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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 6  |  Issue : 1  |  Page : 130-133

Gossypiboma: A diagnosis not to forget


1 Department of Oral and Maxillofacial Surgery, AJ Institute of Dental Sciences, Mangalore, Karnataka, India
2 Department of Oral Medicine and Radiology, AJ Institute of Dental Sciences, Mangalore, Karnataka, India

Date of Web Publication11-Jun-2018

Correspondence Address:
Dr. Charvi Chawla
Department of Oral Medicine and Radiology, AJ Institute of Dental Sciences, Kuntikana, Mangalore - 575 004, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/amhs.amhs_14_17

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  Abstract 


Granuloma formation is a specific type of chronic inflammation initiated by infectious and noninfectious agents with an aggregation of multinucleated giant cells. Foreign bodies can penetrate soft tissues in connection with accidents through open wounds and lacerations. Foreign body giant cells are most commonly observed at the tissue interface where the size of foreign particulate is too large to permit macrophage phagocytosis. A case of foreign body granuloma in the mandible is presented.

Keywords: Foreign body, giant cells, granuloma, inflammation, mandible


How to cite this article:
Sorake S, Chawla C, Kumar Rao J P, Kini R, Peter J. Gossypiboma: A diagnosis not to forget. Arch Med Health Sci 2018;6:130-3

How to cite this URL:
Sorake S, Chawla C, Kumar Rao J P, Kini R, Peter J. Gossypiboma: A diagnosis not to forget. Arch Med Health Sci [serial online] 2018 [cited 2018 Dec 15];6:130-3. Available from: http://www.amhsjournal.org/text.asp?2018/6/1/130/234093




  Introduction Top


Foreign bodies in the head and neck are common, including those of long duration.[1] Penetration of foreign bodies through open wounds, lacerations, or accidents may present a diagnostic challenge to the surgeon. Among the commonly encountered, foreign bodies due to trauma are of glass, metal, and wood in nature.[2] There are circumstances in which the substances that provoke the acute inflammatory reaction are particulate and larger than the phagocytes and cannot be digested by the reacting neutrophils causing granulomatous inflammation. Granulomas are a collection of epithelioid cells which are frequently surrounded by mononuclear cells.[3] The presence of a foreign body that causes a granuloma impairs the healing of the tissues. Some reports on foreign body granuloma originating from a traumatic implantation have been published, with different objects, including fish bones, teeth, and metallic material.[4],[5],[6] However, intraosseous foreign body granulomas with accidents are rarely found. Here, we report a case of intraosseous foreign body granuloma in the mandible.


  Case Report Top


A medically fit 48-year-old male reported to the dental outpatient department with a chief complaint of growth in the lower front region of the jaw since 4 years. The patient gave history of the accident (fall on the floor) 5 years back with no history of loss of consciousness or bleeding from ear, nose, or throat during the fall. Initially, there was a scar after the fall for which he took ayurvedic treatment for wound healing. The patient gives a history of growth 1 year after the fall which was gradual in onset. Initially, growth was small in size which grew to present size without any associated symptoms.

On examination, a single, focal, diffuse growth of size 2 cm × 2 cm was seen on the left side of the chin extending anteriorly from the midline, posteriorly along the corner of the mouth, superiorly along the lower border of the mandible, and inferiorly 1 cm below the lower border of the mandible. The surface of growth appeared normal [Figure 1]a and [Figure 1]b. On palpation, the swelling was firm in consistency, well-defined margins, fixed to the underlying structure and nontender. Hard-tissue examination revealed fixed prosthesis in the upper right (15–18) and upper left (25–27) back region and caries in the lower right (48) and lower left back (38) region. No intraoral changes were appreciated with respect to the growth [Figure 1]c.
Figure 1: (a and b) Extraoral growth, (c) intraoral examination

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Pulp vitality test was carried out from left mandibular second premolar to right mandibular first molar which revealed favorable response; however, right mandibular central incisor was nonvital. The presumable clinical differential diagnosis for the above-mentioned case could be considered namely keloid, foreign body granuloma, or infection.

The radiographic investigation included cone-beam computed tomography (CBCT) where in panoramic view revealed an expanded osteolytic mass in the area, with destruction of most of the bone on the buccal side extending from 41 to 35 regions. Three-dimensional (3D) view revealed bone destruction and extent of the lesion was appreciated in cross-sectional images of each tooth [Figure 2]. Radiopacity was seen in the coronal area, pulp chamber, and root canal suggestive of obturating material in relation to 41.
Figure 2: Cone-beam computed tomography showing expanded osteolytic mass in the area, with destruction of most of the bone on the buccal side extending from 41 to 35 region

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Total surgical excision was the treatment of choice. Treatment was carried out in local anesthesia under aseptic conditions with antibiotic prophylaxis, 0.2% adrenalin was infiltrated locally. An elliptical incision was placed around the lesion and was excised. The soft tissue mass was completely removed and was sent for histological diagnostic examination [Figure 3]a. Bone curettage and irrigation was done. Resorbable sutures were placed [Figure 3]b. The patient was recalled after 15 days for follow-up, and postoperative healing was uneventful [Figure 3]c.
Figure 3: (a) Surgical excision of growth, (b) sutures placed, and (c) postoperative healing

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Histopathology report revealed epithelium of skin with its appendages such as sebaceous glands and hair follicles. Underlying connective tissue comprised inflammatory cells, foreign body, multinucleated giant cells, and thick bundles of collagen fibers in the form of segments. Areas of hemorrhage and bold vessels were seen. Based on clinical, radiographic, and histopathology report, a final diagnosis of foreign body granuloma was achieved.


  Discussion Top


Foreign bodies in the head and neck are common, including those of long duration. They can be detected as a radiographic finding in a routine examination, and a painless reaction is, sometimes, a feature of this lesion, making it difficult to diagnose.[1]

Granuloma formation is a specific type of chronic inflammation characterized by the accumulation of modified macrophages and initiated by infectious and noninfectious agents.[7] It also develops in response to relatively inert foreign bodies forming foreign body granulomas. However, it does not always lead to eradication of the causal agent, which is frequently resistant to killing or degradation and may result in granulomatous inflammation and subsequent fibrosis.[8] Pathologically, two types of reactions are described against them. One is an aseptic fibrinous response that results in adhesion or encapsulation leading to granuloma formation. The other is an exudative type leading to abscess formation with or without bacterial superinfection. Sometimes, the gossypiboma may remain unnoticed for years till the time that they result in a complication or be incidentally picked up.[9]

Formation of granuloma occurs in stages involving protein absorption, macrophage adhesion, macrophage fusion, and crosstalk. As the neutrophil infiltration and adsorption of host proteins to the foreign material occur, monocytes circulating in the blood migrate to the surrounding tissues and differentiate into macrophages. Where the particle volume is greater than the macrophage volume, macrophages aggregate, forming giant cells, and secretes factors, which activate fibroblasts, influencing the development of fibrous capsule around the foreign body material and formation of the foreign body giant cell.[10],[11]

The visibility of different materials on plain radiographs depends on their ability to attenuate X-rays. Foreign bodies may be visualized depending on their inherent radiodensity and proximity with the tissues in which they are embedded.[12] CT and CBCT scans are the most effective methods to diagnose, showing a round, low-intensity, ill-defined mass containing a spongiform air bubble. Ultrasonography is another diagnostic method, showing echogenic masses with intense and sharply delineated acoustic shadows or hypoechogenic masses with complex echogenic foci.[13] When no radio-opaque marker is seen on a radiograph, CBCT, or CT scans, the characteristic internal structure of the gauze granuloma is best visualized using magnetic resonance imaging.[14] Confocal laser scanning is a newer method of identifying the microscopical changes within the tissues where the foreign body is embedded (13 SJ). It helps in providing improved tissue images, bidimensional pictures with better resolution at the cellular level and in particular a 3D imaging and reconstruction are possible.

Foreign bodies located in the mandible resulted from a traumatic implantation are rare. According to Heo et al., no foreign body granuloma occurring in the mandibular area has previously been cited in the literature, being his report the first one.[15] Silveira et al. reported a case of intraosseous foreign body granuloma in the mandible subsequent to a 20-year-old work-related accident.[16] Ding et al. reported a case of foreign body granuloma in the submental region that resulted from a fish bone embedded in the floor of the mouth.[17]

Usually, foreign bodies are small in size and relatively inert in nature, thus, eliciting no or a very limited inflammatory response. Occasionally, foreign bodies may be retained for a prolonged period, causing persistent and distressing symptoms. Complications caused by impacted foreign bodies include infection, peripheral nerve damage, pseudoaneurysm, synovitis, and paresthesia in the inferior alveolar nerve due to the displaced calcium hydroxide paste was reported.[18],[19] A foreign body reaction to a small piece of gauze resulted in a cystic mass in mandible was also reported.[15]

The correct approach in the treatment of these injuries requires a multidisciplinary team and the proper sequencing, with the administration of adequate procedures and techniques that offer a satisfactory result. Although some foreign bodies may be left in situ for good clinical reasons, most are removed before the onset of a complication, notably infection.[20] Surgical complete removal of the granuloma is the first choice of treatment. Prognosis is good and recurrences are rare with effective treatment.


  Conclusion Top


Therefore, we conclude that if possible, these pathologies must be removed at the time of detection to prevent further complications; however, in asymptomatic cases, according to location and the characteristic of the foreign body, they can be kept under observation without performing any operations. Even though intraosseous foreign body granulomas are rare lesions, dentists should be familiar with their features and include them in the differential diagnosis of tissue masses, mainly in the presence of previous surgery or accidental trauma history.

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 Top

1.
Joyce S, Sripathi BR, Mampilly MO, Nyer CF. Foreign body granuloma. J Maxillofac Oral Surg 2014;13:351-4.  Back to cited text no. 1
    
2.
Krimmel 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.  Back to cited text no. 2
    
3.
Mariano M. The experimental granuloma. A hypothesis to explain the persistence of the lesion. Rev Inst Med Trop Sao Paulo 1995;37:161-76.  Back to cited text no. 3
    
4.
Lin CJ, Su WF, Wang CH. A foreign body embedded in the mobile tongue masquerading as a neoplasm. Eur Arch Otorhinolaryngol 2003;260:277-9.  Back to cited text no. 4
    
5.
Baldwin JK, Newton GM. A tooth located in the tongue. Oral Surg Oral Med Oral Pathol 1978;45:860-2.  Back to cited text no. 5
    
6.
Girdler NM. Unusual delayed sequel to facial trauma. Oral Surg Oral Med Oral Pathol 1993;75:264.  Back to cited text no. 6
    
7.
Yallamraju S, Gunupati S. An unusual foreign body in upper lip. Int J Dent Sci 2012;10:1.  Back to cited text no. 7
    
8.
Kumar V, Cotran RS, Robbins SL. Robbins Basic Pathology. 7th ed. India: Harcout Private Limited.; 2012. p. 74.  Back to cited text no. 8
    
9.
Mochizuki T, Takehara Y, Ichijo K, Nishimura T, Takahashi M, Kaneko M, et al. Case report: MR appearance of a retained surgical sponge. Clin Radiol 1992;46:66-7.  Back to cited text no. 9
    
10.
Murphy KM, Traves P, Walport M. Janeway's immunology. New York: Garland Science; 2008.  Back to cited text no. 10
    
11.
Rubin E, Farber JL. Pathology. 3rd Edition. Lippincott Williams & Wilkins 1999.  Back to cited text no. 11
    
12.
Robinson PD, Rajayogeswaran V. Unlikely foreign bodies in unusual facial sites. Br J Oral Maxillofac Surg 1997;35:36-9.  Back to cited text no. 12
    
13.
Cevik I, Dillioglugil O, Ozveri H, Akdas A. Asymptomatic retained surgical gauze towel diagnosed 32 years after nephrectomy. Int Urol Nephrol 2008;40:885-8.  Back to cited text no. 13
    
14.
Bani-Hani KE, Gharaibeh KA, Yaghan RJ. Retained surgical sponges (gossypiboma). Asian J Surg 2005;28:109-15.  Back to cited text no. 14
    
15.
Heo MS, Song MY, Lim JJ, Lee SS. Foreignbody granuloma occurring in the mandible subsequent to orthognathic surgery: A case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;91:4835.  Back to cited text no. 15
    
16.
Silveira VA, Carmo ED, Colombo CE, Cavalcante AS, Carvalho YR. Intraosseous foreignbody granuloma in the mandible subsequent to a 20 yearold workrelated accident. Med Oral Patol Oral Cir Bucal 2008;13:E65760.  Back to cited text no. 16
    
17.
Ding X, Zhu XH, Fang YM, Zhang L. Foreign body granuloma in the sub mental region due to fish bone: A case report. Oral Surg 2010;3:436.  Back to cited text no. 17
    
18.
de 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.  Back to cited text no. 18
    
19.
Nayak RN, Hiremath S, Shaikh S, Nayak AR. Dysesthesia with pain due to a broken endodontic instrument lodged in the mandibular canal – A simple deroofing technique for its retrieval: Case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;111:e48-51.  Back to cited text no. 19
    
20.
Vikram A, Mowar A, Kumar S. Wooden foreign body embedded in the zygomatic region for 2 years. J Maxillofac Oral Surg 2012;11:96-100.  Back to cited text no. 20
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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