J Korean Ophthalmol Soc.  2020 May;61(5):550-553. 10.3341/jkos.2020.61.5.550.

Accidental Swallowing of Nasal Packing Gauze during Silicone Tube Intubation under Local Anesthesia

• Kong JH
• An Y
• Choi YJ

• KMID: 2500729
• DOI: http://doi.org/10.3341/jkos.2020.61.5.550

Abstract

Purpose
To report a case of accidental swallowing of nasal packing gauze during silicone tube intubation under local anesthesia.
Case summary
A 58-year-old male patient underwent silicone tube intubation for partial nasolacrimal duct obstruction on the right side. In preparing for surgery, six cottonoids soaked were packed in righ nasal cavity, to facilitate anesthesia and prevent bleeding. Strings detectable by X-ray were attached at the cottonoids and cut 5 cm from the nostrils. After surgical hand scrubbing, the strings were not present. One cottonoid was found in the nasal cavity, but five cottonoids could not be detected by endonasal endoscopic exploration. The patient said he swallowed “something like sputum”. He did not notice any discomfort and the surgery was performed as scheduled. Abdominal X-ray performed immediately after surgery showed the presence of the five strings in the stomach. The strings were not seen on X-ray conducted 4 days later. The patient defecated normal stools three times and did not notice any discomfort over the course of 4 days.
Conclusions
Surgeons need to be aware of the possibility of accidental swallowing of nasal packing gauze during nasolacrimal duct surgery. Use of gauze detectable by X-ray is helpful to determine its location.

Keyword

Accidental swallowing; Cottonoid; Gauze packing; Silicone tube intubation; X-ray detectable gauze