Barium periostitis: An intraoral complication following barium swallow David C. Stanton, DMD, MD, FACS,a Douglas Seeger, DMD, MD,b and Brian T. Robinson, DDS, MD,c Philadelphia, PA and Rockville, MD UNIVERSITY OF PENNSYLVANIA
Barium is used with great frequency for various gastrointestinal radiographic studies. Complications arising from the use of barium are uncommon and can range from peritonitis, pneumonitis, vascular intravasation, allergic reactions, and even “barium appendicitis.” We report a case of an unusual complication, periostitis, from the use of barium in a 46-year-old male. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:e33-e37)
CASE REPORT A 46-year-old male with a past medical history of morbid obesity (140 kg [306 lbs], 167 cm [66 in] tall, and 49.6 kg/m2 body mass index), gastroesophageal reflux disease, depression, asthma, and hypertension was evaluated at the University of Pennsylvania Department of Oral and Maxillofacial Surgery for obstructive sleep apnea. His initial respiratory disturbance index was 94 events/hour with oxyhemoglobin desaturations to a nadir of 68%. In April of 2002, the patient underwent uvulopalatopharyngoplasty and genioglossus advancement for failed continuous positive airway pressure. The patient tolerated the procedure well and had an uneventful postoperative course. The incisions were healing well. He had the anticipated postoperative paresthesia of the mental nerves. His postoperative panoramic radiograph is shown in Fig. 1. Without consulting the surgical team, he initiated a preoperative evaluation for bariatric surgical procedure, specifically a vertically banded gastroplasty. The preoperative workup for his bariatric surgical procedure included a barium swallow, which occurred approximately 2 weeks after the genioglossus advancement was completed. The patient returned for routine follow-up after his barium swallow and was found to be complaining of pain in the anterior mandibular region. This pain was out of proportion to his physical findings. No erythema, swelling, purulent discharge, or segment mobility was noted on exam. Poor oral hygiene and a significant amount of calculus on the mandibular incisors were noted.
Associate Professor, Department of Oral and Maxillofacial Surgery, University of Pennsylvania; currently in private practice, Westwood Oral Surgery Associates, Woodbury Heights, NJ. b Formerly Chief Resident, Department of Oral and Maxillofacial Surgery, University of Pennsylvania. c Formerly Chief Resident, Department of Oral and Maxillofacial Surgery, University of Pennsylvania; currently in private practice, Maryland Oral Surgery Associates, Rockville, MD. Received for publication Sep 25, 2006; accepted for publication Nov 12, 2006. 1079-2104/$ - see front matter © 2007 Mosby, Inc. All rights reserved. doi:10.1016/j.tripleo.2006.11.020
However, these were not thought to be a source of his discomfort. A panoramic radiograph (Fig. 2) taken that day revealed an area of radiopaque material found in the anterior mandibular region that was not noted on any previous radiographic studies. After reviewing the barium swallow, contrast material could be seen in the area of the osteotomy (Fig. 3). On subsequent discussion with the patient, he revealed that he had the barium swallow approximately 2 weeks after the surgical procedure. His incision and osteotomy healed uneventfully. He was followed for 1 year postoperatively and continued to experience pain upon deep palpation in the region of the barium. The osteotomy, teeth, and incision were nontender. The decision was made to remove the plate and extravasated barium surgically. Intraoperatively, the barium was encapsulated and easily removed from the surrounding soft tissue (Fig. 4). The osteotomy site was poorly healed in areas where barium had entered. This intraosseous barium was removed with a combination of a fissure bur and a curette. Fluoroscopy showed a small amount of barium remaining deep within the genioglossus osteotomy site. It was decided that this barium would cause minimal symptoms and was left behind. This barium can be seen on the postoperative radiographs (Figs. 5 and 6). A radiograph (Fig. 7) of the specimen was also taken. It confirmed barium within the resected soft tissue. Pathological study of the specimen showed a clear crystalline polarizable material consistent with barium. At follow-up, the patient was healing well with expected bilateral mental nerve paresthesia. The previous complaints of pain in the mental region are resolving and are only minimal at present.
DISCUSSION Barium is a metallic element and commonly combined with other elements such as sulfate. Outside of the medical profession, barium is used in the production of such things as rubber, paint, and glass. Complications arising from the use of barium are uncommon and can range from peritonits, pneumonitis, vascular e33
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Fig. 1. Panoramic radiograph, postoperative day 1. Osteosynthesis plate, osteotomy, and mandibular archbar are illustrated. No barium in wound.
Fig. 2. Postoperative panoramic radiograph. Archbar has been removed. Barium is noted in osteotomy and adjacent to osteosynthesis plate.
intravasation, allergic reactions, and even “barium appendicitis.”1-3 Barium sulfate, used in gastrointestinal radiographic procedures, is an inert, water-insoluble compound. The severity of complications from the use of barium is usually associated with the increasing concentration of the barium solution.4 Barium is manufactured currently with properties used to make it more adherent to mucosal surfaces. This adherence leads to clumps when extravasated into the abdomen. In addition, this adherence to the intestinal surfaces makes removal difficult.5 In studies done on the affects of barium on the lungs after aspiration, barium causes an acute inflammatory reaction.6,7 This reaction, with a predominance of polymorphic leukocytes, leads to phagocytosis of the bar-
ium crystals. The initial infiltration of PMNs has been noted to take place within 1 hour of contamination in the abdomen.8 This in turn leads to a foreign body reaction. In the abdomen, this reaction can cause fibrosis and adhesions. The intensity of the reaction has been suggested to be proportional to the size and irregularity of the barium crystals.6 The intensity can also be dependent of the enteric contents that are released into the peritoneal cavity.8 Although extravasation of barium into the abdominal cavity is associated with sepsis from bowel contamination, barium has actually been shown to inhibit bacterial growth.9 Unlike the peritoneum, barium released into the retroperitoneum exhibits a localized foreign body reaction with a fibrous capsule. The treatment of intra-abdominal barium consists of
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Fig. 3. Images from the barium swallow that demonstrate pooling of contrast media in the mandibular vestibules and along the anterior mandibular incision. The arrow denotes the location of the curvilinear incision.
copious irrigation and wiping of the viscera to remove barium to reduce any inflammatory reaction and to decrease the concentration of any bacterial contamination. The patient in the previously mentioned case likely had an intense reaction from extravasation of barium into the site of the genioglossus advancement. Since the incision and osteotomy were noted to be completely healed, the pain the patient was reporting can be assumed to be from the intense reaction from barium as described by other authors.5-9 It is unlikely that his symptoms resulted from an infection, because he has shown no other signs of an infection other than pain. This reaction could be a localized reaction of the anterior mandible like the reaction seen in the retroperito-
Fig. 4. Image of the intraoperative view of the surgical site during barium removal. Inferior screws have been disengaged from the plate. The plate and fibrous encapsulated barium have been rotated superiorly. The arrow denotes free barium.
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Fig. 5. Postoperative panoramic radiograph demonstrating barium removal.
Fig. 6. Postoperative lateral cephalometric radiograph demonstrating almost complete barium removal. The tips of the 2 titanium screws, which were osteointegrated, also remain.
neum—a well-localized acute inflammatory reaction. We characterize this as “barium periostitis.” This case illustrates the importance of a thorough history and physical prior to initiation of any treatment or ordering of a diagnostic study. The extravasation of barium could have been avoided by delaying the barium swallow until after the intraoral incision had healed. Alternatively, a nonirritating contrast such as Gastrografin® could have been used. Obviously, the consistency and texture of barium and Gastrografin® are different, and the Gastrografin® swallow may not provide all of the information that a barium swallow can confer. In this case, the postponement of this elective study until complete heal-
Fig. 7. Specimen radiograph demonstrating the osteosynthesis plate and soft tissue barium.
ing of the intraoral incision would have been most prudent. Physicians and technologists should give consideration to querying patients prior to oral contrast administration as to the presence of any recent intraoral surgical procedure. REFERENCES 1. Ikehata A, Nakano Y, Sakuma T. Acute appendicitis after barium enema examination. J Clin Gastroenterol 1999;28:280-1. 2. Al-Mudallal R, Rosenbaum H, Schwartz HJ, Boyle JM. Anaphylactic reaction to barium enema. Amer J Med 1990;89:251. 3. Zalev AH, Warren RE, Burnstein MJ. Venous intravasation of barium: CT findings. J Comput Assist Tomogr 1993;17:813-5. 4. Hunsaker DM, Hunsaker JC. Therapy-related café coronary deaths. Am J Forensic Med Pathol 2002;23:149-54. 5. Karanikas ID, Kakoulidis D, Gouvas ZT, Hartley JE, Koundourakis
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7. 8. 9.
SS. Barium peritonitis: a rare complication of upper gastrointestinal contrast investigation. Postgrad Med J 1997;73:297-8. Gray C, Sivaloganathan S, Simpkins KC. Aspiration of highdensity barium contrast medium causing acute pulmonary inflammation–report of two fatal cases in elderly women with disordered swallowing. Clin Radol 1989;40:397-400. Whiting J, Fruchter O. Aspiration of barium [letter]. N Engl J Med 2003;348:2582-3. Grobmyer AJ, Kerlan RA, Peterson CM, Dragstedt LR. Barium peritonitis. Am Surg 1984;50:116-20. Walker CW, Purnell GL. Complications from extravasated retro-
Stanton et al. e37 peritoneal barium: case report and review of the literature. Radiology 1989;173:618-20.
Reprint requests: David C. Stanton, DMD, MD, FACS Department of Oral and Maxillofacial Surgery University of Pennsylvania 3400 Spruce Street Philadelphia, PA 19104