A gossypiboma is a mass that originates due to a foreign body reaction, in which a foreign object such as a hemostatic gauze remains inside the body during surgery [1]. Although the mass causes an inflammatory reaction in the body, the findings present a variety of symptoms in the involved organs and non-specific imaging findings. Therefore, early gossypiboma detection is often difficult, and gossypibomas are sometimes confirmed after a long period [2]. The incidence rate is 1 in 1,000 to 1,500 cases of abdominal surgery, and rare case report studies have been conducted on rhinologic surgery [3]. Foreign body reaction, which is expressed as non-specific symptoms such as pain, rhinorrhea, nasal obstruction, and nasal bleeding, may be mistaken for a general postoperative complication. Here, we report a case of nasal septal gossypiboma in a patient who presented with nasal obstruction after rhinoseptoplasty and whose medico-legal issues remain ongoing.

A 33-year-old man visited the outpatient clinic for left nasal obstruction and a foreign body sensation that had begun six months ago. Six years previously, the patient had undergone endonasal rhinoplasty using silicone for dorsal onlay and right conchal cartilage for tip augmentation at a private plastic surgery clinic. He also underwent open-approach rhinoplasty with septoplasty, including septal extension graft, humpectomy, and dorsal onlay graft using silicone implants at another private plastic surgery clinic two years ago. After the second surgery, his left nasal obstruction worsened and he sometimes experienced a foul odor.

Physical examination confirmed no specific problems, including a saddle nose or deviation of the silicone implant in the external nose. Nasopharyngoscopy revealed granulation tissue entangled with foreign material in the left nasal septum (Fig. 1A). Contrast-enhanced paranasal sinus computed tomography (CT) showed a 2.2 cm×1.8 cm×0.9 cm sized ill-defined rim enhancing mass in the nasal septum, and the mass bulged into the left nasal cavity (Fig. 2). Removal of the nasal septum foreign body was planned through the endoscopic approach, and oral antibiotics were prescribed until surgery. Exploratory surgery was performed under general anesthesia. The mucoperichondrial flap was raised through a left-sided hemitransfixation incision. The mass was located on the posterior edge of the L-strut cartilage and anterior part of the perpendicular ethmoid plate (PEP). Because of the severe adhesion between the gossypiboma and the left mucosal flap (Fig. 3A), extensive septal mucosal tears occurred during the separation procedures (Fig. 3B). The removed mass was in the form of folded gauze (Fig. 4A) and was approximately 15 cm in length when unfolded (Fig. 4B). To reconstruct the defective septum, the perforated mucosa was trimmed, and the PEP, which was preserved in the previous operation, was harvested and used as an interposition graft. Septal mucosa was approximated using a quilting suture. The remaining defective area was covered by rotating the left inferior turbinate mucoperiosteal flap posteriorly toward the left nasal septum (Fig. 3C). The operation was terminated by fixing the silicone sheet to the nasal septum and packing both nasal cavities with Rhinocel (polyvinyl acetate sheeted with carboxymethyl cellulose). After surgery, intravenous antibiotics, including ceftriaxone and metronidazole, were prescribed, and the patient was discharged on the fifth day after surgery. On histopathological examination, granulation tissue was found in the form of acute and chronic inflammatory reactions. The culture was positive for Staphylococcus epidermidis, which was resistant to oxacillin and ciprofloxacin but sensitive to clindamycin. Therefore, oral clindamycin was prescribed for one week during the follow-up period.

Figure 1. Endoscopic images of the left nasal cavity. (A) The preoperative image shows granulation tissue entangled with gauze filaments in the left nasal septum. (B) A six-month- postoperative image shows a well-healed nasal septum without septal perforation. (C) An eight-month-postoperative image shows a 2-mm septal perforation in the mid portion of septum.

Figure 2. Contrast-enhanced paranasal computed tomography shows a 2.2 cm×1.8 cm×0.9 cm sized ill-defined rim enhancing lesion in the nasal septum (asterisks), which is bulging to the left nasal cavity. Previously implanted silicone is seen on the dorsum. (A) Axial view. (B) Coronal view.

Figure 3. Perioperative endoscopic images. (A) There is severe adhesion (black arrows) between the gossypiboma and the mucoperichondrial flap. (B) A 3.0 cm×2.0 cm sized significant septal mucosal defect (white arrows) occurred after gossypiboma removal. (C) A posterior-based inferior turbinate flap (asterisk) covered the left septal defect area. (D) The left inferior turbinate pedicle was transected four weeks after the surgery.

Figure 4. Intraoperative photographs. (A) Gossypiboma immediately after removal. (B) Whole form of the gauze when unfolded.

The patient was followed up at the outpatient clinic every two weeks. Four weeks after the operation, the left inferior turbinate pedicle was transected (Fig. 3D), and the silastic sheet was removed. Subsequent follow-up confirmed that flap vitality was well maintained. The nasal septum was straight and fully recovered by six months (Fig. 1B); however, a 2-mm perforation was found at the 8-month visit (Fig. 1C), without saddle nose deformity. The left nasal obstruction and foreign body sensation disappeared during the initial visit. However, the medicolegal issues remain ongoing after a year. The exemption from review was obtained from the Pusan National University Yangsan Hospital Institutional Review Board (No. 05-2022-210).

Gossypiboma is caused by the retention of surgical gauze made of cotton material in the body. It does not change its properties nor cause a chemical reaction over time, but it causes complications due to an inflammatory reaction with the surrounding tissues [4]. In a study on factors that increased the occurrence of foreign bodies, surgery performed in an emergency situation showed the highest risk, followed by multiple surgical teams operating at the same time and changing surgical teams, and procedures performed in a double lumen of the body at the surgical site [5]. In this case, the nasal septum, where the foreign body was present, represented the narrow and deep spatial characteristics of the nasal cavity, which seems to be associated with a relatively high risk for leaving gauze during hemostatic procedures.

Gossypibomas can cause two types of reactions in the body. One is an exudative reaction that leads to the formation of an abscess accompanied by bacterial infection, and the other is a sterile fibrotic reaction that results in adhesions or encapsulation, leading to the formation of granulomas. The latter usually presents with sequelae much later than the exudate response [2]. Therefore, they remain asymptomatic and are discovered by incidental imaging findings or diagnosed with sudden complaints of symptoms several years after surgery. In this case, the gossypiboma was present as an aseptic fibrotic lesion for several years after surgery. It is assumed that an exudative reaction followed and resulted in pressure exerted by the gossypiboma that may have induced mucosal necrosis, extruded septum, and exposure to the left nasal cavity, leaving large sequelae.

It is important to diagnose asymptomatic gossypiboma using imaging tests. In the case of plain X-ray imaging, if there is no radio-opaque marker in the gauze foreign body or if the size of the marker is small, the body is very difficult to distinguish by imaging. A typical spongiform pattern is the most characteristic finding on CT [6]. As chronic gossypiboma can be misinterpreted as a malignancy on CT; thus, careful judgment is required when deciding on the surgical treatment [7].

The defect size following surgical gossypiboma removal varies depending on the site and degree of adhesion. In this case, a 3.0 cm×2.0 cm sized large septal mucosal defect was observed. Local flap grafting or inferior turbinate flap grafting can be used [8]. In addition, human dermal grafts such as AlloDerm can also be used [9]. An ipsilateral posterior-based inferior turbinate flap was used in this case, as it was reported to have good results and avoids other synthetic materials that may have possible foreign body reactions [8]. In addition, the endoscopic approach may minimize the foreign body sensation at the tip of the nasal septum compared to the open approach with a columellar incision. To reduce the risk of medical disputes that may occur after the diagnosis and treatment of gossypiboma, it is important not to leave gauze during surgery. The guidelines provided by the Association of Perioperative Registered Nurses suggest the following preventive measures: First, when the surgical and nursing teams are replaced, the gauze coefficient can be accurately transferred. Second, the gauze is counted at the end of the operation, and if it does not match, the lost gauze is checked through imaging examination and re-exploitation of the surgical site. Third, a radiopaque swab was used for gauze. Fourth, it is suggested that the sensitivity of the search should be increased by nearly 100% by applying a radio-frequency identification chip to the gauze [10]. It was assumed that accurate gauze counting was not performed in the previous operation because a non-radiopaque gauze was left. Counting gauze is even more important if commercialized radiopaque gauze is not used.

Gossypiboma detection may be delayed, as symptoms may appear several years after the operation. Rhinoplasty surgeons should be cautious about the gauze left inside the patient, especially when rhinoplasty is combined with septoplasty and reconstruction is planned. The removal of septal gossypiboma may induce large septal perforation and cause critical medico-legal issues.

This work was supported by a 2021 research grant from Pusan National University Yangsan Hospital.

The authors have nothing to disclose.