International Journal of Pediatric Otorhinolaryngology Extra
Volume 1, Issue 4 , Pages 282-285, December 2006

Removal of a bristle from a child's tongue base using intraoperative fluoroscopy

Division of Otolaryngology/Head and Neck Surgery, Department of Surgery, Penn State University, College of Medicine, The Milton S. Hershey Medical Center, 500 University Drive, P.O. Box 850, Hershey, PA 17033-0850, USA

Received 9 July 2006; accepted 9 August 2006.

Article Outline

Summary 

We present an unusual case of a metallic barbecue brush bristle embedded in the oropharyngeal tissues of a healthy 11-year-old girl. The case is interesting because the foreign body was extremely tiny but very symptomatic, and required a specific intraoperative technique for removal. To date, this is the first reported case using intraoperative fluoroscopy radiography for the removal of a foreign body in the oropharynx of a pediatric patient. Current methods of removal and a protocol for successful removal are discussed.

Keywords: Foreign body, Fluoroscopy, Oropharynx, Pediatric

 

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1. Introduction 

Foreign body (FB) in the pharynx is not uncommon especially in the pediatric population with a prevalence of 2–5% in this group [1]. Common FBs include fish bones, coins, pins, screws, button batteries, toy parts and food. The literature shows a variety of ways of removing these FBs. The plethora of techniques shows perhaps the difficulty in removing pharyngeal FBs as well as the wide variation in their clinical presentation. We present a unique case to demonstrate the different techniques and the efficacy of intraoperative fluoroscopy.

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2. Case report 

An 11-year-old female with no significant medical history was transferred from an outside hospital to the pediatric general surgery service for removal of a foreign body (FB) seen on a neck X-ray (Fig. 1). On the evening prior to admission, the patient had felt something stuck in her throat immediately after eating a meal consisting of barbecued pork ribs cooked at home. She felt “something was poking out” in her throat when she swallowed. However, she had no dysphagia or dyspnea at any time. By report, the oropharynx and the oral cavity were examined and the FB was not seen. There was no edema, drooling or erythema over the base of tongue, posterior pharyngeal wall, or tonsils. The patient was taken to the operating room by the pediatric general surgery service for direct laryngoscopy and esophagoscopy but they did not visualize the FB. The otolaryngology service was then consulted intraoperatively. The team performed direct laryngoscopy, esophagoscopy and bronchoscopy without visualizing the FB.

A CT scan of the neck showed a hair-thin radio-opaque FB within the soft tissue of the base of the tongue (Fig. 2). The patient was taken back to the OR the following day with the plan of using intraoperative fluoroscopy for locating the FB. A careful visualization of the vallecula and base of tongue did not reveal a FB. Palpation was undertaken by two different surgeons, both of whom felt a needle-like object intermittently, but were unable to visualize it. A sweetheart tongue retractor and a towel clip were used to pull the tongue anteriorly while fluoroscopy was used in the region of the base of the tongue (Fig. 3). Using a metallic clamp as a marker and fluoroscopic views at 90° from each other, the apparent position of the object was determined. A small incision was made in the mucosa immediately above this location using a #12 blade. Even so, the FB was not directly visualized by the surgeon. With a long forceps, the surgeon reached a few millimeters deep within the incision and felt the FB in the forceps and was able to extract it successfully. It was a straight hair-thin 1.2cm-long silver wire (Fig. 4). Discussion with her parents revealed that a metal bristled barbecue brush had been used to clean the grill in between uses, but they had not noticed it losing bristles. Upon waking up from the operation, the patient immediately felt relief from the globus sensation. The postoperative period was uneventful. At a 4-week follow-up visit, the patient continued to be well without dyspnea, dysphagia or odynophagia and was able to tolerate a normal diet.

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3. Discussion 

There are various methods of removing FBs in the oropharynx. Wai et al. suggest a management protocol using direct examination with a tongue depressor, transnasal laryngoscope, lateral neck X-ray, chest X-ray, Macintosh laryngoscope and rigid pharyngo-esophagoscopy [2]. In addition, Lee and Sato and Nakashima have published the use of video endoscopy for the removal of FBs [3], [4], [5]. These techniques are less useful for embedded FBs such as the one described. Once embedded, removal is notoriously difficult. Palpation is often helpful, although in the case of very small or thin objects, palpation may not be helpful in localization. In addition, our patient's FB was embedded within the posterior aspect of the base of tongue, an area that is difficult to visualize directly, at least in the awake patient. For these reasons, fluoroscopy was useful to locate this thin radio-opaque object intraoperatively. In terms of radiation exposure, a C-arm fluoroscopy emits 1600mR/min at our institution. Each exposure lasts less than one second and we used no more than 20 exposures which calculate to less than 533mR for the entire case. Comparatively, a portable chest X-ray would give 10–20mR per exposure and a CT of chest would emit 1263mR at our institution. Consequently, this is a method that exposes the patient to radiation within commonly used limits.

Not surprisingly, this technique has been used for locating lost surgical needles in the OR [6], [7]. There is also one reported use of fluoroscopy for the removal of a metallic FB in the foot [8]. However, only one reported case of removing a FB in the pharynx of an adult using this technique can be found in literature [9]. That report is similar to our case in that the FB was not directly visualized and it was a 3cm long metal wire.

In order for successful removal of small FBs embedded within the oropharyx, we suggest the following protocol. First, the patient needs to be examined well while awake. This includes visualization using tongue blade and possibly a nasophargygoscope. Also, the patient should be palpated in the vicinity of the FB; this should include neck and intraoral palpations. Next, appropriate imaging studies should be ordered and may include X-ray and CT. In the case of extremely small and/or thin FBs, intraoperative fluoroscopy should be planned in advance. In the OR, a thorough examination of the oropharynx needs to be done. This will include direct visualization, finger palpation within the mucosa, bimanual palpation, direct laryngoscopy and possibly esophagoscopy and bronchoscopy. When the FB is still not visualized, fluoroscopy should be used. Furthermore, surgeons must remember that some small FBs can migrate within the mucosa. For instance, there have been cases of fish bone migrating into the soft tissues of the neck [10]. This accentuates the need for intraoperative fluroscopy which can be helpful in locating the FB which may have moved after obtaining the imaging study. Recently, image-guided navigation systems have been used for FB removal [11]. This method may be safe and useful. However, because it relies on preoperatively imaged data, removal of potentially mobile FBs is limited.

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4. Conclusion 

In summary, surgeons faced with embedded oropharyngeal FBs need to keep in mind a broad armamentarium in order to treat these patients efficiently, effectively and safely. When dealing with a small, mobile FB, intraoperative fluoroscopy will be helpful.

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References 

  1. Rothman BF, Boeckman CR. Foreign bodies in larynx and tracheobronchial tree in children. A review of 225 cases. Ann. Otol. Rhinol. Laryngol. 1980;89:434–436
  2. Wai Pak M, Chung Lee W, Kwok Fung H, van Hasselt CA. A prospective study of foreign-body ingestion in 311 children. Int. J. Pediatr. Otorhinolaryngol. 2001;58(1):37–45
  3. Lee FP. Removal of fish bones in the oropharynx and hypopharynx under video laryngeal telescopic guidance. Otolaryngol.—Head Neck Surg. 2004;131(1):50–53
  4. Sato K, Nakashima T. Office-based foreign-body management using videoendoscope. Am. J. Otolaryngol. 2004;25(3):167–172
  5. Sato K. Extraction of minute pharyngeal foreign bodies with the videoendoscope. Ann. Otol. Rhinol. Laryngol. 2003;112(8):693–696
  6. Thompson M, Wright S, Cheng LH, Starr D. Locating broken dental needles. Int. J. Oral Maxillofacial Surg. 2003;32(6):642–644
  7. Macilquham MD, Riley RG, Grossberg P. Identifying lost surgical needles using radiographic techniques. AORN J. 2003;78(1):73–78
  8. Siciliano CJ, Lefkowitz H. Removal of an intraosseous metallic foreign body in the calcaneus utilizing a fluoroscopically guided bone trephine. J. Foot Ankle Surg. 1994;33(1):83–86
  9. Bhatt C, Reddy NV, Reddy TN. Removal of sub-mucosal foreign body (metal wire) from the pharynx using image intensifier. J. Laryngol. Otol. 2003;117(11):902–904
  10. Lehman DA, Astor FC, Roy S. Impacted pharyngeal fish bone migrating to the retropharynx. ENT J. 2005;84(84):692–693
  11. Eggers G, Haag C, Hassfeld S. Image-guided removal of foreign bodies. Brit. J. Oral Maxillofacial Surg. 2005;43:404–409

PII: S1871-4048(06)00080-3

doi:10.1016/j.pedex.2006.08.001

International Journal of Pediatric Otorhinolaryngology Extra
Volume 1, Issue 4 , Pages 282-285, December 2006

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