Retained foreign bodies sometimes occur in various surgical procedures and can lead to severe complications. Foreign bodies in the oral and maxillofacial region are not rare because of the use of many small items and the natural communication with the outside environment in some areas. We experienced a case of foreign body in the nasal cavity, which was discovered 1 year later at a second operation for hardware removal after maxillofacial surgery. A small, soft material is usually placed between the nasal endotracheal tube and nostril to avoid nasal pressure ulcer at the ala of nose after prolonged anesthesia after our group’s experiencing some cases of this complication. The foreign body was found in the pharynx during induction of a second anesthesia. Attention should be directed to not leaving any materials in the patient after surgery. In addition to the normal counts of sponges, needles, etc, other small nonsurgical materials used should be recorded by medical staff to help ensure nothing is retained in the patient.
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