Hong Kong Journal of Emergency Medicine
Retained gauze material in the nasal cavity after functional endoscopic
sinus surgery for ten years: a case report
A Dalgic, T Kandogan, H Gonullu, N Erkan
We report a case of retained packing gauze material in the right nasal cavity for ten years. A 55-year-old
woman presented to the emergency service with headache, nasal discharge, and epistaxis from the right nasal
cavity. Her past surgical history included a functional endoscopic sinus surgery because of nasal polyposis
10 years ago. In the endoscopic nasal examination, foreign body similar to nasal packing material about
5 cm in length was detected in the right anterior ethmoid sinus. CT of the paranasal sinuses showed only
loss of aeration in the right nasal cavity. The nasal packing material was removed under local anaesthesia on
the same day. Foreign body left behind after operation is a serious medicolegal issue and is often underreported. (Hong Kong j.emerg.med. 2010;17:502-505)
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Keywords: Emergencies, foreign bodies, operative surgical procedures
Introduction
Post-operative complications in surgery unfortunately
are not uncommon, often serious, and frequently
unavoidable. However, some complications result from
human error, both in the intra-operative and postoperative periods. One such complication, which is
Correspondence to:
Nazif Erkan, MD
Izmir Bozyaka Teaching and Research Hospital, Department of
Emergency Medicine, Bozyaka Izmir, Turkey
Email: [email protected]
Hayriye Gonullu, MD
Izmir Bozyaka Teaching and Research Hospital, Department of
Otolaryngology, Bozyaka Izmir, Turkey
Abdullah Dalgic, MD
Tolga Kandogan, MD
frequently underreported, is retained postoperative
foreign bodies, of which sponges are the most common.
It is a rare condition and due solely to human factors.1,2
Gossypiboma (also called textiloma or cottonoid) is a
term used to describe a mass in the body that is
composed of a cotton matrix surrounded by foreign
body reaction. Retained sponges were first referred to
as "textilomas", but were renamed "gossypiboma" in
1978.2,3 This originates from the Latin word gossypium,
meaning cotton, and the Swahili word boma, meaning
place of concealment.
Iatrogenic foreign bodies in the head and neck area
are very rare but unfortunately a few have been
reported after operations on the nose or sinuses. If
foreign bodies stay in the nose for a long period, they
can cause pain, nasal discharge or foul smell, blockage
of nasal air flow and epistaxis. 4,5 A foreign body left
Dalgic et al./Retained gauze material in the nasal cavity
503
behind after operation is a serious medicolegal issue
and often under-reported. 6,7 Since there are very few
reports describing retained surgical foreign bodies in
the head and neck region, we report a case of retained
packing gauze material in the right nasal cavity for ten
years.
body. Preventable medical and surgical errors
commonly result in malpractice litigation. Retained
surgical foreign bodies that are inadvertently left in
place often serve as the basis for such litigation. 8,9
A foreign body left behind after operation is a serious
medicolegal issue. The low report rate of foreign bodies
may be due to the fear of medicolegal repercussions.1
The medicolegal cost associated with a foreign body
left behind after operation can be significant, with a
per-occurrence cost to a hospital being between
$50,000 to $150,000 even if there is little harm to the
patient. 9,10 It is estimated that anywhere between
0.3 to 1.0 per 1000 surgical cases are associated with
retained surgical foreign body. 3 Surgical sponges
account for about 80% of retained foreign bodies, with
an estimated frequency of 1 case per 1000-5000
surgical procedures. 1-3,6 The abdominal cavity is the
most frequent site of sponge retention, although other
sites have been described, including the knee, sinus
cavities, breast, and spine.2,7,8
Case report
A 55-year-old woman presented with headache, nasal
discharge, and epistaxis from the right nasal cavity to
the emergency service in February 2009. Her past
surgical history included a functional endoscopic
sinus surgery for nasal polyposis 10 years ago. In the
endoscopic nasal examination, a foreign body similar
to nasal packing material about 5 cm in length was
detected in the right anterior ethmoid sinus (Figures
1a and 1b). CT of the paranasal sinuses showed only
loss of aeration in the right nasal cavity. The nasal
packing was removed under local anaesthesia on the
same day (Figure 2).
There are very few reports describing retained
surgical foreign bodies in the head and neck region.
Retained surgical foreign bodies have been reported
in approximately 0.9% of head and neck cases in one
large series describing classification and consequences
of errors in otolaryngology.11 Packing gauze used for
nasal surgery does not usually contain radiopaque
marker material; hence retained masses formed by the
gauze may be difficult to recognise on radiologic
studies.8,12
Discussion
Retained surgical foreign bodies continue to be a
serious problem that affects the entire healthcare
system − patients, practitioners, and hospitals.
Currently, there are no known methods of completely
preventing the occurrence of retained surgical foreign
(a)
(b)
Figure 1. Foreign body similar to nasal packing material, in the right anterior ethmoid sinus.
504
Figure 2. Nasal packing material, on removal.
The clinical presentation of foreign bodies left behind
after operation may be acute or delayed.7 While many
of them are identified and retrieved immediately or
shortly after surgical wound closure, some may go
unnoticed for years or even decades.4,5,13 It is estimated
that retained surgical foreign bodies occur most often
following abdominal procedures (52%), followed by
gynaecologic (22%), urologic and vascular (10%),
orthopaedic and spinal procedures (6%).7
Factors associated with greater risk of retained surgical
foreign body include: (a) emergency surgical procedure;
(b) unexpected change in the course of a surgical
procedure; and (c) increasing body mass index.1 Other
factors include: (a) complex and/or prolonged surgical
procedure; (b) procedure that involves more than one
body cavity; (c) involvement of more than one surgical
team; and (d) use of unusually large number of
instruments/instrument sets. 1 It has to be noted that
while emergency operations are implicated in 30% of
cases of retained surgical foreign bodies, approximately
70% of retained surgical foreign bodies are associated
with elective surgical procedures.7
The clinical presentation and the time interval between
the original operation and the diagnosis of gossypiboma
are variable and depend on the location and type of
reaction evoked. About a third of gossypiboma patients
Hong Kong j. emerg. med. „ Vol. 17(5) „ Nov 2010
remain asymptomatic, with the foreign body solely
detected radiographically, because cotton sponges do
not undergo any specific decomposition or biomedical
reaction. 6 Accordingly, diagnosis is difficult because
of less severe symptoms and delay in onset from the
previous surgery. Patients usually remain asymptomatic
and the gossypibomas are detected incidentally. On
the other hand, cotton sponge may lead to exudative
inflammatory reaction, with abscess or fistula
formation. This usually presents much earlier than
fibrinous reaction. 2,14 The resultant abscess and the
pressure exerted by the foreign body may lead to an
external opening, or this may force an opening into
an adjacent adherent hollow organ. During this erosion
process, which may take years, most patients are
symptomatic. Although surgical swabs have been
widely labelled with radio-opaque markers after the
1980s, which facilitates their detection, the diagnosis
of gossypiboma is not easy. 7,10 The markers may be
distorted by folding, twisting or disintegration over
time.
Given the fact that a significant proportion of retained
surgical foreign bodies go undetected despite
appropriate safety procedures being followed, it is
unlikely that any single method of retained surgical
foreign body prevention will become the 'magic
solution' for this multi-faceted problem. Instead, it
is most likely that a combination of various safety
procedures, in conjunction with numerous 'checks and
balances' at multiple levels within the healthcare
delivery system, will ultimately be most effective in
reducing the incidence of retained surgical foreign
bodies.
Conclusion
The discovery of a gossypiboma can lead to serious
consequences for the surgeon involved. This is usually
in terms of a potential medicolegal challenge, and
from criticism both publicly and within the medical
profession. Prevention of gossypiboma is far better than
cure. The best general approach to retained surgical
foreign body is to prevent their occurrence.
505
Dalgic et al./Retained gauze material in the nasal cavity
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