DISCUSSION
A foreign body in the paranasal sinus is an uncommon clinical
presentation. The condition is primarily associated with previous
history of surgery, maxillofacial trauma, or dental procedures. The most
common site of involvement is the maxillary sinus. Ethmoidal and
sphenoid sinus foreign bodies are extremely rare. After diagnosis, the
primary treatment modality is surgical retrieval, and the approach is
typically along the course of penetration. Prior reviews have suggested
treatment algorithms according to clinical scenario. Since foreign
bodies in both symptomatic and asymptomatic cases may serve as a
permanent source of irritation, it seemed reasonable to remove the
object to prevent irritation and inflammation of the paranasal sinus.
However, this case that was asymptomatic for 40 years emphasizes the
importance of questioning and considering the true indications of
surgical removal of foreign bodies in the paranasal sinus.
There are only a few cases that have reported foreign body impaction for
more than 20 years.3,4 Lee et al.4reported maxillary sinus fungus ball development caused by retained
foreign bodies and that was asymptomatic for 25 years and was
successfully removed via a combined endoscopic and Caldwell-Luc
approach. In addition, Kuhnel et al.3 reported an air
gun pellet that had remained in the maxillary sinus for 50 years.
Retained foreign bodies theoretically result in infectious
complications, such as sinusitis.4,5 However, the
actual clinical course of foreign body lodgment remains unclear. Prior
reports of paranasal foreign bodies have identified pencils,
paintbrushes, cues, chopsticks, ball pens, wire, and plastic sticks.
Most cases consist of a metallic or plastic foreign body. A metallic
foreign body comprised of a toxic element, such as a lead-containing
bullet, prompts urgent retrieval due to the possibility of blood
poisoning. To date, no reports have discussed the surgical necessity to
treat other kinds of substances. Natural substances such as wood and
plants are highly associated with infection, so prompt removal is
indicated. In comparison, plastic foreign bodies do not tend to induce
inflammation. There is currently no consensus for metallic foreign
bodies other than those containing lead. We were not able to analyze the
exact composites of the scissor blades but hypothesize that the
materials differ from those, such as stainless steel, currently used to
make scissors. Stainless steel consists of nickel or iron, and the
advances in technology could have impacted the corrosivity.
Therefore, it is possible that a foreign body consisting of stainless
steel might not directly cause critical inflammation, and immediate
surgery may not be necessary. For example, cases that could wait and be
kept under observation would include instances where the surgical
removal approach is particularly difficult, if the foreign body is not
in close proximity to neurovascular structures, or if the patient
refuses surgery. Additionally, multiple fragments of foreign bodies may
not be implicated for surgical removal. Therefore, surgeons must weigh
benefits and harms and carefully discuss with the patient. If surgeons
opt for an observation approach, there is a secondary issue about the
relevant artifacts that may hinder precise evaluation when performing
computed tomography or MRI. This must be also discussed with the patient
to optimize treatment and outcomes.