaine and prilocaine cream applied to the oral vestibule between the superior canine and premolar teeth. Five minutes after the cream was applied, the maxillary periosteum was infiltrated with 3 mL of 3% mepivacaine ± adrenaline 1 in 200,000. The tip of the trocar was positioned superior and lateral to the root of the upper canine tooth (Fig. 1), and the trocar was rotated to penetrate the maxillary sinus. Sinus endoscopy was performed, using a rigid endoscope 4 mm in diameter, with an optical viewing angle of 30° and 70° to visualize all the sinus recesses. The foreign body was then visualized using an optical viewing angle of 0° to position the metal guide of the trocar in a direct line with the fixture (Fig. 2 A and B). The endoscope was then withdrawn and microsurgical biopsy forceps were introduced, keeping the metal guide in the same position. The foreign body was grasped, without visual control, and removed by extracting the forceps together with the cannula of the trocar (Fig. 3). Occasionally, this procedure had to be repeated because the grip was lost while the foreign body was passing through the opening in the bone. The mucosal incision in the oral vestibule has not required suturing in any of our cases. All patients were discharged 4 hours after the procedure, with antibiotic and anti-inflammatory cover for 2 to 4 days. Between December 1993 and July 1997 we treated seven patients (two women and five men) aged between 34 and 52 years (mean, 43.6 y), who presented with fixtures in the maxillary sinus. All the patients had been treated between 3 years and 1 month previously with osteointegrated implants for partial edentulousness of the upper jaw. The foreign body was located in the left maxillary sinus in three cases, and in the right maxillary sinus in four cases. Three patients complained of facial pain, unilateral nasal respiratory obstruction, and mucopurulent nasal discharge; one patient suffered from facial pain and cacosmia, one from frontal headache, and one from face pain. One patient was not suffering from any symptom (Table. I). Positioning of the trocar in the canine fossa. Five patients were referred to us by the dental staff after routine postimplantation radiographs revealed the fixtures free in the maxillary sinus; two patients came under our observation after the onset of rhinosinusal symptoms. In all cases, preliminary nasal endoscopy was performed first. Pour subjects presented with inflammation and obstruction of the ostiomeatal complex. In three of these cases there was a mucopurulent discharge in the area of the fontanellae, anterior to the torus tubarius; in four patients there was bulging of the area of the posterior fontanellae, while the aspect of the nasal cavity was found to be normal in three cases. None of the patients presented any structural abnormality of the ostiomeatal complex. Five patients already had an orthopantomogram when they came to see us; in two further cases we performed a computed tomography scan of the facial structure in axial, coronal, and sagittal projections, without contrast medium (Fig. 4). In all cases, the X-ray studies showed that there was a metal foreign body in the maxillary sinus. Follow-up was from 3 to 12 months. In all cases total remission of symptoms had been obtained by the first follow-up visit at 7 days. Subsequent follow-up endoscopy showed that the ostiomeatal complex was normal in all patients, with the middle meatus clearly patent and with no signs of inflammation. There was no residual scarring of the mucosa of the buccal sulcus. An X-ray study was not necessary owing to negative endoscopic examination and an absence of symptoms. No patients subsequently developed sinus disease. A. Fixture, inside the right maxillary sinus, surrounded by purulent secretions. B. Fixture situated inside the left maxillary sinus. Endoscopic view with 4-mm-diameter 30° fiberoptic endoscope. Trocar, cannula, and grasping forceps with foreign body. Foreign bodies in the paranasal sinuses must be removed surgically, even when they are asymptomatic. This treatment strategy was adopted because the foreign body may cause tissue reactions. The weight, size, and chemical composition of a metal foreign body that is present in the paranasal sinuses cause chronic irritation of the mucosa, leading to partial or complete ciliary insufficiency.11 Bjor-land12 has described three cases of sinusitis caused by dental material displaced inside the maxillary sinus, while Kobayashi13 has reported a fungal superinfection from a foreign body in the maxillary sinus. Birnmeyer has reported a case in which carcinoma of the maxillary sinus developed in a patient with a metal foreign body in the antrum for 48 years.14 Mladina believes that metal foreign bodies should always be removed from the paranasal sinuses in order to prevent the development of both physical and chemical chronic irritation, and subsequent malignant alteration.9 Besides the seven fixtures, with this technique we removed root-filling material (gutta-percha) and dental roots. The largest foreign body extracted was a dental root with a maximum cross-section of 6 mm. Before removing the foreign body, diagnostic endoscopy should be performed to evaluate the functional status of the ostiomeatal complex. In cases in which there are associated episodes of sinusitis, minor anatomical lesions compromising the functional status of the ostiomeatal complex should be excluded. Otherwise, any disorder of the ostiomeatal complex should be treated endoscopically when the foreign body is removed. If the structure of the ostiomeatal complex appears to be normal, it is possible to limit the procedure to endoscopic sinus surgery alone through the canine fossa. This has been the case in all the patients we have treated. The method is atraumatic, well tolerated by patients, and can usually be performed as an outpatient procedure. A minimum of local anesthetic is needed and the buccal sulcus does not require suturing, in contrast to the classical Caldwell-Luc approach. There is a further advantage in that all of the sinus recesses can be visualized using endoscopes with a viewing angle of 30° and 70° in combination with videorecording of the images. The approach via the canine fossa allows 360° movement of the trocar, a range of movement considerably larger than that obtained using a traditional approach through the inferior meatus, which considerably restricts motion, as it requires an oblique entry under the inferior turbinate. Computed tomography scan (axial, coronal, and sagittal views) showing a free metal foreign body in the left maxillary sinus. in the right maxillary sinus the superior margin of a fixture is visible embedded in the bone of the floor, with reactive mucosa thickening. This fixture was subsequently extracted by the dentist through oral procedure. Barcelona, Spain XLVII Temporal Bone Dissection Course: March 15–19, 1999 XLVIII Temporal Bone Dissection Course: June, 1999 XLIX Temporal Bone Dissection Course: November, 1999 XXVII Course on Dissection and Microsurgery of the Paranasal Sinus: November, 1999 Spaces are limited. In Spanish and English. For information contact the Garcia-Ibañez Otologic Institute, 91, Dr. Roux St., 08017 Barcelona, Spain. TEL: [phone]; FAX: [phone]