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University Hospital of Innsbruck A-6020 Innsbruck, Austria
A 33-year-old man was referred for follow-up CT because of persistent symptoms after sinus surgery. The patient had initially presented with recurrent sinusitis. Functional endonasal sinus surgery had been performed, and both nasal cavities had been tamponaded postoperatively. The patient had insisted on early discharge after the procedure and had failed to return for routine postsurgical follow-up. Six months later, the patient returned to the clinic complaining of general discomfort and nasal congestion. Endoscopy of the nasal cavity revealed inflammatory mucosal changes.
CT performed with and without IV-administered contrast agent revealed a soft-tissue mass with an average attentuation value of 50 H in the right ethmoidal sinuses and moderate space-occupying effect (Figs. 4A and 4B). No contrast enhancement of the mass was seen. The bony septa were mildly displaced. At the time of revision surgery, the retained packing gauze that was under normal-appearing mucosa was removed from the right ethmoidal sinus (Fig. 4C).
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Packing gauze used for nasal surgery does not usually contain radiopaque
marker material; hence, retained masses formed by the gauze may be difficult
to recognize on radiologic studies
[1,
2]. In this patient, the mass
in the ethmoidal sinuses was initially interpreted as a mucocele on the basis
of the space-occupying effect of the gossypiboma, including apparent bone
remodeling. Typically, a mucocele in the ethmoidal sinuses is revealed as a
homogeneous mass of mucoid attenuation on CT scans. Although attenuation
values in a mucocele usually range from 10 to 20 H, the attenuation values may
be higher in a long-standing mucocele with a high protein content, especially
in patients with a secondary hemorrhage
[3,
4].
,,,
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After administration of an IV contrast agent, the lining membrane of the mucocele will usually enhance although contrast enhancement may be subtle. A sinonasal malignancy almost always shows contrast enhancement and therefore was excluded as a possibility in our patient. Furthermore, we did not consider the possibility of an encephalocele because of the absence of a breach at the cribriform plate and because of the high CT attenuation values of the detected mass.
Although retained packing gauze in the ethmoidal sinuses is an infrequent complication of sinus surgery, a soft-tissue mass with X-ray attenuation greater than 40 H that does not enhance should alert the radiologist to the possibility of a gossypiboma in the sinonasal cavities. A mild space-occupying effect and bone remodeling may occur. Because of legal issues, the ability to detect sponges or surgical devices and report them immediately is highly useful.
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