An unusual case of unilateral sinus disease may reveal the p
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A 50-year-old man in good health with no prior medical history, who has been working as a gardener for more than 30 years, referred to have been injured on the job in May 2010. He explained that he experienced a violent blow to the left zygomatic region, while he was using his grass trimmer. Even though he was wearing his safety helmet with a face shield and earmuffs, he had the sensation to have been hit by an object coming from the soil. After the trauma, the patient immediately noticed a 2-mm lesion on his skin; he thought that it was insignificant so much so that he did not seek care. A few hours later the man suffered from burning pain and ipsilateral rhinorrhea with mild bleeding; however, the patient did not feel the presence of any foreign bodies in the subcutaneous tissue on palpation.

Additionally, the zygomatic region did not present edema or bruising. The patient visited his Dentist for a regular dental check-up. The dental X-ray revealed the “presence of a metal prosthesis located in the left side of the facial skeleton and the absence of areas of apical/radicular osteolysis affecting the teeth”. Surprisingly, the patient had never undergone any dental implant operations from the time of injury to his presentation to our clinic. Given these last findings the dentist suggested the man consult an Otolaryngologist, but the patient decided to follow this suggestion only after five years, when he started experiencing facial pain. The fiberoptic nasolaryngological examination showed a deviation of the nasal septum. The computed tomography (CT) of the paranasal sinuses executed without contrast evidenced the “presence of a metal foreign body with thread-like shape located in the region of the left maxillary sinus, which determined intense inflammatory reaction of the sinonasal mucosa interesting the same maxillary sinus”. Additionally, “the ipsilateral anterior ethmoidal air cells were partially involved”. Radiological findings of minor importance were the presence of left concha bullosa and nasal septum deviation, while the other paranasal sinuses were within normal limits.

Given this radiology report, the patient underwent Functional Endoscopic Sinus Surgery (FESS) with septoplasty. The pre-operative testing, including blood chemistry test, electrocardiogram and chest X-ray, were all within normal limits. General endotracheal anesthesia was induced, but unfortunately, the Otolaryngologist was not able to remove the foreign body from the maxillary sinus. However, the patient was ensured that the foreign body would not cause him any additional symptoms or harm and he was discharged on post-operative day 3. Post-surgical care at home included nasal irrigations, topical antibiotics, steroids and proton pump inhibitors. In addition, the first follow-up visit was scheduled at 15 days after the surgery in order to remove silastic sheeting.

Three years later in 2018, the patient started experiencing left nasal obstruction accompanied by purulent blackish discharge and ipsilateral headache. His chief complaint however was a fetid odor coming from inside the nose and described it as “the carcass of a dog”. The sensation generally worsened in the morning, especially when he leaned forward.

Firstly, the Otolaryngologist executed uncinectomy and bullectomy. Subsequently, a left maxillary antrostomy was performed; after enlarging the ostium of the maxillary sinus, a purulent, blackish, and fetid discharge was observed. The foreign body was located in correspondence to the anterior wall of the maxillary sinus and finally retrieved; it was described as a metal nail covered by black encrustations. Final surgical steps consisted of intraoperative control of bleeding and positioning of Silastic sheeting in the left middle meatus. In conclusion, the retained foreign body for eight years was the cause of the left maxillary sinusitis.

No postoperative complications were noted. The patient tolerated the surgical procedure well and was discharged on postoperative day 2.

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