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   Table of Contents      
CASE REPORT
Year : 2019  |  Volume : 5  |  Issue : 3  |  Page : 142-144

A Rare Case of Metallic Foreign Body in Parapharyngeal Space: Preoperative Imaging and Surgical Removal


Department of ENT and Head and Neck Surgery, Lok Nayak Hospital and associated Maulana Azad Medical College and G.B. Pant Hospital, New Delhi, India

Date of Submission20-Jul-2019
Date of Decision20-Jul-2019
Date of Acceptance01-Sep-2019
Date of Web Publication17-Dec-2019

Correspondence Address:
Dr, MS, Senior Resident Suryaprakash Dhandapani
Department of ENT and Head and Neck Surgery, Lok Nayak Hospital and associated Maulana Azad Medical College and G.B. Pant Hospital, New Delhi - 110002
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mamcjms.mamcjms_57_19

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  Abstract 


Parapharyngeal space is an infrequent site for foreign bodies to lodge. Presence of neurovascular structures in this space mandates immediate and meticulous removal of the foreign body to prevent any complications. In this case report, we present a rare case of metallic foreign body (sewing needle) in the parapharyngeal space that was removed using external approach without any complications after appropriate imaging (contrast-enhanced computed tomography). Only one case has been reported so far in the literature and ours is the second one.

Keywords: Computed tomography, foreign body, needle, parapharyngeal space


How to cite this article:
Dhandapani S, Meher R, Wadhwa V, Chaudhary D. A Rare Case of Metallic Foreign Body in Parapharyngeal Space: Preoperative Imaging and Surgical Removal. MAMC J Med Sci 2019;5:142-4

How to cite this URL:
Dhandapani S, Meher R, Wadhwa V, Chaudhary D. A Rare Case of Metallic Foreign Body in Parapharyngeal Space: Preoperative Imaging and Surgical Removal. MAMC J Med Sci [serial online] 2019 [cited 2020 Jan 29];5:142-4. Available from: http://www.mamcjms.in/text.asp?2019/5/3/142/273283




  Introduction Top


Foreign body ingestion in adults is relatively uncommon as compared to children. In adults, it occurs more commonly in edentulous and psychiatric patients.[1] Oral and oropharyngeal foreign bodies sometimes migrate into subcutaneous tissue,[2] thyroid tissue,[3] mediastinum,[4] and parapharyngeal space (PPS) due to repeated attempt to remove it blindly with the finger or due to contraction of pharyngeal musculature. Foreign bodies in the PPS are dangerous if not removed due to close proximity to great vessels like internal and external carotid arteries, internal jugular vein, and cranial nerves IX, X, XI, and XII. In this case report, we present an interesting case of a foreign body ingestion, a sewing needle, that migrated from the oropharynx to the PPS.

Case Report

A 40-year-old male patient presented to our department with the history of accidental ingestion of sewing needle while eating that stuck in the throat on left side 2 days back. The patient had tried to remove it blindly using fingers that ended in vain. He presented to a nearby hospital on the second day with dull aching pain on the left side of throat that was more during swallowing. No intervention was performed as they could not find the foreign body and the patient was referred to our hospital.

At the time of presentation to our hospital, he had no symptoms like fever, neck swelling, dyspnea, or dysphagia. His past medical history was unremarkable. He was a tobacco chewer for the past 20 years. Examination of oral cavity showed submucosal fibrosis with mild trismus. Angled endoscopes were used to examine the oropharynx in detail but there was no foreign body visible nor any signs of entry point or inflammation. Gentle palpation was done but no foreign body could be palpated.

X-ray of soft tissue neck anterior–posterior and lateral view revealed a metallic linear foreign body in the left PPS. The patient was admitted and kept nil per oral for contrast-enhanced computed tomography (CT). There was a linear foreign body on CT about a length of 4 cm in the left PPS that was parallel and medial to the styloid process [Figure 1]. The great vessels were in close proximity to the needle but intact.
Figure 1 Contrast-enhanced computed tomography showing needle in left parapharyngeal space (arrow).

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The patient was planned for removal of the foreign body under general anesthesia after getting written informed consent for the same. As the foreign body was in close relation to the styloid process, an intraoral approach was planned. Around 2 cm curved intraoral small incision was given along the anterior pillar and dissection was performed to expose the PPS. The styloid process was palpated and dissection was performed along it. In spite of meticulous dissection in the PPS, the foreign body could not be visualized and we stopped because of fear of damaging the great vessels and nerve in PPS. At this point, it was decided to go for an external approach. Under aseptic precautions, a longitudinal incision was given on the left side about 5 cm along the anterior border of the sternocleidomastoid muscle. Dissection was continued, subplatysmal flap elevated, and the tail of the parotid was retracted superiorly. Facial nerve was identified, preserved, and retracted superiorly. Dissection was continued till the styloid process. The needle was found lying anteromedial and parallel to the styloid process that was exposed in its entire length meticulously and removed carefully [Figure 2] and [Figure 3]). There was no neurovascular injury. Hemostasis was achieved and the wound was closed in layers. The postoperative period was uneventful.
Figure 2 Foreign body − needle; intraoperative view (arrow).

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Figure 3 Foreign body − needle; after removal.

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  Discussion Top


In adults, foreign body ingestion is less common compared to children. It is more common in mentally retarded patients and edentulous people[1] and most common are bones (fish and meat).[5] Foreign bodies can reach the PPS from either oropharynx following ingestion[6],[7] or the neck by penetrating injuries.[8]

PPS is an inverted pyramidal-shaped space and its base is at the skull base and the apex is toward the greater cornu of hyoid bone. It is bound medially by pharyngobasillar fascia and superior constrictor and laterally by ramus of the mandible. This space is divided by the styloid process and its attachments into prestyloid and poststyloid compartments. Its major contents are internal carotids maxillary artery, jugular vein, and cranial nerves IX, X, XI, and XII as well as mandibular branch of trigeminal nerve. For diagnosing foreign body in the PPS, CT is better than X-ray or ultrasound. CT will give us the exact relationship of the foreign body with the major neurovascular structures. Oropharyngeal foreign bodies should be removed under vision either using angled endoscopes or rigid laryngoscope. Blind attempt with fingers will lead to migration of the foreign body.[6] Foreign bodies in the PPS can present as a neck swelling or subcutaneous mass,[9],[10] pain in throat, or odynophagia.[6] It may lead to complications like erosion of the carotid wall[11] or abscess formation[10] if not removed as early as possible. So early intervention is needed to prevent complications.

In the above case, we thought of removing the foreign body by intraoral approach as we wanted to avoid an external approach. The intraoral approach is not a good approach as it offers a limited exposure to the PPS compared to the external transcervical approach with consequent unsatisfactory control of great vessels of the neck, making it difficult to control massive hemorrhage, if it occurs, and increased incidence of nerve damage.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Webb WA. Management of foreign bodies of the upper gastro-intestinal tract: update. Gastrointest Endosc 1995;41:39-51.  Back to cited text no. 1
    
2.
Gertner R, Barel E, Fradis M, Podoshin L. Unusual complication of an ingested foreign body. J Laryngol Otol 1991;105:146-7.  Back to cited text no. 2
    
3.
Bendet E, Horowitz Z, Heyman Z, Faibel M, Kronenberg J. Migration of fishbone following penetration of the cervical esophagus presenting as a thyroid mass. Auris Nasus Larynx 1992;19:193-7.  Back to cited text no. 3
    
4.
Sinha A, Shotton JC. An unusual foreign body migrating from pharynx to mediastinum. J Laryngol Otol 1996;110:279-80.  Back to cited text no. 4
    
5.
Singh B, Kantu M, Har-el G, Lucente FE. Complications associated with 327 foreign bodies of the pharynx, larynx and oesophagus. Ann Otol Rhinol Laryngol 1997;106:301-4.  Back to cited text no. 5
    
6.
Aydogan B, Soylu L, Tuncer U, Akcali C. Parapharyngeal foreign body. Otolaryngol Head Neck Surg 2001;124:424-5.  Back to cited text no. 6
    
7.
Burduk PK. Parapharyngeal space foreign body. Eur Arch Otorhinolaryngol 2006;263:772-4.  Back to cited text no. 7
    
8.
Enomoto K, Nishimura H, Inohara H, Murata J, Horii A, Doi K et al. A rare case of a glass foreign body in the parapharyngeal space: pre-operative assessment by contrast-enhanced CT and three-dimensional CT images. Dent Maxillo Fac Rad 2009;38:112-5.  Back to cited text no. 8
    
9.
Leung NMW, Chan HS, Vlantis AC, Tong MCF. A pharyngeal foreign body presenting as a painful neck mass. Otolaryngol Head Neck Surg 2010;143:315-6.  Back to cited text no. 9
    
10.
Coales UF, Tandon P, Hinton AE. Limitations of imaging for foreign bodies in parapharyngeal abscess and the importance of surgical exploration. J Laryngol Otol 1999;133:683-5.  Back to cited text no. 10
    
11.
Osinubi OA, Osiname AI, Pal A, Lonsdale J. Foreign body in the throat migrating through the common carotid artery. J Laryngol Otol 1996;110:793-5.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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