The Journal of Craniofacial Surgery
Correspondence
4. Choueiri T, Lichtin AE. Hereditary hemorrhagic telangiectasia, idiopathic thrombocytopenic purpura, and chronic lymphocytic leukemia treated with rituximab. Am J Med 2002;113:700Y701 5. Livandovski I, Listratov SI, Naumova GA. Rare case of association of Rendu-Osler disease with lymphocytic leukemia [in Russian]. Klin Med (Mosk) 1975;53:118Y119 6. Twomey JJ, Levin WC, Melnick MB, et al. Laboratory studies on a family with a father and son affected by acute leukemia. Blood 1967;29:920Y930
Reply: Endoscope-Assisted Versus Open Repair of Craniosynostosis: A Comparison of Perioperative Cost and Risk To the Editor: Chan et al1 have recently compared the 2 main surgical techniques in craniosynostosis retrospectively. Before all else, we all appreciate the authors for their long-term well-documented and excellent care. However, they did not state whether there is any secondary cranial vault correction. The criteria for comparison were age, operating room time, blood loss, transfused blood volume, length of hospitalization, and overall cost of treatments. Even though the results of Chan and colleagues are consistent and support the idea of decreased blood loss and shorter operative times/hospitalization length in previous studies,2Y4 the study was planned as a retrospective review, and demographic data did not seem equalized or were not homogeneous between compared techniques, that is, involvement of mixed or only sagittal suture or coronal suture and distribution of syndromic. Second, operating room time and volume of blood loss may be increased in syndromic cases versus nonsyndromic or in cases with the involvement of coronal suture only or mixed suture versus sagittal suture only when especially treated with open technique. In addition, we all agree with the statement of the authors about the importance of compliance of caregivers in postoperative helmet therapy. Kemalettin Yildiz, MD Department of Plastic, Reconstructive and Aesthetic Surgery Bezmialem Vakif University, Istanbul, Turkey [email protected]
& Volume 25, Number 2, March 2014
Medial Orbital Wall Fracture Caused by Forceful Nose Blowing To the Editor: A blowout fracture is caused by the application of traumatic force to the rim, globe, or soft tissues of the orbit. Blowout fractures are generally assumed to be accompanied by a sudden increase in intraorbital pressure.1 Among orbital fractures, isolated orbital floor fractures are most common (26.9%) followed by medial wall fractures (13.3%), and the average defect size of the orbital floor has been 14.7 17.7 mm, and that of the orbit medial wall was 18.3 12.8 mm.2 Orbital blowout fractures are typically caused by blunt trauma to the orbit during sports activities, fights, traffic accidents, and so on.3 Several cases of blowout fracture of the orbital floor caused by vigorous nose blowing have been reported.3Y8 For the medial orbital wall, however, only 1 case of barotraumatic blowout fracture has been reported.9 We report a case of fracture of the medial orbital wall caused by forceful nose blowing and discuss how much air pressure is sufficient causing the fracture of the medial orbital wall. A 35-year-old woman presented with sudden swelling of the left orbital region following forceful nose blowing. She had a feeling of leaking air onto her eye while blowing her nose. She could not open her left eye. On physical examination on the day of injury, she had swelling and tenderness in her left periorbital region and cheek (Fig. 1). A computed tomography (CT) scan revealed a blowout fracture of the medial wall of the right orbit with some herniation of the orbital soft tissue into the ethmoidal sinus and subcutaneous emphysema in the left eyelids and the cheek (Fig. 2). Entrapment of the medial rectus muscle was not evident in the CT images. A forced duction test was negative; the eyeball mobility was intact, and the fundus was normal. She was treated with oral antibiotics and nonsteroidal anti-inflammatory drug for 3 days. The edema of the periorbital area and cheek subsided in 14 days after the injury. She did not have diplopia or visual disturbance throughout this period. She was advised to avoid strong nose blowing, and her clinical course has been uneventful thereafter. In our previous article, we experienced a medial orbital wall fracture and pneumocephalus caused by a high-pressure air injection (compressed air jet) in the eyeball in a workshop.10 In the literature, the thickness of the medial orbital wall is thinner than the orbital floor.11Y13 In Duke-Elder and Wybar’s11 textbook and Wolff’s12 anatomy, it was stated that the orbital floor is 0.5 to 1.0 mm thick,
Halil Ibrahim Canter, MD Department of Plastic, Reconstructive and Aesthetic Surgery Acibadem University, Istanbul, Turkey Meliha Gundag Papaker, MD Department of Neurosurgery, Bezmialem Vakif University Istanbul, Turkey
REFERENCES 1. Chan JWH, Stewart CL, Stalder MW, et al. Endoscope-assisted versus open repair of craniosynostosis: a comparison of perioperative cost and risk. J Craniofac Surg 2013;24:170 Y174 2. Murad GJ, Clayman M, Seagle MB, et al. Endoscopic-assisted repair of craniosynostosis. Neurosurg Focus 2005;19:E6 3. Keshavarzi S, Hayden MG, Ben Haim S, et al. Variations of endoscopic and open repair of metopic craniosynostosis. J Craniofac Surg 2009;20:1439, 1444 4. Cohen SR, Holmes RE, Ozgur BM, et al. Fronto-orbital and cranial osteotomies with resorbable fixation using and endoscopic approach. Clin Plast Surg 2004;31:429, 442
720
FIGURE 1. Schema of a 35-year-old woman. Following forceful nose blowing, she had swelling and tenderness in the left periorbital region and cheek.
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 2, March 2014
Correspondence
ACKNOWLEDGMENT The authors thank Kwan Hyun Youn, PhD (medart@ medart.co.kr), medical illustrator, for his drawing. REFERENCES
FIGURE 2. Computed tomography scan of the patient. Left, Axial view. Blowout fracture of the medial wall of the right orbit with some herniation of the orbital soft tissue into the ethmoidal sinus. Right, Coronal view: fracture of the medial wall and subcutaneous emphysema in the left eyelids and the cheek.
whereas Jones and Evans13 described the thickness of the orbital floor ranges from 0.23 to 1.25 mm according to the region. For the medial orbital wall, Wolff’s anatomy wrote the medial wall is 0.2 to 0.4 mm thick, whereas Jones measured and described it being 0.26 to 0.28 mm.11Y13 The question in our case was whether the elevation of the paranasal sinus (ethmoidal or maxillary) pressure is sufficient to cause the blowout fracture. Several experiments have provided different results for the assessment of the pressure needed to cause blowout fractures. Green et al14 demonstrated that a consistent force 2.08 J is necessary to fracture the orbital floor in monkeys. Bullock et al15 measured the force by dropping a metal rod onto the ‘‘removed’’ orbital floors from human cadavers and stated the energy required to cause an orbital floor blowout fracture was 78 mJ (range, 29Y127 mJ). Rhee et al16 tested the hydraulic theory by impacting fresh, unfixed cadaver heads with a pendulum apparatus made of a 1-kg iron cylinder measuring 2.5 cm in diameter, and a fracture threshold was found at a drop height of 0.3 m (2940 mJ). Ahmad et al17 measured the strain of the orbital floor with strain gauges and wrote that the energy required to fracture the orbital floor was 1.22 J and 1.54 J with a hydraulic mechanism and buckling mechanism, respectively. The energy required to cause a blowout fracture varies according to their methods, yet remains within certain ranges in the experiments using the en bloc orbit (1.2 J by Ahmad et al, 2.08 J by Green et al, 2.94 J by Rhee et al). We think that the reason of the extraordinary low energy (78 mJ; range, 29Y127 mJ by Bullock et al) to cause an orbital floor blowout fracture is that they used the ‘‘inferior orbit specimen’’ denuded and removed from the skull. For the volume of the paranasal sinuses, Emirzeoglu et al18 measured the volume of the maxillary and ethmoidal sinus using CT images. The volume of the maxillary sinus was 19.8 T 6.3 mL in males and 16.0 T 5.0 mL in females. The volume of the ethmoidal sinus was 6.3 T 1.6 mL in males and 5.5 T 1.5 mL in females.18 Clement and Chovanova19 measured the pressures generated during nose blowing by rhinomanometry. They found that in the control group the mean amount of pressure generated was 204.444 T 118.928 daPa during left-sided nose blowing and 195.000 T 90.894 daPa during rightsided nose blowing with 1 nostril open without decongestion. If both nostrils were closed and without decongestion, the pressure generated were 620.000 T 208.891 daPa during left-sided nose blowing and 533.333 T 183.143 daPa during right-sided nose blowing.19 We think that nose blowing can exert sufficient pressure to induce orbital blowout fracture. Kun Hwang, MD, PhD Han Joon Kim, MD Department of Plastic Surgery Inha University School of Medicine Incheon, Korea [email protected]
1. Rodriguez ED, Dorafshar AH, Manson PN. Ch. 3. Facial fractures. In: Neligan PC, ed. Plastic Surgery. 3rd ed. Vol. 3, London: Elsevier, 2013:53Y54 2. Hwang K, You SH, Sohn IA. Analysis of orbital bone fractures: a 12-year study of 391 patients. J Craniofac Surg 2009;20:1218Y1223 3. Watanabe T, Kawano T, Kodama S, et al. Orbital blowout fracture caused by nose blowing. Ear Nose Throat J 2012;91:24Y25 4. Oluwole M, White P. Orbital floor fracture following nose blowing. Ear Nose Throat J 1996;75:169Y170 5. Garcı´a de Marcos JA, del CastilloYPardo de Vera JL, Caldero´n-Polanco J. Orbital floor fracture and emphysema after nose blowing. Oral Maxillofac Surg 2008;12:163Y165 6. Rahmel BB, Scott CR, Lynham AJ. Comminuted orbital blowout fracture after vigorous nose blowing that required repair. Br J Oral Maxillofac Surg 2010;48:e21Ye22 7. Oba E, Pamukcu C, Erdeno¨z S. Traumatic orbital emphysema: a case report. Ulus Travma Acil Cerrahi Derg. 2011;17:570Y572 8. Halpenny D, Corbally C, Torreggiani W. Blowout fracture of the orbital floor secondary to vigorous nose blowing. Ir Med J 2012;105:245Y246 9. Suzuki H, Furukawa M, Takahashi E, et al. Barotraumatic blowout fracture of the orbit. Auris Nasus Larynx 2001;28:257Y259 10. Hwang K, Kim DH, Lee HS. Orbital fracture due to high-pressure air injection. J Craniofac Surg 2011;22:1506Y1507 11. Duke-Elder S, Wybar KC. System of Ophthalmology. Vol. II. The Anatomy of the Visual System. St Louis, MO: CV Mosby, 1961:407Y408 12. Bron AJ, Tripathi RC, Tripathi BJ. Wolff’s Anatomy of the Eye and Orbit. 8th ed. London, UK: Arnold, 1998:6Y8 13. Jones DE, Evans JN. ‘‘Blow-out’’ fractures of the orbit: an investigation into their anatomical basis. J Laryngol Otol 1967;81:1109Y1120 14. Green RP Jr, Peters DR, Shore JW, et al. Force necessary to fracture the orbital floor. Ophthal Plast Reconstr Surg 1990;6:211Y217 15. Bullock JD, Warwar RE, Ballal DR, et al. Mechanisms of orbital floor fractures: a clinical, experimental, and theoretical study. Trans Am Ophthalmol Soc 1999;97:87Y110; discussion 110Y113 16. Rhee JS, Kilde J, Yoganadan N, et al. Orbital blowout fractures: experimental evidence for the pure hydraulic theory. Arch Facial Plast Surg 2002;4:98Y101 17. Ahmad F, Kirkpatrick NA, Lyne J, et al. Buckling and hydraulic mechanisms in orbital blowout fractures: fact or fiction? J Craniofac Surg 2006;17:438Y441 18. Emirzeoglu M, Sahin B, Bilgic S, et al. Volumetric evaluation of the paranasal sinuses in normal subjects using computer tomography images: a stereological study. Auris Nasus Larynx 2007;34:191Y195 19. Clement P, Chovanova H. Pressures generated during nose blowing in patients with nasal complaints and normal test subjects. Rhinology 2003;41:152Y158
Forgotten Foreign Object in the Neck: A Neck Surgery Complication To the Editor: Surgical sponges are foreign objects frequently used during operations to control bleeding. Sponges soaked with blood can be hard to distinguish from normal tissue and are thus sometimes forgotten. Gossypiboma is a technical term used to refer to the
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
721
Correspondence
4. Choueiri T, Lichtin AE. Hereditary hemorrhagic telangiectasia, idiopathic thrombocytopenic purpura, and chronic lymphocytic leukemia treated with rituximab. Am J Med 2002;113:700Y701 5. Livandovski I, Listratov SI, Naumova GA. Rare case of association of Rendu-Osler disease with lymphocytic leukemia [in Russian]. Klin Med (Mosk) 1975;53:118Y119 6. Twomey JJ, Levin WC, Melnick MB, et al. Laboratory studies on a family with a father and son affected by acute leukemia. Blood 1967;29:920Y930
Reply: Endoscope-Assisted Versus Open Repair of Craniosynostosis: A Comparison of Perioperative Cost and Risk To the Editor: Chan et al1 have recently compared the 2 main surgical techniques in craniosynostosis retrospectively. Before all else, we all appreciate the authors for their long-term well-documented and excellent care. However, they did not state whether there is any secondary cranial vault correction. The criteria for comparison were age, operating room time, blood loss, transfused blood volume, length of hospitalization, and overall cost of treatments. Even though the results of Chan and colleagues are consistent and support the idea of decreased blood loss and shorter operative times/hospitalization length in previous studies,2Y4 the study was planned as a retrospective review, and demographic data did not seem equalized or were not homogeneous between compared techniques, that is, involvement of mixed or only sagittal suture or coronal suture and distribution of syndromic. Second, operating room time and volume of blood loss may be increased in syndromic cases versus nonsyndromic or in cases with the involvement of coronal suture only or mixed suture versus sagittal suture only when especially treated with open technique. In addition, we all agree with the statement of the authors about the importance of compliance of caregivers in postoperative helmet therapy. Kemalettin Yildiz, MD Department of Plastic, Reconstructive and Aesthetic Surgery Bezmialem Vakif University, Istanbul, Turkey [email protected]
& Volume 25, Number 2, March 2014
Medial Orbital Wall Fracture Caused by Forceful Nose Blowing To the Editor: A blowout fracture is caused by the application of traumatic force to the rim, globe, or soft tissues of the orbit. Blowout fractures are generally assumed to be accompanied by a sudden increase in intraorbital pressure.1 Among orbital fractures, isolated orbital floor fractures are most common (26.9%) followed by medial wall fractures (13.3%), and the average defect size of the orbital floor has been 14.7 17.7 mm, and that of the orbit medial wall was 18.3 12.8 mm.2 Orbital blowout fractures are typically caused by blunt trauma to the orbit during sports activities, fights, traffic accidents, and so on.3 Several cases of blowout fracture of the orbital floor caused by vigorous nose blowing have been reported.3Y8 For the medial orbital wall, however, only 1 case of barotraumatic blowout fracture has been reported.9 We report a case of fracture of the medial orbital wall caused by forceful nose blowing and discuss how much air pressure is sufficient causing the fracture of the medial orbital wall. A 35-year-old woman presented with sudden swelling of the left orbital region following forceful nose blowing. She had a feeling of leaking air onto her eye while blowing her nose. She could not open her left eye. On physical examination on the day of injury, she had swelling and tenderness in her left periorbital region and cheek (Fig. 1). A computed tomography (CT) scan revealed a blowout fracture of the medial wall of the right orbit with some herniation of the orbital soft tissue into the ethmoidal sinus and subcutaneous emphysema in the left eyelids and the cheek (Fig. 2). Entrapment of the medial rectus muscle was not evident in the CT images. A forced duction test was negative; the eyeball mobility was intact, and the fundus was normal. She was treated with oral antibiotics and nonsteroidal anti-inflammatory drug for 3 days. The edema of the periorbital area and cheek subsided in 14 days after the injury. She did not have diplopia or visual disturbance throughout this period. She was advised to avoid strong nose blowing, and her clinical course has been uneventful thereafter. In our previous article, we experienced a medial orbital wall fracture and pneumocephalus caused by a high-pressure air injection (compressed air jet) in the eyeball in a workshop.10 In the literature, the thickness of the medial orbital wall is thinner than the orbital floor.11Y13 In Duke-Elder and Wybar’s11 textbook and Wolff’s12 anatomy, it was stated that the orbital floor is 0.5 to 1.0 mm thick,
Halil Ibrahim Canter, MD Department of Plastic, Reconstructive and Aesthetic Surgery Acibadem University, Istanbul, Turkey Meliha Gundag Papaker, MD Department of Neurosurgery, Bezmialem Vakif University Istanbul, Turkey
REFERENCES 1. Chan JWH, Stewart CL, Stalder MW, et al. Endoscope-assisted versus open repair of craniosynostosis: a comparison of perioperative cost and risk. J Craniofac Surg 2013;24:170 Y174 2. Murad GJ, Clayman M, Seagle MB, et al. Endoscopic-assisted repair of craniosynostosis. Neurosurg Focus 2005;19:E6 3. Keshavarzi S, Hayden MG, Ben Haim S, et al. Variations of endoscopic and open repair of metopic craniosynostosis. J Craniofac Surg 2009;20:1439, 1444 4. Cohen SR, Holmes RE, Ozgur BM, et al. Fronto-orbital and cranial osteotomies with resorbable fixation using and endoscopic approach. Clin Plast Surg 2004;31:429, 442
720
FIGURE 1. Schema of a 35-year-old woman. Following forceful nose blowing, she had swelling and tenderness in the left periorbital region and cheek.
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 2, March 2014
Correspondence
ACKNOWLEDGMENT The authors thank Kwan Hyun Youn, PhD (medart@ medart.co.kr), medical illustrator, for his drawing. REFERENCES
FIGURE 2. Computed tomography scan of the patient. Left, Axial view. Blowout fracture of the medial wall of the right orbit with some herniation of the orbital soft tissue into the ethmoidal sinus. Right, Coronal view: fracture of the medial wall and subcutaneous emphysema in the left eyelids and the cheek.
whereas Jones and Evans13 described the thickness of the orbital floor ranges from 0.23 to 1.25 mm according to the region. For the medial orbital wall, Wolff’s anatomy wrote the medial wall is 0.2 to 0.4 mm thick, whereas Jones measured and described it being 0.26 to 0.28 mm.11Y13 The question in our case was whether the elevation of the paranasal sinus (ethmoidal or maxillary) pressure is sufficient to cause the blowout fracture. Several experiments have provided different results for the assessment of the pressure needed to cause blowout fractures. Green et al14 demonstrated that a consistent force 2.08 J is necessary to fracture the orbital floor in monkeys. Bullock et al15 measured the force by dropping a metal rod onto the ‘‘removed’’ orbital floors from human cadavers and stated the energy required to cause an orbital floor blowout fracture was 78 mJ (range, 29Y127 mJ). Rhee et al16 tested the hydraulic theory by impacting fresh, unfixed cadaver heads with a pendulum apparatus made of a 1-kg iron cylinder measuring 2.5 cm in diameter, and a fracture threshold was found at a drop height of 0.3 m (2940 mJ). Ahmad et al17 measured the strain of the orbital floor with strain gauges and wrote that the energy required to fracture the orbital floor was 1.22 J and 1.54 J with a hydraulic mechanism and buckling mechanism, respectively. The energy required to cause a blowout fracture varies according to their methods, yet remains within certain ranges in the experiments using the en bloc orbit (1.2 J by Ahmad et al, 2.08 J by Green et al, 2.94 J by Rhee et al). We think that the reason of the extraordinary low energy (78 mJ; range, 29Y127 mJ by Bullock et al) to cause an orbital floor blowout fracture is that they used the ‘‘inferior orbit specimen’’ denuded and removed from the skull. For the volume of the paranasal sinuses, Emirzeoglu et al18 measured the volume of the maxillary and ethmoidal sinus using CT images. The volume of the maxillary sinus was 19.8 T 6.3 mL in males and 16.0 T 5.0 mL in females. The volume of the ethmoidal sinus was 6.3 T 1.6 mL in males and 5.5 T 1.5 mL in females.18 Clement and Chovanova19 measured the pressures generated during nose blowing by rhinomanometry. They found that in the control group the mean amount of pressure generated was 204.444 T 118.928 daPa during left-sided nose blowing and 195.000 T 90.894 daPa during rightsided nose blowing with 1 nostril open without decongestion. If both nostrils were closed and without decongestion, the pressure generated were 620.000 T 208.891 daPa during left-sided nose blowing and 533.333 T 183.143 daPa during right-sided nose blowing.19 We think that nose blowing can exert sufficient pressure to induce orbital blowout fracture. Kun Hwang, MD, PhD Han Joon Kim, MD Department of Plastic Surgery Inha University School of Medicine Incheon, Korea [email protected]
1. Rodriguez ED, Dorafshar AH, Manson PN. Ch. 3. Facial fractures. In: Neligan PC, ed. Plastic Surgery. 3rd ed. Vol. 3, London: Elsevier, 2013:53Y54 2. Hwang K, You SH, Sohn IA. Analysis of orbital bone fractures: a 12-year study of 391 patients. J Craniofac Surg 2009;20:1218Y1223 3. Watanabe T, Kawano T, Kodama S, et al. Orbital blowout fracture caused by nose blowing. Ear Nose Throat J 2012;91:24Y25 4. Oluwole M, White P. Orbital floor fracture following nose blowing. Ear Nose Throat J 1996;75:169Y170 5. Garcı´a de Marcos JA, del CastilloYPardo de Vera JL, Caldero´n-Polanco J. Orbital floor fracture and emphysema after nose blowing. Oral Maxillofac Surg 2008;12:163Y165 6. Rahmel BB, Scott CR, Lynham AJ. Comminuted orbital blowout fracture after vigorous nose blowing that required repair. Br J Oral Maxillofac Surg 2010;48:e21Ye22 7. Oba E, Pamukcu C, Erdeno¨z S. Traumatic orbital emphysema: a case report. Ulus Travma Acil Cerrahi Derg. 2011;17:570Y572 8. Halpenny D, Corbally C, Torreggiani W. Blowout fracture of the orbital floor secondary to vigorous nose blowing. Ir Med J 2012;105:245Y246 9. Suzuki H, Furukawa M, Takahashi E, et al. Barotraumatic blowout fracture of the orbit. Auris Nasus Larynx 2001;28:257Y259 10. Hwang K, Kim DH, Lee HS. Orbital fracture due to high-pressure air injection. J Craniofac Surg 2011;22:1506Y1507 11. Duke-Elder S, Wybar KC. System of Ophthalmology. Vol. II. The Anatomy of the Visual System. St Louis, MO: CV Mosby, 1961:407Y408 12. Bron AJ, Tripathi RC, Tripathi BJ. Wolff’s Anatomy of the Eye and Orbit. 8th ed. London, UK: Arnold, 1998:6Y8 13. Jones DE, Evans JN. ‘‘Blow-out’’ fractures of the orbit: an investigation into their anatomical basis. J Laryngol Otol 1967;81:1109Y1120 14. Green RP Jr, Peters DR, Shore JW, et al. Force necessary to fracture the orbital floor. Ophthal Plast Reconstr Surg 1990;6:211Y217 15. Bullock JD, Warwar RE, Ballal DR, et al. Mechanisms of orbital floor fractures: a clinical, experimental, and theoretical study. Trans Am Ophthalmol Soc 1999;97:87Y110; discussion 110Y113 16. Rhee JS, Kilde J, Yoganadan N, et al. Orbital blowout fractures: experimental evidence for the pure hydraulic theory. Arch Facial Plast Surg 2002;4:98Y101 17. Ahmad F, Kirkpatrick NA, Lyne J, et al. Buckling and hydraulic mechanisms in orbital blowout fractures: fact or fiction? J Craniofac Surg 2006;17:438Y441 18. Emirzeoglu M, Sahin B, Bilgic S, et al. Volumetric evaluation of the paranasal sinuses in normal subjects using computer tomography images: a stereological study. Auris Nasus Larynx 2007;34:191Y195 19. Clement P, Chovanova H. Pressures generated during nose blowing in patients with nasal complaints and normal test subjects. Rhinology 2003;41:152Y158
Forgotten Foreign Object in the Neck: A Neck Surgery Complication To the Editor: Surgical sponges are foreign objects frequently used during operations to control bleeding. Sponges soaked with blood can be hard to distinguish from normal tissue and are thus sometimes forgotten. Gossypiboma is a technical term used to refer to the
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
721
