|Year : 2015 | Volume
| Issue : 2 | Page : 136-138
A retained iatrogenic foreign body in nasal cavity presenting with a hard palatal fistula
Chandni Shankar, Karoon Agrawal
Department of Burns, Plastic and Maxillofacial Surgery, VMMC and Safdarjung Hospital, New Delhi, India
|Date of Web Publication||17-Aug-2015|
Dr. Chandni Shankar
Department of Burns, Plastic and Maxillofacial Surgery, VMMC and Safdarjung Hospital, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
A 30-year-old male presented with a hard palate fistula. He had a history of faciomaxillary injury 8 months back. He had nasal regurgitation after the injury. He had severe halitosis at the time of presentation. A large foam piece was removed through the fistula under general anesthesia. There was a lack of documentation regarding the placement of foam piece as a nasal pack during initial treatment. A need of good documentation of the removal of the foreign body is emphasized.
Keywords: Foreign body, hard palate fistula, iatrogenic, palate fistula
|How to cite this article:|
Shankar C, Agrawal K. A retained iatrogenic foreign body in nasal cavity presenting with a hard palatal fistula. J Cleft Lip Palate Craniofac Anomal 2015;2:136-8
|How to cite this URL:|
Shankar C, Agrawal K. A retained iatrogenic foreign body in nasal cavity presenting with a hard palatal fistula. J Cleft Lip Palate Craniofac Anomal [serial online] 2015 [cited 2021 Sep 17];2:136-8. Available from: https://www.jclpca.org/text.asp?2015/2/2/136/162976
| Introduction|| |
Foreign body in the nasal cavity is not uncommon. Most often it is encountered in children.  The foreign materials are used for many nasal conditions by otolaryngologists, which are removed after a specific period of time. There is always a risk of retained foreign body after nasal procedures. However, retained iatrogenic foreign body has been reported extremely rarely.  We are reporting a case of an iatrogenic foreign body in the nasal cavity in an adult, reporting with hard palate fistula after 8 months of its placement.
| Case Report|| |
A 30-year-old male presented to the plastic surgery outpatient clinic with complaints of nasal regurgitation of ingested liquids for 8 months. The patient had met with a road traffic accident 8 months ago, had severe nasal bleeding for which he was treated conservatively. The records show that he was intubated and was on ventilatory support for 2 days. The patient attended neurosurgery clinic for focal contusions in the right parietal and temporal lobes and multiple fractures in occipital, right frontal, parietal and temporal bones for which he was treated conservatively. The symphyseal fracture, dentoalveolar injury and incomplete Le Fort 2 fractures were also managed conservatively. The patient had follow-up consultation with otolaryngologist after a month for nasal regurgitation of fluids since the time of injury. The otolaryngologist detected a 1 cm × 2 cm oronasal fistula on the left side of the hard palate with debris. The records did not show of any retained foreign body. The patient and relatives were not aware of insertion of any material in the nose.
On examination, there was severe halitosis. There was a 3 cm × 1 cm linear palatal defect in the region of the hard palate on the left side of the midline [Figure 1]. It appeared that the bony palate was exposed with a grey color floor of the defect. While examining, manipulation was avoided due to fear of bleeding. Intranasal manipulation and endoscopic examination were not done as there was no suspicion of intranasal abnormality. He had significant hypernasality, though had intelligible speech. The patient was taken for surgical closure of palate fistula with sequestrectomy of exposed hard palate. Examination of palate under general anesthesia revealed the presence of a fistula. A soft material was palpable on probing through the fistula. An attempt was made to remove the material through the palatal gap using a hemostat [Figure 2]. To everyone's surprise, a 8 cm × 3 cm size foam piece was retrieved through the fistula [Figure 3]. This foam piece was smeared with purulent discharge with debris on the surface [Figure 4].
|Figure 1: "Mucosal defect" like appearance of the fistula preoperatively|
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|Figure 2: Intraoperative picture showing sponge being pulled out of the palatal fistula|
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|Figure 4: The sponge taken out from the nasal cavity through the palatal fistula|
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The nasal cavity was irrigated with copious irrigation fluid. In turn halitosis significantly decreased during the surgery. There was no bleeding from the nasal cavity or the fistula site.
The palatal fistula was then closed in two layers by raising turnover flap for nasal lining and bilateral mucoperiosteal palatal flaps for oral cover. The complete palatal closure was performed without leaving raw area [Figure 5]. The postoperative period was uneventful. There was no halitosis, and the palate was fistula free at 2 months follow-up [Figure 6]. Mild hypernasality still persisted, though it is significantly reduced. There is a perceptible improvement in speech intelligibility.
|Figure 5: Following repair of the fistula using two large mucoperiosteal flaps|
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| Discussion|| |
Nasopharyngeal foreign bodies have often been described in cleft palate patients.  Retained or forgotten foreign body in the nasal cavity in an adult is quite rare. One such case is the report of iodoform-soaked gauze misdiagnosed as an intranasal tumor. 
This patient had multiple fractures in the maxillofacial region. In all probability, the treating physician packed the nasal cavity with foam for managing the nasal bleeding. This foam piece was left unnoticed as the patient did not report back to the treating physician. It is a well-known fact that foreign body in the nasopharynx may remain unnoticed for a significant period of time.  If the patient would have followed with the same physician, in all probability, it could have been removed on time.
Immediately after weaning off the ventilator, during the post-trauma period, the patient had nasal regurgitation. The palatal fracture might have been associated with palatal fistula. Because of the presence of foreign body the fracture did not heal well and resulted in a fistula of significant dimension causing nasal regurgitation and hypernasality.
There have been sporadic cases of a foreign body in nasal cavity presenting with or without palatal defect. Also, there are very few reports of a foreign body on the surface of palate presenting with the palatal defect. A coin causing palatal defect  and a shiny disc embedded in palate misdiagnosed as a palatal fistula in a child have been reported.  Wooden pieces inside the nasal cavity presenting with nasal obstruction  and a cancellous bone piece causing a bony defect in the hard palate  have been reported. Interestingly, an iatrogenic foreign body - an iodoform-soaked gauze pack causing incessant epistaxis in a 76-year-old adult has also been reported.  However, there is no case of palate fistula with iatrogenic retained foreign body in an adult.
For a foreign body, a hemostatic material of nearly half the length of the average adult hand, being retained in the nasal cavity, unnoticed and asymptomatic for almost a year and presenting as a fistula in the hard palate is an unusual occurrence.
This case report emphasizes that the nasal packing, if done, must be removed by the treating team at the appropriate time or patient must be informed regarding the importance of its removal early in the follow-up period. It is essential to document insertion and removal of a foreign body in the case records as well as discharge summary so that the treating physician in follow-up takes care appropriately.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
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Kanotra SP, Kanotra S, Paul J. Cleft palate secondary to an ingested foreign body: A learning experience. J Emerg Med 2012;43:e315-7.
Samiullah, Chandra K, Dar NH, Abrari A. An unique case of organic foreign body (bone) in the hard palate. Indian J Otolaryngol Head Neck Surg 2003;55:296-7.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]