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A radiologic view of migration of a foreign body in the maxillary sinus by mucociliary movement.

A 53-year-old man was referred to the Department of Otolaryngology of a university hospital for evaluation of mild right-sided facial pain. Eight days earlier, the patient had presented to a dental clinic for routine extraction of the upper right first permanent molar, which had become necessary because of pulpitis secondary to caries. During extraction of the tooth, the palatal root was fractured. When an attempt was made to remove the palatal root, it became displaced superiorly and was no longer visible within the socket. The root fragment could not be found on basic exploration of the surgical site. The patient was informed of the situation and referred to us.

Findings on nasal endoscopy were normal except for a mild mucosal swelling of the right middle meatus. The remainder of the ENT examination was normal. Coronal computed tomography (CT) detected a foreign body in the right maxillary sinus ostium (figure). At that point, it was suggested that the foreign body could be removed via an endoscopic approach, but the patient declined. He was prescribed amoxicillin/clavulanate at 500/125 mg three times daily for 7 days, and followed up 3 weeks later.

At follow-up, the patient was not experiencing any nasal symptoms or headaches. A plain radiograph (Waters view) revealed no signs of sinusitis, such as mucosal thickness or an air-fluid level.

Fractured root fragments are the most common foreign objects displaced into the maxillary sinus. Other foreign objects that have been described include dental burs, endodontic filling material, dental implants, and bullets. (1) Displaced foreign objects should be removed from the antrum to prevent the development of maxillary sinusitis.

The foreign objects can be removed by suction from the socket of an extracted tooth, by the classic Caldwell-Luc operation, or by endoscopic sinus surgery. (2) If the root fragment is small (2 to 3 mm) and there is no associated infection, periapical inflammatory process, or other pathology, leaving the fragment in situ may be a conservative management option. (3) However, in the presence of pathology or a history of maxillary sinus disease, or if the root fragment is larger than 3 mm, surgical removal should be considered.

The cilia of the sinuses are in constant motion, and they act in concert to propel mucus in a specific direction. The pattern of flow is specific for each sinus and will persist, even if other openings are made. In the maxillary sinus, the cilia beat centripetally toward the primary ostium. (4) The beat frequency ranges from 10 to 20 Hz (mean: 14) at body temperature. Other factors affecting ciliary action include drying of the mucous layer, pH, infection, and drugs. (5)

This case showed the spontaneous movement of a foreign body to the natural ostium of the maxillary sinus with the aid of mucociliary action. Also, this case illustrated that the foreign body moved from the floor of the maxillary sinus to the natural ostium in 8 days. Fortunately, a foreign body can be removed through the maxillary ostium.

References

(1.) Liston PN, Walters RE Foreign bodies in the maxillary antrum: A case report. Aust Dent J 2002:47(4);344-6.

(2.) Varol A, Tinker N, Goker K, et al. Endoscopic retrieval of dental implants from the maxillary sinus. Int J Oral Maxillofac Implants 2006;21(5):801-4.

(3.) Ong JC, Silva RD, Tong DC. Retrieval of a root fragment from the maxillary sinus--an appreciation of the Caldwell-Luc procedure. N Z Dent J 2007;103(1):14-16.

(4.) Wigand ME, Steiner W, Jaumann MP. Endonasal sinus surgery with endoscopic control: From radical operation to rehabilitation of the mucosa. Endoscopy 1978;10(4):255-60.

(5.) Pang KP, Siow JK, Tan HM. Migration of a foreign body in the maxillary sinus illustrating natural mucociliary action. Med J Malaysia 2005;60(4):523-5.

Jae Hoon Lee, MD

From the Department of Otolaryngology, Institute of Wonkwang Medical Science, Wonkwang University School of Medicine, Iksan, Chonbuk, Republic of Korea.
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Title Annotation:IMAGING CLINIC
Author:Lee, Jae Hoon
Publication:Ear, Nose and Throat Journal
Article Type:Clinical report
Geographic Code:1USA
Date:Sep 1, 2015
Words:652
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