Highlights
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Chronic headaches may show a foreign body.
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Our objective was to bring attention to examine the patient post traffic accident well and follow up.
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Foreign bodies may go unnoticed.
Keywords: Case report, Metallic body, Ethmoid sinus, Foreign body, Transnasal endoscopy
Abstract
Introduction and importance
Ethmoid sinus foreign body is a rare condition. We describe an unusual case of an intra-ethmoid foreign body that was diagnosed late, we have reported this case to makeover fellow readers aware of the need to carefully examine the patient victim of a road traffic accident and the imaging performed.
Case presentation
A radio-opaque foreign body was detected at CT- scan of a 70- year-old man, who was the victim of a road traffic accident three years previously. The metallic foreign body was removed from the nasal cavity endoscopically without complications.
Discussion
The presence of foreign bodies in the paranasal sinuses is extremely rare, especially following a road traffic accident, and has a lower incidence compared to facial injuries. The Symptoms are vague, which Paranasal computed tomography is the examination of choice to locate the foreign body. The best ethmoidal sinus surgical approach is endoscopy.
Conclusion
It is important to make a diagnosis and include foreign objects with a recurrence of symptoms especially from an accident on a public road and early removal with extensive debridement results in minimal tissue destruction.
1. Introduction
Foreign bodies in different nature from the ENT cause severe damage, due to chronic irritation and infection [1] and the most frequently affected site is the nasal cavity [2].
This case report describes a case of retained foreign body in the ethmoid sinus, which was removed after 3 years despite the first physical examination post road traffic accident revealed especially by frontal headaches, however it ‘is therefore forgotten due to the medical inexperience or a doctor overwhelmed in an emergency. We have reported this case to makeover fellow readers aware of the need to carefully examine the patient victim of a road traffic accident and the imaging performed. This case report in line with the SCARE Criteria [3].
2. Case presentation
This was a 70-year-old male patient who presented with recurrent right unilateral anterior rhinorrhea, associated with intermittent ipsilateral nasal obstruction and frontal headache, progressing for over 2 years. History began three years ago following a road traffic accident. The patient consulted in our training 2 years later. Anterior rhinoscopy showed inflammatory pituitary mucosa without rhinorrhea. Paranasal computed tomography revealed a rounded hyperdense image in the right anterior ethmoid sinus without reaction filling of the ipsilateral frontal and ethmoid sinuses (Figs. 1 and 2 ).
Figs. 1 and 2.
Axial and Coronal CT scans of the bone window of the paranasal sinuses showing the location of a radiopaque foreign body in the right ethmoid sinus projected next to the frontonasal duct.
The location of the foreign body required an anterior ethmoidectomy was be performed under general anesthesia after achieving topical decongestion by inserting neurosurgical patties, soaked in 2 mL of 1:1000 adrenaline and the transnasal ethmoidectomy was performed by a qualified surgeon with 20 years of experience (Fig. 3 ).
Fig. 3.
An intraoperative endoscopic image of the metallic body after completion of the anterior ethmoidectomy.
The foreign body was disengaged from the ethmoid by identifying the frontonasal duct which was free of damage and pushing it further from the sinus kidney with surrounding mucosal resection without complications. It turned out to be a round metallic object (Fig. 4 ).
Fig. 4.
A Round metallic body was observed after its ablation.
The immediate postoperative period was uneventful.
the patient is discharged after 3 days with appropriate pain medications, oral steroids for 5 days, combined amoxicillin and clavulanic acid (1 g¤3/day) for 7 days, and instructions for nasal saline irrigations after having removed the packing on the third day after surgery.
A follow-up examination in the hospital via patient interview and physical examination at the first-week post-surgery and 4th week was without particularity insisting on nasal irrigation.
3. discussion
The presence of foreign bodies in the paranasal sinuses is extremely rare, especially following a road traffic accident, and has a lower incidence compared to facial injuries [4,5].
The most frequent location of foreign bodies in more than 50 % of cases is in the maxillary sinus [6].
Symptoms are vague and usually discovered after extracranial and intracranial complications or by occasional X-ray images [6].
In the patient of this case, the presence of the foreign body was manifested by intermittent frontal headaches and recurrent right purulent rhinorrhea very probably related to the obstruction of the frontonasal duct during an episode of cold or added inflammation.
Whose exact entry point and foreign body trajectory were unidentified due to the 3-year deferred consultation.
Paranasal computed tomography is the examination of choice to locate the foreign body, assess its relationships for possible extraction [4].
The paranasal computed tomography (CT) scan of our patient revealed an opaque foreign body in the ethmoid sinus related to the frontonasal duct, however, the ipsilateral frontal and maxillary sinuses were without abnormalities.
CT-scan plays an important role in assessing the foreign body to surrounding structures [7].
Although MRI has the advantage of not involving any radiation, it is advisable to be careful if there is concern that there is a magnetic component in the foreign body [8].
The best ethmoidal sinus surgical approach is endoscopy which is minimally invasive safe and causes fewer complications of which a large retrospective study of complications associated with functional endoscopic sinus surgery revealed an overall complication rate of 0.50 % [9].
For our part, we performed the extraction under general anesthesia, which is safer and more comfortable. The post-operation consequences after extraction of a foreign body are generally simple. Two-day wicking is usual, associated with eight-day nasal disinfection with or without postoperative antibiotic therapy [10].
4. Conclusion
A patient who presents for recurrent symptoms of the ENT Head and Neck Surgery (otorhinolaryngology) and in particular after a trauma of the public highway with point of craniofacial impact to maintain the suspicion of a foreign body and to explore it by carrying out a nasal sinus CT-scan.
Declaration of Competing Interest
The authors report no declarations of interest.
Sources of funding
We have any financial sources for our research.
Ethical approval
The study committee of the university hospital center approves the favorite opinion to publish this work.
Consent
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is a available for review by the Editor-in-Chief of this journal on request.
Author contribution
Dr. AB, Pr.AL,Pr.DB,Pr.AA, Pr.FE, analysed and performed the literature research and Pr. RG performed the examination and performed the scientific validation of the manuscript. Dr. Asmae Bazzout was the major contributors to the writing of the manuscript. All authors read and approved the manuscript.
Registration of research studies
Not applicable.
Guarantor
Dr. Asmae Bazzout.
Availability of data and material
The datasets in this article are available in the repository of the ENT database, Chu Mohamed VI Oujda, upon request, from the corresponding author.
Provenance and peer review
Not commissioned, externally peer-reviewed.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets in this article are available in the repository of the ENT database, Chu Mohamed VI Oujda, upon request, from the corresponding author.