Accidental Ingestion of Nasal Packing Gauze during Endonasal Endoscopic Dacryocystorhinostomy under Local Anesthesia: A Case Report

<b><i>Purpose:</i></b> To report a case of accidental ingestion of a nasal packing gauze during endonasal endoscopic dacryocystorhinostomy (en-DCR) under local anesthesia. <b><i>Case Report:</i></b> A 66-year-old female patient underwent an en-DCR for a right acquired nasolacrimal duct obstruction. The surgery was performed in a supine position under local anesthesia. An X-ray detectable ribbon gauze soaked in 0.02% epinephrine was placed in the middle meatus to prevent blood and liquid from flowing into the pharynx. The same packing gauze was also used for hemostasis during the surgery. At the end of the surgery, 1 piece of gauze was missing and could not be detected by the endonasal endoscopic exploration. An abdominal X-ray image performed on the same day demonstrated the presence of the gauze in the stomach although the patient did not notice swallowing the gauze. The gauze was not there on the X-ray 1 week later. <b><i>Conclusion:</i></b> Surgeons need to be aware of accidental ingestion of a nasal packing gauze in en-DCR under local anesthesia. Keeping the gauze end out of the nostril is likely preventive for this complication. The use of X-ray detectable gauze was helpful to detect its location.