Gossypiboma is an inflammatory reaction to a foreign body, specifically composed of a cotton matrix left behind
after surgery. The present study aims to present a case report of gossypiboma 23 years after a dental surgery and to
make a literature review of the English language cases published on the issue. A 42-year-old woman was attended
to evaluate complaints of pain on the right side of the maxilla. The patient reported that dental extractions in this
region had been performed over a period of nearly 23 years. The panoramic radiograph demonstrated an opacity in
the right maxillary sinus, which presented a spongiform aspect, irregularly shaped radiopaque image, as well as a
rupture of the maxillary sinus's lower cortical layer. A surgical excision was performed, and the histopathological
diagnosis was of gossypiboma. Six similar cases have also reported of gossypiboma in the oral region; however,
calcification was only identified in the present case report. The patient is currently undergoing follow-up and has
presented no complaints of pain or recurrence

Alves-de-Oliveira, Camila-de-Nazaré

Mesquita, Ricardo Alves

Pimenta-do-Amaral, Tania-Mara

Souto, Giovanna Ribeiro

Journal of Clinical and Experimental Dentistry

PubMed

CdN Alves-de-Oliveira

TM Pimenta-do-Amaral

G. Ribeiro-Souto

R. Alves-Mesquita

Crossref

Gossypiboma in the oral region: case report and literature review

Repositori d'Objectes Digitals per a l'Ensenyament la Recerca i la Cultura

e444J Clin Exp Dent. 2014;6(4):e444-7. Gossypiboma in oral regionJournal section: Oral Medicine and Pathology  Publication Types: Case ReportGossypiboma in the oral region: case report and literature reviewCamila-de-Nazaré Alves-de-Oliveira 1, Tania-Mara Pimenta-do-Amaral 1, Giovanna Ribeiro-Souto 1, Ricardo Alves-Mesquita 11 Department of Oral Pathology and Surgery. School of Dentistry. Universidade Federal de Minas Gerais. Faculdade de Odonto-logia. BrasilCorrespondence:Department of Oral Pathology and Surgery. School of DentistryUniversidade Federal de Minas GeraisFaculdade de Odontologia, sala 3202DAv. Antônio Carlos 6627Pampulha - 31270-901Belo Horizonte, MG - Brasilcnao20@yahoo.com.brReceived: 22/02/2014Accepted: 01/05/2014Abstract Gossypiboma is an inflammatory reaction to a foreign body, specifically composed of a cotton matrix left behind after surgery. The present study aims to present a case report of gossypiboma 23 years after a dental surgery and to make a literature review of the English language cases published on the issue. A 42-year-old woman was attended to evaluate complaints of pain on the right side of the maxilla. The patient reported that dental extractions in this region had been performed over a period of nearly 23 years. The panoramic radiograph demonstrated an opacity in the right maxillary sinus, which presented a spongiform aspect, irregularly shaped radiopaque image, as well as a rupture of the maxillary sinus’s lower cortical layer. A surgical excision was performed, and the histopathological diagnosis was of gossypiboma. Six similar cases have also reported of gossypiboma in the oral region; however, calcification was only identified in the present case report. The patient is currently undergoing follow-up and has presented no complaints of pain or recurrence.Key words: Gossypiboma, textiloma, muslinoma, gauzoma, oral region.Alves-de-Oliveira CdN, Pimenta-do-Amaral TM, Ribeiro-Souto G, Alves-Mesquita R. Gossypiboma in the oral region: case report and literature review. J Clin Exp Dent. 2014;6(4):e444-7.http://www.medicinaoral.com/odo/volumenes/v6i4/jcedv6i4p444.pdfArticle Number: 51553                http://www.medicinaoral.com/odo/indice.htm© Medicina Oral S. L. C.I.F. B 96689336 - eISSN: 1989-5488eMail:  jced@jced.esIndexed in:PubmedPubmed Central® (PMC)ScopusDOI® Systemdoi:10.4317/jced.51553http://dx.doi.org/10.4317/jced.51553IntroductionGossypiboma is derived from the Latin “gossypium”, the genus of cotton plant types and from boma, a Swahi-li word meaning “place of concealment.” This term is applied to the inflammatory response caused by the in-troduction of a foreign body (1). Gossypiboma has also been labeled in prior literature as textiloma, cottonoid, gauzoma, or muslinoma, which are rare conditions cau-sed solely by iatrogenic factors. However, a gauze left behind after surgery is a serious medical/legal issue and is thus often under-reported in the literature (2,3).Physical surgeries with large openings, including ab-dominal, otorhinolaryngology, plastic, orthopedic, and cardiothoracic surgeries, have all reported cases of gos-sypibomas (4,5). Prior literature has reported a 76% in-cidence of a false count of surgical sponges after having completed the surgical procedures, while an incidence of gossypiboma varies between 1/1000 and 1/10000 (2). Most commonly found in the literature are cases of gossypiboma associated with neurosurgical procedures in the head and neck region, with only a few reported cases associated with oral surgery. A search in the annals e445J Clin Exp Dent. 2014;6(4):e444-7. Gossypiboma in oral regionless possible options.Surgical exploration for the biopsy was performed. However, because of the intraoperative condition, in which the lesion was well-defined and could be easily excised, the lesion was surgically removed (Fig. 1). A fibrin sponge was placed inside the maxillary sinus to avoid bleeding and to facilitate the closure of the in-cision. The surgical specimens (Fig. 1) were sent for histopathology analysis. The largest fragment was hard and had undergone decalcification. Microscopic analy-sis demonstrated an epithelial lining of the respiratory tract, loose connective tissue with chronic inflammatory cells, and dystrophic calcification (Fig. 2). The decalci-fied fragment appeared as numerous, eosinophilic, linear structures, which were at times angular and birefringent (Fig. 2). Staining for PAS and Gomori-Grocott proved to be negative. Considering the possibility that these struc-tures represent an exogenous material made of gauze, a sample of gauze was processed and included in labora-tory. The image of the included gauze proved to be iden-tical to the previously described material (Fig. 2).In follow-up, the patient was again questioned about her prior surgeries. Was reported that they had been quite traumatic and that had to return to the dentist repeatedly to stop the bleeding and put this “thing” [as the patient called it] in place of the extracted teeth. This information made it clear that the proper diagnosis was of gossypi-boma.A panoramic radiograph was taken 15 days after this fi-nal surgical procedure. No remnant of the gauze could be observed. What could be observed was a partial opa-city of the maxillary sinus, which was compatible with the inflammation in the region (Fig. 3). The patient sub-sequently underwent the surgical correction of oroantral communication, and in follow-up, the patient reported no complaints of pain or recurrence (Fig. 3).Fig. 1. (a) Panoramic radiograph: showing radiopaque image in left maxillary sinus; (b) The lesion and the rupture of the lower cortical layer (yellow arrow) can be seen in greater detail; (c) in-traoperative procedure demonstrates a removal of a well-defined lesion; (d) and the major specimens presented an oval shape.of PUBMED for gossypiboma, textiloma, cottonoid, gauzoma, or muslinoma in oral region, as well as in the maxillary sinus, revealed six similar cases (4-7). Fever, swelling, tenderness, and purulent discharge from an oral wound after surgery may indicate the presence of gossypiboma (6). Some patients are either asymptomatic or take a very long time to present any symptoms of in-flammation or fistula formation. Diagnosis is determined both by the association of clinical and imaging exams as well as by surgical removal, in which the gauze left behind can be identified. Radiographic or computed to-mography [CT] features of oral gossypiboma may vary among radiolucent, isodense, low-density, or heteroge-neous masses, depending on the type of reaction pro-duced by the body due to the gauze (2,5). Ultrasound analysis shows a hypoechogenic mass associated with the hyperechogenic region (6).The present study aims to report on a case of gossypibo-ma in the maxillary sinus after a 23-year period of tooth treatment and extraction, as well as presents a literature review of case reports in the English-language concer-ning gossypiboma in the oral region.Case ReportA 42-year-old woman was attended to evaluate com-plaints of pain on the right side of the maxilla. The patient’s medical history included hypertension, gastric ulcers, dizziness, and fainting, all controlled with me-dication. Extraoral examination revealed no abnormali-ties. The patient reported pain in the maxilla, which had begun two years ago and which had become more inten-se in the last two months. This pain was accompanied by a pus secretion from the lesion, which often presen-ted a foul smelling secretion within the nasal discharge. Nearly 23 years before, the patient had undergone dental extractions in this same dental region, producing a com-plication within the maxillary sinus that had not been previously addressed. Intraoral evaluation revealed an edentulous maxilla with a fistula in the right molar re-gion, which presented a purulent, foul-smelling draina-ge. The patient does not use removable upper dentures, but pain was reported during palpation. The panoramic radiograph presented an opacity on the right maxillary sinus and a homogeneous, slightly circular with ill-de-fined borders, radiopaque image, measuring approxima-tely 2.0 x 2.5 cm. In addition, a rupture of the lower cortical layer could also be observed (Fig. 1).The differential clinical-radiographic diagnosis inclu-ded either inflammatory or infectious processes, such as chronic sinusitis caused by oroantral perforation, the for-mation of fungus balls [mycetoma or aspergillosis], the presence of a foreign body, or large antroliths. Cemen-toblastoma, complex odontoma, calcifying epithelial odontogenic tumors, fibrous dysplasia, calcifying cystic odontogenic tumors, and osteosarcoma were found to be e446J Clin Exp Dent. 2014;6(4):e444-7. Gossypiboma in oral regionDiscussionA review of the English language literature in the PUB-MED database was carried out on case reports of gossy-piboma in the oral region and the maxillary sinus, using the following keywords: gossypiboma, textiloma, mus-linoma, and gauzoma. Six cases were found, as shown in table 1. The patients ranged between 27 and 60 years of age, and were predominantly female. Three cases of gossypibo-ma were reported after having undergone plastic surgery of the mandibular contour (6), one case in the subman-dibular region after the right submandibular gland had been removed (7), another after extraction of the third molar from the retromolar region (5), and yet another in the maxillary sinus (4). The maxillary sinus case de-veloped after having removed a cyst form the maxillary sinus using the Caldwell-Luc approach. In the current case report, the gossybipoma proved to be related to too-th extraction.The formation of gossypiboma is directly linked to ia-trogenesis in surgical procedures, in such a way that the chances of identifying a gossypiboma after major sur-gery are higher, since the gauze used are larger in both size and number. Swelling and improper closing of the surgical wound, with drainage of a purulent discharge, are indicative of inflammation or infection, which may not be related to the presence of a foreign body. Song et al. [2009] (6) cited 2 types of reactions. One is an aseptic fibrinous response that results in adhesion or encapsu-lation, in turn leading to the formation of granulomas. The other is an exudative-type formulation leading to an abscess, with or without bacterial superinfection. In the current case, the presence of chronic inflammation with purulent drainage could be identified, thus indicating the exudative-type formulation.Considering all the cases, the longest time in which the gauze was retained in the oral region was of 8 years (7), whereas in current case, this time was of 23 years before its removal. The main symptoms were reported in nearly every case [except one], in which the body’s reaction was to encapsulate the foreign body. In five cases, as in the current case report, symptoms of pain, swelling, and drainage of pus for long periods of time were reported.Panoramic radiography, CT, magnetic resonance, and/or ultrasound contribute significantly to the diagnosis of gossypiboma. The radiographic features of gossypibo-ma are not well-defined. It could be observed that gos-sypiboma depends on the local reaction to the foreign body, the composition of the gauze, the containing or not of a radiopaque marker, and the retention time. These factors can also lead to misdiagnoses (2). In the cases of gossypiboma of the oral region and maxillary sinus, no images could be observed featuring radiopaque foreign bodies in the panoramic radiograph, but these did appear as well-demarcated radiolucencies (5). In the cases eva-luated by CT, the image was described as an opacity in the maxillary sinus (4), determined by blind cavity fis-tulograma (7) or even a low-intensity, ill-defined mass with a spongiform aspect and irregular borders, contai-ning air bubbles (6). The current case report demonstra-ted a radiopaque image, with irregular borders and some small radiolucent areas inside, due to the long period [23 years], which made the formation of dystrophic calcifi-cation possible.Fig. 2. (a) Microscopic features demonstrate respiratory epithe-lium with inflammatory infiltrate; (b, blue arrow) and calcification; (c, green arrow) Figure display linear, angular, and sometimes bi-refringent structures;  (d, green arrow) that can be observed in the gossypiboma; note the similar structures in the microscopic view of the lesion and in the inclusion of gauze.Fig. 3. (a) Panoramic radiograph 15 days after surgery; (b, red arrow) showed a partial opacity of the maxillary sinus, compatible with inflammation in the region in remission, and follow-up after 4 months,  where a thin radiopaque line of the lower cortical layer of the maxillary sinus can be observed.e447J Clin Exp Dent. 2014;6(4):e444-7. Gossypiboma in oral regionIn the oral region and maxillary sinus, there are several pathological processes with images and clinical symp-toms that are similar to those caused by gossypiboma. According to the region and radiographic features found in cases in the literature, the differential diagnoses of the gossypiboma included: the recurrence of cysts in the maxillary region salivary fistula [submandibular], resi-dual cysts or cystic ameloblastoma [retromolar region], and surgical wound infections [mandibular contour].Histological examination is important in determining the diagnosis of gossypiboma. Sigron and Locher [2011] (5) reported a histopathology similar to that described in the current case report, that is, an aseptic chronic inflamma-tory infiltration with birefringent gauze fragments and dystrophic calcifications.Treatment of the gossypiboma in the oral region consists of eliminating the inflammatory process by surgically removing the gauze, especially in symptomatic cases. Gossypiboma detected in other regions of the body so-metimes it is left untreated, due to the absence of clinical symptoms (2). This conduct was not observed in the oral region. The treatment prognosis is generally quite good, as can be observed in all cases: when the causative factor was removed, the patient was cured.Few case reports on gossypiboma after dental surgery can be found in English-language literature. Dental pro-fessionals need to pay closer attention when performing intraoperative procedures so as to minimize the chances of gauze retention in the oral region. Moreover, profes-sionals should properly diagnose this disease, given that it commonly presents clinical signs and radiographic re-sults that can easily be confused with other pathologies in the oral region.References1. Peloquin P, Vannemreddy PS, Watkins LM, Byrne RW. Intracranial cotton ball gossypiboma mimicking recurrent meningioma: report of a case with literature review for intentional and unintentional foreign body granulomas. Clin Neurol Neurosurg. 2012;114:1039-41.2. Cheng TC, Chou AS, Jeng CM, Chang PY, Lee CC. Computed tomo-graphy findings of gossypiboma. J Chin Med Assoc. 2007;70:565-9.3. Is M, Karatas A, Akgul M, Yildirim U, Gezen F. A retained surgical sponge (gossypiboma) mimicking a paraspinal abscess. Br J Neuro-surg. 2007;21:307-8.4. Pons Y, Schouman T. Maxillary sinus textiloma: a case report. J Med Case Rep. 2010;24:288. 5. Sigron GR, Locher MC. A gossypiboma (foreign body granuloma) mimicking a residual odontogenic cyst in the mandible: a case report. J Med Case Rep. 2011;28:211.6. Song SY, Hong JW, Yoo WM, Tark KC. Gossypiboma after mandi-bular contouring surgery. J Craniofac Surg. 2009;20:1607-10.7. Amr AE. A submandibular gossypiboma mimicking a salivary fistu-la: a case report. Cases J. 2009;7:6413.Conflict of InterestThe authors declare that they have no conflict of interest.Author/year Age Gender Localization Retention time Signs/symptoms Image ExamSong SY et al 200927 years *F Contour man-dibular27 days Swelling, dehis-cence, purulent discharge**CT - a low-intensity, ill-defined mass that contains a spongiform air bubbleSong SY et al 200945 years F Contour man-dibular23 days Swelling and tender-ness CTSong SY et al 200927 years F Contour man-dibular15 days Swelling, tender-ness, purulent dischargeNot doneAmr AE 200927 years *M Submandibular 8 years Pain and purulent dischargeNeck radiograph - no changeA CT fistulogram – cav-ity below floor of mouth.Pons & Schouman 201060 years M Maxillarysinus3 months Recurrent sinusal-gia with purulent rhinorrheaCT-opacity sinusSigron & Locher 201142 years F Mandibular – retro molar region7 years Asymptomatic Panoramic radiographdefined and oval radio-lucentCurent case – Oliveira et al 201342 years F Maxillary Sinus23 years Recurrent sinusal-gia with purulent rhinorrheaPanoramic radiograph - radiopaque image with irregular contours*F: Female, *M: Men, **CT: computed tomographyTable 1. Summary of gossypiboma in oral region and maxillary sinus reported in English-language literature.

Gossypiboma in the oral region: case report and literature review

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