British Joumal of Plastic Surgery (Ig75),
AN UNUSUAL
28, 272-273
CAUSE
OF A PARANASAL
FISTULA
By ROBERT B. BERGMAN, M.D.
Department of Plastic and Reconstructive Surgery, Dtjkzigt Hospital, Erasmus University, Rotterdam, The Netherlands
A 35-YEAR-OLD woman complained of a nasal deformity which she attributed to an accident sustained when she was I year old. An E.N.T. surgeon, since deceased, had performed 2 operations to improve her nasal airways when she was aged 20 and 24. It was agreed that she would benefit from a rhinoplasty, but when she was admitted 4 months later a small sinus had developed just to the right of her nose (Fig. I). This had started as an abscess some days after her visit to the out-patient clinic and had continued to discharge pus ever since. The patient was otherwise well, had no further complaints and had never been seriously ill or admitted to hospital, except for her nose operations. When the sinus was probed the tip of the sound emerged beneath the irregular enlarged inferior concha. The cutaneous opening had sharp edges and the surrounding skin showed some induration. The regional lymph nodes were not enlarged and no obvious lesion could be found in the oropharyngeal cavity. Blood and urine analyses, a Mantoux-test and a cultured swab of the wound were unremarkable. Standard X-rays of the skull showed no abnormalities but tomograms revealed broadening of the right lateral nasal wall with changes suggestive of osteitis, enlargement of the inferior concha, opacity of the right maxillary antrum and thickening of its mucosa (Fig. 2). A sinogram provided no useful information and a dacryocystogram on the right side outlined a
FIG. 2.
Tomogram
FIG. I. The paranasal fistula. showing thickening of the right lateral nasal wall. 272
AN UNUSUAL
FIG. 3.
CAUSE OF A PARANASAL
FISTULA
273
Foreign body removed at operation.
normal looking lacrimal system. Biopsies of the nasal lining and enlarged concha showed signs of chronic inflammation but no suggestion of malignancy. The fistula was explored under general anaesthesia and a piece of glass-like material (Fig. 3) measuring 20 x 5 x 5 mm was removed. It appeared to be some sort of a nasal strut inserted during one of the previous operations. The fistula was excised, the wound closed in layers and an uneventful recovery followed. DISCUSSION
Preoperative diagnosis was prevented by 2 factors: Firstly, the patient was unaware of having had an implant inserted in her nose. Whether she had forgotten or was not informed about the implant is of less importance than the fact that none of the parties involved in the preoperative investigations considered the presence of foreign material. Synthetic materials are being used increasingly frequently in corrective and reconstructive surgery and it should be obligatory that their implantation be recorded in the patient’s notes and the patienr informed. Secondly, the synthetic material used was radiolucent. Maisels (1973) reviewed the literature on undiagnosed but trouble-causing radiolucent foreign bodies in the head. These were mostly plastic parts of motor cars and he and others have pleaded that plastic objects in cars liable to be driven into the tissues in an accident should be made radio-opaque. It is equally imperative that materials designed for implantation should have radio-opaque components which would show clearly on a routine X-ray. REFERENCES MAISELS,
D. 0. and PRIESTLAND, H. A. (1973). Plastic trismus-a problem. British Journal of Plastic Surgery, 26, 223.
28/4-s
difficult diagnostic
AN UNUSUAL
28, 272-273
CAUSE
OF A PARANASAL
FISTULA
By ROBERT B. BERGMAN, M.D.
Department of Plastic and Reconstructive Surgery, Dtjkzigt Hospital, Erasmus University, Rotterdam, The Netherlands
A 35-YEAR-OLD woman complained of a nasal deformity which she attributed to an accident sustained when she was I year old. An E.N.T. surgeon, since deceased, had performed 2 operations to improve her nasal airways when she was aged 20 and 24. It was agreed that she would benefit from a rhinoplasty, but when she was admitted 4 months later a small sinus had developed just to the right of her nose (Fig. I). This had started as an abscess some days after her visit to the out-patient clinic and had continued to discharge pus ever since. The patient was otherwise well, had no further complaints and had never been seriously ill or admitted to hospital, except for her nose operations. When the sinus was probed the tip of the sound emerged beneath the irregular enlarged inferior concha. The cutaneous opening had sharp edges and the surrounding skin showed some induration. The regional lymph nodes were not enlarged and no obvious lesion could be found in the oropharyngeal cavity. Blood and urine analyses, a Mantoux-test and a cultured swab of the wound were unremarkable. Standard X-rays of the skull showed no abnormalities but tomograms revealed broadening of the right lateral nasal wall with changes suggestive of osteitis, enlargement of the inferior concha, opacity of the right maxillary antrum and thickening of its mucosa (Fig. 2). A sinogram provided no useful information and a dacryocystogram on the right side outlined a
FIG. 2.
Tomogram
FIG. I. The paranasal fistula. showing thickening of the right lateral nasal wall. 272
AN UNUSUAL
FIG. 3.
CAUSE OF A PARANASAL
FISTULA
273
Foreign body removed at operation.
normal looking lacrimal system. Biopsies of the nasal lining and enlarged concha showed signs of chronic inflammation but no suggestion of malignancy. The fistula was explored under general anaesthesia and a piece of glass-like material (Fig. 3) measuring 20 x 5 x 5 mm was removed. It appeared to be some sort of a nasal strut inserted during one of the previous operations. The fistula was excised, the wound closed in layers and an uneventful recovery followed. DISCUSSION
Preoperative diagnosis was prevented by 2 factors: Firstly, the patient was unaware of having had an implant inserted in her nose. Whether she had forgotten or was not informed about the implant is of less importance than the fact that none of the parties involved in the preoperative investigations considered the presence of foreign material. Synthetic materials are being used increasingly frequently in corrective and reconstructive surgery and it should be obligatory that their implantation be recorded in the patient’s notes and the patienr informed. Secondly, the synthetic material used was radiolucent. Maisels (1973) reviewed the literature on undiagnosed but trouble-causing radiolucent foreign bodies in the head. These were mostly plastic parts of motor cars and he and others have pleaded that plastic objects in cars liable to be driven into the tissues in an accident should be made radio-opaque. It is equally imperative that materials designed for implantation should have radio-opaque components which would show clearly on a routine X-ray. REFERENCES MAISELS,
D. 0. and PRIESTLAND, H. A. (1973). Plastic trismus-a problem. British Journal of Plastic Surgery, 26, 223.
28/4-s
difficult diagnostic
