Indian Journal of Dental Sciences

ORIGINAL ARTICLE
Year
: 2020  |  Volume : 12  |  Issue : 2  |  Page : 73--76

Management of foreign body in the maxillofacial region – A retrospective study


S Devakumari1, N Bhavani Rekha2, T Vijhayapriya3, Neil Dominic1, S Devameena4,  
1 Department of Dentistry, Indira Gandhi Medical College and Research Institute (Government), Madurai, Tamil Nadu, India
2 Department of Dentistry, Government Rajaji Hospital, Madurai Medical College, Madurai, Tamil Nadu, India
3 Department of Ophthalmology, Indira Gandhi Medical College and Research Institute (Government), Madurai, Tamil Nadu, India
4 Department of Prosthodontics, Sri Venkateswara Dental College and Hospital, Ariyur, Puducherry, India

Correspondence Address:
N Bhavani Rekha
1/403, Kaveri Main Street, Iyer Bungalow, Madurai - 625 017, Tamil Nadu
India

Abstract

Background: Foreign bodies (FBs) in the maxillofacial region are not rare due to increasing trends of accidents and interpersonal assaults. This leads due to a steady increase in facial injuries. The management of FB starts with the development of strong clinical suspicion of the presence of FB during the initial wound examination. Face being the most appealing and esthetic part of the body, early recognition and removal of FB decrease the patient's morbidity. Further, chronic infection and recurrent surgeries can be avoided. Objectives: This retrospective study gives the clinical experience of the management of FB in the maxillofacial region in most referred tertiary care government hospital in South India. Further, the intricacies and the sequence of effective management were discussed in detail. Materials and Methods: A retrospective study was conducted in the Department of Dentistry, Government Rajaji hospital, Madurai Medical College, Tamil Nadu, India, for 5 years from 2014 to 2019 on the management of FBs in the maxillofacial region. Patient's records were analyzed for demographic data, etiology, clinical presentation, investigation, type of FB, and management. Results: Thirty-five patients were treated in the period of 5 years. Out of 35 patients, males were predominantly treated for retrieval of FB; the most common etiology is renal tubular acidosis, most of them presented early; computed tomography is the diagnostic modality used to detect most of the FB; the most common type of FB is the glass followed by wood, and the removal of FB was predominantly done under General anaesthesia (GA). Conclusion: Early recognition of FB in the maxillofacial region is important. This hastens the removal along with the management of fractures, if any without additional investigations and surgery.



How to cite this article:
Devakumari S, Rekha N B, Vijhayapriya T, Dominic N, Devameena S. Management of foreign body in the maxillofacial region – A retrospective study.Indian J Dent Sci 2020;12:73-76


How to cite this URL:
Devakumari S, Rekha N B, Vijhayapriya T, Dominic N, Devameena S. Management of foreign body in the maxillofacial region – A retrospective study. Indian J Dent Sci [serial online] 2020 [cited 2020 Aug 11 ];12:73-76
Available from: http://www.ijds.in/text.asp?2020/12/2/73/284670


Full Text



 Introduction



Foreign bodies (FBs) in the maxillofacial region had become a routine in the practice of maxillofacial surgery. An increase in renal tubular acidosis (RTA) and assault leads to impregnation of FB into the face. Clinical acumen of suspecting the presence, diagnosis, and adequate management is mandatory.

Commonly encountered FBs include glass, wood, and metallic splinters. A thorough clinical examination, ordering of investigations based on the composition suspected FB, and right intervention pave the way for successful management. This clinical study gives the insight on the management of FB at a tertiary care hospital in Madurai, South India.

 Materials and Methods



A retrospective study was conducted in the Department of Dentistry, Government Rajaji hospital, Madurai Medical College, Tamil Nadu, India, for 5 years from 2014 to 2019 (ethical clearance obtained). Informed consent for performing surgery and publication of clinical photographs were obtained from all patients. Patients' treatment records, photographs, and radiological records were retrieved and analyzed for demographic data, etiology, clinical presentation, investigations used, type of FB, and the management. On analysis of inpatient records and minor surgery records, thirty patients were found to have undergone the removal of FB.

Inclusion criteria

Patients from the age group of 5–70 years were included in the studyPatients who had undergone surgical removal were included in the study.

Exclusion criteria

The common FB encountered in everyday dental practice is fish-bone removal. This entity was excluded as most of the patients would have undergone the removal of FB without the use of anesthesia.

 Results



Out of n = 35 patients, 60% was found to be male. The most common etiology being RTA (45%) followed by fall from height and assault, sports injuries, and the least being retained FB. Most of the FB was removed under GA (23 patients) as they were found to be associated with fractures. The common FBs encountered include glass, followed by metal, plastic, wood, and stone. The diagnostic technique that demonstrated most of the FB was computed tomography (CT) followed plain radiographs, ultrasound, and the least used modality is magnetic resonance imaging (MRI).

 Discussion



FBs in the maxillofacial region pose a diagnostic challenge based on their size and their visibility in imaging technique. Further, the visibility is always based on their composition and the position of the FB in the anatomical background. Maxillofacial skeleton has numerous articulated bones piled-like a three-dimensional (3D) building block. This is further complicated by the pneumatization, i.e. the presence of sinuses of the face. With this complex anatomy in place, it is difficult to delineate a FB in this region. The task of diagnosis becomes difficult if the FB is an organic one. The demonstration of an organic FB which is small becomes a herculean task.

It is reported that the one-third of the FB was not diagnosed during the initial clinical examination.[1] Organic FBs include fish bone, wooden splinters [Figure 1], [Figure 2], [Figure 3], [Figure 4], and food remnants placed deep inside the periodontal pockets were also reported Commonly encountered radio-opaque FBs in the maxillofacial region were glass fragments [Figure 5] and 6], metal splinters, plastic splinters, graphite from pencil tip, stone, and broken tooth.{Figure 1}{Figure 2}{Figure 3}{Figure 4}{Figure 5}

FBs get accidentally impregnated into the soft tissue, bone, bone and soft-tissue interface, and into the sinuses of the face.[2] An array of diagnostic techniques was used to demonstrate the FB depending on their position of lodgment and their composition. The commonly used methodologies include plain radiography, ultrasonography, CT, and MRI.

Plain radiology, the first simple diagnostic aid, is considered to be sensitive in detecting metallic FB (69%–90%), for glass (71%–77%), and for wooden FB (0%–15%).[3] Plain radiographs are also sensitive to graphite FBs. Plain radiographs are excellent in diagnosing metallic FB as radiography is largely dependent on the density of the material.

CT is the best-imaging modality commonly available and routinely ordered for indicated cases of RTA. This is considered to be the valuable tool in the diagnosis of metallic splinters, glass, plastic, stone,[4],[5] and graphite.[6] CT is excellent in showing the tooth fragments than plain radiographs.[7] The presence of enamel and dentine in the bony background is well appreciated in CT than in plain radiographs.

CT not only aids in the diagnosis but also helps in locating the FB in relation to adjacent structures in 3D volume. This largely helps in the easy removal of FB.[8] Digital-volume tomography helps in the diagnosis of larger radio-opaque FB with lower exposure to X-rays.[9] Computer-assisted navigation surgery for the removal of FB is the novel approach, which reduces the time of surgery with minimal exploration in the head-and-neck region. Minimal exploration is the expected norm, and this largely reduces surgical time, postoperative hospital stay, and the patient's morbidity.[10]

If the FB is in close relation to the vital structures as in the submandibular region or on the medial aspect of the mandible, then CT with subtraction angiography was done to retrieve the FB. With image navigation, FB is removed without inducing any risk to the vital blood vessels.[8]

Ultrasonography, a readily available diagnostic tool even in the emergency departments, is the diagnostic aid for wooden FB in the maxillofacial region. Dentist and maxillofacial surgeons do not routinely use ultrasound. This study recommends the maxillofacial surgeons to inculcate the use of ultrasound examination in all suspected injuries with the presence of FB. Wooden FB cannot be identified due to their low density.[11],[12] Due to the acoustic difference between the wood and soft tissue, it is easily identified in ultrasound. If wooden FB are superficial and not enveloped by gas or bone, then they are easily demonstrated in ultrasound.[13],[14],[15] Wooden FBs <0.5 cm is not detectable by ultrasound too. This small FB can only be demonstrated after 48 h in CT.

Normally, wooden FBs are not visible in CT during the initial time of injury, it is well demonstrated after it absorbs body fluids in 48 h.[16] Missed wooden FBs were known to induce persistent infection and carry microbes.[17] Wood being organic and porous leads to microbial growth-like clostridium tetani.[18],[19] Wood is soft and easily friable, so it leads to reparative granulomas which evades the naked eye.[20] Wooden FB can always potentially create late complications. To detect deeper wooden FB, a high-frequency transducer ultrasound is mandatory.[21]

MRI, a diagnostic tool, which is commonly available nowadays does not have much role to play in the diagnosis of FB. Instead, it carries a precaution. If a metallic FB is suspected, it is imperative to avoid MRI. The magnetic effect induced may move the metallic FB inside the tissues.[22] This is potentially dangerous if the FB is in close relation to the vital structures.[23]

In our study, we found that predominantly males had undergone surgery for FB removal. The most common etiology is RTA. This is because of driving without a helmet or without seatbelts. As RTA being the common etiology, the FB we encountered was also glass pieces from the wind shield, patients' spectacles, and the mirrors followed by metal and plastic splinters from the vehicles. All these patients had early removal as they were associated with fractures. Seventeen percent of the patient had undergone delayed removal, and in all these cases except one, the FB was wooden FB. One child had undergone series of three surgical explorations under LA elsewhere as the patient had a wooden FB in the infraorbital rim and a sinus in the cheek region. This is due to the fact that wood was not demonstrated in plain radiographs.

Patients with reparative granulomas and osteomyelitis were treated after injecting a dye into the sinus followed by a thorough surgical exploration. FB if left unnoticed leads to chronic infection in face leading to sinus formation. The granulation tissue formed was always found to be tough for dissection. FB has to be demonstrated before exploration, and their 3D position should be clear before the surgery. An unplanned surgery leads to over manipulation and unsightly scar in the face. The availability of ultrasound and image-guided CT is important for in any setup for the successful management of FB.[Figure 6]{Figure 6}

 Conclusion



Successful management of FB in the maxillofacial region is very important to avoid repeated surgeries and unsightly scar in the face. A sequential management begins with the strong suspicion of the presence of FB during the wound management. Demonstration of the FB by imaging techniques and prompt surgical removal paves the way for successful management. Further, a nonhealing sinus in the face with h/o injury to the face in recent should always prompt a maxillofacial surgeon about the possibility of the presence of wooden FB.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Rudagi BM, Halli R, Kini Y, Kharkhar V, Saluja H. Foreign bodies in facial trauma-report of 3 cases. J Maxillofac Oral Surg 2013;12:210-13.
2Swathi N, Umadevi J. An undetected intraorbital foreign body after a “trivial” facial injury. J Craniofac Surg 2014;25:1782-3.
3de Santana Santos T, Avelar RL, Melo AR, de Moraes HH, Dourado E. Current approach in the management of patients with foreign bodies in the maxillofacial region. J Oral Maxillofac Surg 2011;69:2376-82.
4Aras MH, Miloglu O, Barutcugil C, Kantarci M, Ozcan E, Harorli A. Comparison of the sensitivity for detecting foreign bodies among conventional plain radiography, computed tomography and ultrasonography. Dentomaxillofac Radiol 2010;39:72-8.
5Pattamapaspong N, Srisuwan T, Sivasomboon C, Nasuto M, Suwannahoy P, Settakorn J, et al. Accuracy of radiography, computed tomography and magnetic resonance imaging in diagnosing foreign bodies in the foot. Radiol Med 2013;118:303-10.
6Choudhri AF, Patel BJ, Phillips ME, Mills KA, Whitehead MT, Fleming JC. Diamagnetic susceptibility artifact associated with graphite foreign body of the orbit. Ophthalmic Plast Reconstr Surg 2013;29:e105-7.
7Lagalla R, Manfrè L, Caronia A, Bencivinni F, Duranti C, Ponte F. Plain film, CT and MRI sensibility in the evaluation of intraorbital foreign bodies in an in vitro model of the orbit and in pig eyes. Eur Radiol 2000;10:1338-41.
8Gui H, Yang H, Shen SG, Xu B, Zhang S, Bautista JS. Image-guided surgical navigation for removal of foreign bodies in the deep maxillofacial region. J Oral Maxillofac Surg 2013;71:1563-71.
9Eggers G, Mukhamadiev D, Hassfeld S. Detection of foreign bodies of the head with digital volume tomography. Dentomaxillofac Radiol 2005;34:74-9.
10Hunter TB, Taljanovic MS. Foreign bodies. Radiographics 2003;23:731-57.
11Oikarinen KS, Nieminen TM, Mäkäräinen H, Pyhtinen J. Visibility of foreign bodies in soft tissue in plain radiographs, computed tomography, magnetic resonance imaging, and ultrasound. Anin vitro study. Int J Oral Maxillofac Surg 1993;22:119-24.
12Graham DD Jr. Ultrasound in the emergency department: detection of wooden foreign bodies in the soft tissues. J Emerg Med 2002;22:75-9.
13Krimmel M, Cornelius CP, Stojadinovic S, Hoffmann J, Reinert S. Wooden foreign bodies in facial injury: a radiological pitfall. Int J Oral Maxillofac Surg 2001;30:445-7.
14Ng SY, Songra AK, Bradley PF. A new approach using intraoperative ultrasound imaging for the localization and removal of multiple foreign bodies in the neck. Int J Oral Maxillofac Surg 2003;32:433-6.
15Ginsburg MJ, Ellis GL, Flom LL. Detection of soft-tissue foreign bodies by plain radiography, xerography, computed tomography, and ultrasonography. Ann Emerg Med 1990;19:701-3.
16Vikram A, Mowar A, Kumar S. Wooden foreign body embedded in the zygomatic region for 2 years. J Maxillofac Oral Surg 2012;11:96-100.
17Specht CS, Varga JH, Jalali MM, Edelstein JP. Orbitocranial wooden foreign body diagnosed by magnetic resonance imaging. Dry wood can be isodense with air and orbital fat by computed tomography. Surv Ophthalmol 1992;36:341-4.
18van der Wal KG, Boukes RJ. Intraorbital bamboo foreign body in a chronic stage: case report. Int J Oral Maxillofac Surg 2000;29:428-9.
19Akgüner M, Atabey A, Top H. A case of self-inflicted intraorbital injury: wooden foreign body introduced into the ethmoidal sinus. Ann Plast Surg 1998;41:422-4.
20Auluck A, Behanan AG, Pai KM, Shetty C. Recurrent sinus of the cheek due to a retained foreign body: report of an unusual case. Br Dent J 2005;198:337-9.
21Jacobson JA, Powell A, Craig JG, Bouffard JA, van Holsbeeck MT. Wooden foreign bodies in soft tissue: detection at US. Radiology 1998;206:45-8.
22Stockmann P, Vairaktaris E, Fenner M, Tudor C, Neukam FW, Nkenke E. Conventional radiographs: are they still the standard in localization of projectiles? Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:e71-5.
23Faguy K. Imaging foreign bodies. Radiol Technol 2014;85:655-78.