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 Table of Contents    
Year : 2023  |  Volume : 16  |  Issue : 1  |  Page : 145-147  

Phantosmia: A neglected symptom after Dacryocystorhinostomy with intubation (A case report)

1 Department of Ophthalmology, Karachi Medical and Dental College, Abbasi Shaheed Hospital, Karachi, Pakistan
2 ENT Surgeon, Karachi Medical and Dental College, Abbasi Shaheed Hospital, Karachi, Pakistan

Date of Submission01-Nov-2021
Date of Decision13-Jun-2022
Date of Acceptance29-Jun-2022
Date of Web Publication21-Feb-2023

Correspondence Address:
Erum Shahid
Department of Ophthalmology, Karachi Medical and Dental College, Abbasi Shaheed Hospital, C 88, Block A, North Nazimabad, Karachi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ojo.ojo_318_21

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A 62-year-old female presented with complaints of persistent phantosmia (foul smell) for the last 4 months. She has a past history of right-sided dacryocystorhinostomy (DCR) 18 months back and left-sided DCR 12 months back. In the initial follow-up period, the patient had frequent visits to her otolaryngologist and ophthalmologist. She experienced phantosmia often but was reassured. The patient presented to us and was examined in an operation theater. It was discovered that the foul-smelling foreign body was present in her right nasal cavity above the middle turbinate. It was removed. A retained gauze piece was revealed to be a cause of phantosmia. The purpose of reporting is to create awareness among ophthalmologists and otolaryngologists. Retained gauze piece following DCR surgery presenting as phantosmia is a new symptom after DCR surgery previously not reported in the literature. Repeated complaints of a postoperative patient, should be dealt with vigilantly and timely.

Keywords: Dacryocystorhinostomy, gossypiboma, phantosmia

How to cite this article:
Shahid E, Nasir M, Khan FA, Fasih U. Phantosmia: A neglected symptom after Dacryocystorhinostomy with intubation (A case report). Oman J Ophthalmol 2023;16:145-7

How to cite this URL:
Shahid E, Nasir M, Khan FA, Fasih U. Phantosmia: A neglected symptom after Dacryocystorhinostomy with intubation (A case report). Oman J Ophthalmol [serial online] 2023 [cited 2023 Mar 31];16:145-7. Available from: https://www.ojoonline.org/text.asp?2023/16/1/145/370049

   Introduction Top

Phantosmia is an abnormal persistent olfactory sensation in the absence of any other smell. It is described as the smell of something that may be rotten, burnt, foul, or spoiled. It may either be in one nostril or in both nostrils.[1],[2] It may be caused by a nasal infection, nasal polyps, dental infection, neurological disorders such as migraine, head trauma, and Parkinson's disease.[2],[3] It can also be a symptom of any psychiatric disorder as an olfactory hallucination, schizophrenia, anxiety, and depression. Environmental exposures are sometimes the cause as well such as exposure to a certain type of industrial chemicals.[4]

Dacryocystitis is an inflammation and infection of the lacrimal sac triggered by retained stagnant contents within the sac and, mostly due to acquired nasolacrimal duct obstruction.[5] Dacryocystorhinostomy (DCR) with or without intubation is the treatment of choice for dacryocystitis. It is a procedure in which a passage is created between the lacrimal sac and nasal cavity by making a bony ostium to drain tears from canaliculi to the lateral wall of the nose. It may be carried out through an external or endonasal approach. Both approaches have a success rate of more than 90% with fewer complications reported.[6]

Common complications of DCR are a failure, recurrence of epiphora, purulent discharge, and wound Infection.[7]

We are reporting a new symptom after DCR i.e., phantosmia due to a retained gauze piece in the nasal cavity of a patient after surgery. We are reporting this complaint after surgery for the first time in the literature. This case is reported to create awareness among the ophthalmologists and otolaryngologists for proper evaluation and to decrease the negligence rate. This case was reported in a tertiary care hospital in Karachi in 2021.

   Case Report Top

A 62-year-old, married female, resident of, Karachi with no known comorbid presented with complaint of phantosmia, persistent for the last 4 months. She was given a history of right external DCR with intubation 18 months back and left external DCR 12 months back in another hospital. DCR tube was removed 6 months after the surgery. She had no significant history of any systemic illness. Her vision was 20/20 and was pseudophakic bilaterally.

The patient started to feel a foul smell often after her DCR surgery. She reported this phenomenon to her primary surgeon. She was reassured that the surgery went well and was referred to an otolaryngologist. An otolaryngologist examined her in an outpatient department (OPD) and was advised for steam inhalation. Four months back, her complaint of phantosmia became persistent, not relieved by any medication or steam inhalation. Her family members also noticed a foul smell coming from the patient's nose. She visited our hospital. She was advised for a paranasal sinus X-ray. Her X-ray was clear and was referred for nasal examination. Her nose was examined with help of a nasal speculum by an otolaryngologist in an OPD. It revealed a foreign body or suspected mass in her right-sided nasal cavity above the middle turbinate. The next day patient was examined in an operation theater for further evaluation. It was discovered that the foul-smelling foreign body was a gauze piece. Her otolaryngologist tried to pull it but it was stuck up in her nose causing pain and bleeding. She was then advised to instill liquid paraffin for 2 days to soften the gauze piece. The patient was then followed after 2 days in an operation theater. Four percent xylocaine with adrenaline-soaked gauze piece was placed in her nasal cavity for 5 min and removed. The retained gauze piece was then pulled out with a Tilley's nasal pack forceps [Figure 1]. It was about 6.3 cm long surrounded by granulation tissue and blood [Figure 2]. There was slight bleeding and hemostasis was achieved by applying pressure. The patient was discharged on the same day with systemic antibiotics and analgesics. After 1 week follow-up, there was no foul smell or any discharge from the nasal cavity.
Figure 1: Retrieving gauze piece from the nasal cavity of a patient

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Figure 2: Removed gauze piece soaked with blood and blood clot

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   Discussion Top

A nasal pack is usually placed after DCR surgery to attain hemostasis. It is generally removed 24 h or 48 h postoperatively depending upon the surgeon's preference. Hemostasis is assessed, the wound is cleaned and the patient is discharged on oral and topical medications and nasal decongestant. The patient is reviewed after 6 weeks, 12 weeks, and then 6 months. DCR tube removal is usually done at 12 weeks in case of intubation.[8]

Gauze packing is also used to support the nasal bone during nasal fractures. It has a tendency to shift resulting in an inflammatory response which can cause foul-smelling odor.[9] The retention of gauze pieces is a part of medical negligence, and different cases have been reported on the retained gauze piece in body cavities. Most cases of them had been reported after intra-abdominal and pelvic surgeries. It has been referred as gossypiboma.[10] The manifestations of gossypiboma may be nonspecific and take weeks, months, and even years after the surgery. Therefore, the diagnosis is delayed and can result in complications including, the formation of an abscess, adhesions, mass lesions, and fistulas.[11] A case was reported about a piece of gauze left in the medial aspect of the inferior orbital margin after 8 months of external DCR surgery.[12] However, no case has been reported about the gauze piece in the nasal cavity after DCR surgery in the literature.

This patient had frequent follow-ups after surgery, for tube removal and for phantosmia. The gauze piece was missed during the follow-up period. We are labeling phantosmia a new symptom due to retained gauze piece following DCR surgery. Retention of a gauze piece is a medical negligence. It is preventable if the surgeon makes sure he removes the gauze piece on the first postoperative day himself. Gauze pieces used during the surgery should be counted and removed before closing the wound. The nasal cavity should be thoroughly examined on follow-ups and the patient's complaint of phantosmia should not be ignored.

In conclusion, phantosmia is a new symptom after DCR surgery due to retained gauze pieces not previously reported in the literature. Repeated complaints of a patient, postoperatively should be dealt with vigilantly and timely to avoid serious complications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given her consent for images and other clinical information to be reported in the journal. The guardian understands that her names and initials will not be published and due efforts will be made to conceal the patient's identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Hong SC, Holbrook EH, Leopold DA, Hummel T. Distorted olfactory perception: A systematic review. Acta Otolaryngol 2012;132 Suppl 1:S27-31.  Back to cited text no. 1
Leopold D. Distortion of olfactory perception: Diagnosis and treatment. Chem Senses 2002;27:611-5.  Back to cited text no. 2
Sjölund S, Larsson M, Olofsson JK, Seubert J, Laukka EJ. Phantom smells: Prevalence and correlates in a population-based sample of older adults. Chem Senses 2017;42:309-18.  Back to cited text no. 3
Frasnelli J, Landis BN, Heilmann S, Hauswald B, Hüttenbrink K, Lacroix JS, et al. Clinical presentation of qualitative olfactory dysfunction. Eur Arch Otorhinolaryngol 2004;261:411-5.  Back to cited text no. 4
DeAngelis D, Hurwitz J, Oestreicher J, Howarth D. The pathogenesis and treatment of lacrimal obstruction: The value of lacrimal sac and bone analysis. Orbit 2001;20:163-72.  Back to cited text no. 5
Yang JW, Oh HN. Success rate and complications of endonasal dacryocystorhinostomy with unciformectomy. Graefes Arch Clin Exp Ophthalmol 2012;250:1509-13.  Back to cited text no. 6
Besharati MR, Rastegar A. Results and complications of external dacryocystorhinostomy surgery at a teaching hospital in Iran. Saudi Med J 2005;26:1940-4.  Back to cited text no. 7
Ali MJ, Naik MN, Honavar SG. External dacryocystorhinostomy: Tips and tricks. Oman J Ophthalmol 2012;5:191-5.  Back to cited text no. 8
[PUBMED]  [Full text]  
Manzella A, Filho PB, Albuquerque E, Farcas F, Kaecher J. Imaging gossypiboma: Pictorial review. AJR 2009;193 Suppl 6:S94-101.  Back to cited text no. 9
Umunna J. Gossypiboma and its implications. J West Afr Coll Surg 2012;2:95-105.  Back to cited text no. 10
Kosaka M, Sai K, Shiratake Y, Ohjimi H. Nasal bone clip: A novel approach to nasal bone fixation. J Craniofac Surg 2010;21:552-4.  Back to cited text no. 11
Shoaib KK. An enlarging mass due to a retained gauze piece-an unusual complication of dacryocystorhinostomy. Can J Ophthalmol 2011;46:372-3.  Back to cited text no. 12


  [Figure 1], [Figure 2]


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