Removal of a Surgical Bur Lodged in the Maxillary Sinus for 9 Years: Case Report

The maxillary sinuses are pyramidal-shaped pneumatic cavities located inside the maxillary bones. Due to their anatomical location, the maxillary sinuses are prone to accidental entry of foreign bodies. Cases arising from iatrogenic factors are mainly linked to dental causes, with the main artifacts found being: fractured tooth roots, implants, needles, root filling material and dental impression materials. Therefore, the aim of this study was to report a rare case of a patient who had had a surgical drill lodged in the maxillary sinus for 9 years. This is only the second study to report the presence of a drill inside the maxillary sinus, reinforcing the contribution of this study to the literature. A 47-year-old male patient with leukoderma came to the oral surgery department due to dental pain. During radiographic assessment, a foreign body was observed in the left maxillary sinus. The surgical technique adopted was Cadwel-Luc due to the location and size of the surgical drill. In conclusion, the displacement of surgical drills into the maxillary sinus is an extremely rare complication and the Cadwel-Luc approach proved to be an excellent treatment option.

Introduction

The maxillary sinuses are pneumatic cavities with a pyramidal shape located inside the maxillary bones, occupying a volume of 15 mL in adults. Its base is towards the midline of the face and its apex is towards the zygomatic process [1].

Due to their anatomical location, the maxillary sinuses are prone to accidental entry of foreign bodies [2]. 60% of foreign bodies found in the maxillary sinus are of iatrogenic origin and 25% are due to trauma. The cases arising from iatrogenic factors are mainly linked to dental causes, with the main artifacts found being: fractured tooth roots, implants, needles, root filling material, dental molding materials, dental drills [3].

The proximity of the maxillary sinus to the maxillary posterior teeth increases the possibility of buccosinusal communication after extraction of these elements, thus enabling invasion of this space. In addition, although symptomatology is more common, it may or may not be present [1], [2].

Symptoms can be present in a variety of ways, such as a slight fever, facial pain, headache, nasal obstruction and chronic nasal secretion, and are related to the nature and cause of the foreign body’s entry, the length of time it has been in the sinus and the remaining oral-sinusal communication [4], [5]. In asymptomatic cases, the diagnosis is usually made during routine radiographic examinations, suspicion or during a diagnostic examination for sinusitis [3].

A definitive diagnosis must be made using imaging tests. Panoramic radiographs are indicated for detecting and assessing the radiopacity of the foreign body, but they do not provide conclusive information on the area of intervention. In this context, cone beam computed tomography is essential for surgical planning, as it can provide more precise images of hard and soft tissues, as well as the location and size of the foreign body [4].

Removal of foreign bodies from the maxillary sinus should always be carried out after diagnosis, associated in most cases with oral antibiotic therapy [6]. The method of choice for removing a foreign body is determined according to its size, shape and location [4]. The literature highlights two main techniques: the Caldwell-Luc technique and endoscopic sinus surgery. The latter is a conservative technique performed using a less traumatic nasal approach, as it preserves the anterior wall of the maxillary sinus. However, endoscopic surgery has some disadvantages, such as the difficulty in removing foreign bodies located in the anterior and inferior parts of the maxillary sinus, as well as its high cost when compared to the Caldwell-Lu technique [6], [7].

Although it requires greater bone removal, the Caldwell-Luc approach allows direct access and vision of the maxillary sinus [8]. It is an easy and safe technique to perform. Its main indications are for the removal of impacted foreign bodies in regions that are not visible or where the use of endoscopic instruments is not possible, excision of benign tumors, proximity to the floor of the orbit and failed endoscopic surgeries [4].

Objectives

The aim of this paper is to report a rare case of a 47-year-old male patient who had a surgical drill bit lodged in his left maxillary sinus after exodontia of a dental element 9 years ago and the removal of this foreign body using the Caldwell-Luc technique.

Case Report

A 47-year-old patient came to the oral surgery department of a private university complaining of pain in tooth 38. During anamnesis, the patient reported complaints compatible with sinusitis, especially on cold days, but he was not taking any medication. In addition, the patient reported being normosystemic and, on intraoral examination, nothing noteworthy was observed. A panoramic X-ray revealed a radiopaque foreign body in the left maxillary sinus (Fig. 1).

Fig. 1. Panoramic radiography.

When informed of the presence of a foreign body, the patient reported that the incident had happened 9 years ago during surgery to remove elements 26 and 27. A Cone Beam Computed Tomography (CBCT) scan was then requested for better assessment and planning. Through the CT reconstructions, it was possible to assess the nature of the artifact in question, which consisted of a 25 mm surgical drill, located in a horizontal position, close to the inferior wall of the left maxillary sinus (Fig. 2).

Fig. 2. Cone-Beam Computed Tomography showing a foreign body in the left maxillary sinus. Left. Axial section; middle. Parasagittal section; right. Coronal section.

Outpatient surgery was planned to remove the foreign body. For this purpose, a blood count, coagulogram, fasting glucose, GOT (oxalacetic transaminase or aspartate aminotransferase), GPT (pyruvic transaminase or alanine aminotransferase) and creatinine and urea analyses were requested. The patient was instructed to take preoperative medication for 5 days before the procedure, consisting of Clavulin^® (Amoxicillin + Potassium Clavulanate) 625 mg, 1 tablet every 8 hours, Novalgina^® 1 g, every 8 hours, and Dexamethasone 4 mg, every 12 hours.

For the surgical procedure, intraoral and extraoral antisepsis was carried out with 0.12% and 2% chlorhexidine digluconate, respectively. Next, the posterior superior alveolar nerve, middle superior alveolar nerve, anterior superior alveolar nerve, greater palatine nerve and nasopalatine nerve were blocked by infiltrating three 1.8 ml tubes of 4% articaine hydrochloride with epinephrine 1:100. 000, followed by a rectilinear incision in the alveolar ridge, extending from the canine region to the mesial of element 28, with anterior relaxation using a n° 15 scalpel blade on a n° 3 scalpel handle and subsequent mucoperiosteal detachment with a n° 9 Molt detacher (Figs. 3 and 4).

Fig. 3. Initial intraoral appearance.

Fig. 4. Incision in the alveolar ridge.

The osteotomy was performed with a 702 drill in a straight piece (Fig. 5a) and, in order to perform the Caldwell-Luc technique, a bone window approximately 1 cm in diameter was created in the anterior wall of the left maxillary sinus. After the mucosinusal membrane was dissected, it was possible to see the foreign body, surrounded at one end by inflammatory tissue (Fig. 5b). The bur was removed using curved hemostatic forceps (Fig. 5c), followed by irrigation and aspiration of the cavity with 0.9% saline solution. The suture was made with 4–0 non-resorbable nylon thread in single stitches (Fig. 5d).

Fig. 5. Details of the operation. (a) The osteotomy. (b) Making the surgical window using the Caldwell-Luc technique and localization of the foreign body. (c) The surgical materials used and foreign bodies. (d) The final appearance of the surgery after suturing.

The operation was uneventful. In the post-operative period, the patient was prescribed Clavulin^® (Amoxicillin + Clavulanate Potassium) 625 mg, 1 tablet every 8 hours, Novalgina^® 1 g, every 8 hours, and Dexamethasone 4 mg, every 12 hours, for 5 days. The patient was instructed on oral hygiene and physical protection for a better recovery. The sutures were removed 15 days after the surgical procedure at the UNIFIP School of Dentistry Clinic, and the healing was satisfactory and uneventful.

Discussion

Anatomically, the maxillary sinuses are susceptible to accidental lodging of foreign bodies [2]. Tooth extractions are among the most common etiological factors for this iatrogenic occurrence [3]. The close anatomical relationship between the maxillary sinus and the maxillary molars justifies this situation, as there is a greater possibility of oroantral communication after the extraction of these elements, increasing the chances of invasion of this space by some artifact [1].

Most cases of foreign bodies displaced into the maxillary sinus are iatrogenic in origin and iatrogenic origin and are associated with dental practice [3]. Previous studies have shown that the main artifacts found in the maxillary sinus are dental implants, needles, root-filling materials, restorative materials such as amalgam, and fractured tooth roots [1], [3], [9], [10]. In the present report, it was observed that a surgical drill measuring approximately 25 mm was displaced into the maxillary sinus. To our knowledge, this is only the second study to report the presence of a drill bit inside the maxillary sinus, reinforcing this study’s contribution to the literature.

The presence of artifacts lodged in the maxillary sinus can trigger acute or chronic infections [11]. Symptomatic cases often present with mild fever, rhinorrhea, unpleasant odor, swelling and headache [12], [13]. In the study of kyrgidis (2022), symptoms of acute sinusitis were observed in 11 patients with oral-sinusal communication [3].

The presence of inflammation inside the sinus can alter the integrity of the mucous gland ducts present in the sinus lining and cause them to become obstructed. As a result, chronic maxillary sinusitis can lead to the development of mucus retention cysts in the maxillary sinus [14]. The patient in this report had signs of chronic sinusitis due to the presence of a foreign body lodged in the maxillary sinus, but no mucus retention cyst.

To prevent chronification, displaced foreign bodies should be removed, even in asymptomatic patients [3].

Holding a foreign body can cause chronic inflammation of the affected maxillary sinus and increase the chances of more severe complications [15]–[17]. Reports point to the association of foreign bodies with pansinusitis and, due to their proximity to the orbit, the formation of orbital abscesses as well [18], [19]. The patient described in this report had symptoms compatible with sinusitis; however, these symptoms were not self-limiting, and the surgical drill remained inside the maxillary sinus for 9 years. The non-exacerbation of sinus symptoms can be explained by the patient’s good immune status, which attenuated the worsening of symptoms.

A foreign body lodged in the maxillary sinus region can only be diagnosed through radiological investigations [20]. Panoramic radiography and routine radiographs with at least two incidences may be able to determine the location and displaced contents. However, cone beam computed tomography (CBCT) remains the gold standard for diagnosing and planning the surgical approach to this complication [5], [20]. This report requested a CBCT scan for surgical planning and better precision in locating the surgical drill. This examination allowed for predictability, safety in the trans-operative period and an excellent surgical time for the removal of the surgical drill.

The preferred method for removing a foreign body is determined by its location, shape and size [4]. There are two main approaches in the literature: endoscopic sinus surgery and the Caldwell-Luc technique. The former is considered a more conservative procedure, using a nasal approach, which is less invasive and results in the preservation of the anterior wall of the maxillary sinus [6], [7]. On the other hand, the Caldwell-Luc technique requires more extensive bone removal; however, it offers more direct, faster and safer access to the anterior wall and floor of the maxillary sinus [8]. In addition to the advantages described by the Caldwell-Luc technique, this approach was used due to the favorable location of the foreign body, which is close to the maxillary sinus floor. Another factor that contributed to the choice of technique was the size of the object, which was approximately 25 mm.

Despite being a more conservative approach, the endoscopic technique has some limitations, such as the difficulty in removing foreign bodies located in the anterior and inferior parts of the maxillary sinus and a higher cost than the intraoral technique [6], [7].

Conclusion

Displaced surgical drills are extremely rare complications and deserve to be described in the literature so that surgeons are aware of the use of appropriate surgical techniques in order to prevent this complication. The Cadwel-Luc approach for the surgical removal of a drill displaced into the maxillary sinus proved to be an excellent treatment option.