Unusual foreign body of skull base by a penetrating injury of oropharynx

Krishna Chaitanya Vemuru; Krishna Kumar Markapuram; Ramakrishna Tirumalabukkapatnam; Janardhan N Nara

doi:10.4103/2277-8632.146651

CASE REPORT

Year : 2014 | Volume : 3 | Issue : 4 | Page : 276-279

Unusual foreign body of skull base by a penetrating injury of oropharynx

Krishna Chaitanya Vemuru¹, Krishna Kumar Markapuram², Ramakrishna Tirumalabukkapatnam¹, Janardhan N Nara¹
¹ Department of ENT, Narayana Medical College, Nellore, Andhra Pradesh, India
² Department of General Surgery, Narayana Medical College, Nellore, Andhra Pradesh, India

Date of Web Publication

10-Dec-2014

Correspondence Address:
Ramakrishna Tirumalabukkapatnam
Department of ENT, Narayana Medical College, Nellore - 524 002, Andhra Pradesh
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/2277-8632.146651

Abstract

Brushing of teeth has become an integral part of our daily routine and is regarded as very safe even in children. Tooth brush is made up of relatively pliable material and has a smooth surface and round corners and is designed in such a way that it should not harm the delicate tissues of the oral cavity. Keeping the toothbrush in the mouth and doing other works with both arms may lead to injury of the oral tissues. Toothbrush injury has been reported in children who have slipped and fallen down with the tooth brush inside their mouth. Very rarely, it occurs in adults with the belief that the adults will be careful, while brushing their teeth. It is rare to see a penetrating injury in the oral cavity with a tooth brush. It is much rarer to see such penetrating foreign body going through neck spaces that too within the vicinity of great vessels. Here is a case wherein a penetrating injury of the oropharynx and neck spaces by a tooth brush has been encountered and is being reported for its rarity.

Keywords: Oropharyngeal trauma, tooth brush injury, unusual foreign body

How to cite this article:
Vemuru KC, Markapuram KK, Tirumalabukkapatnam R, Nara JN. Unusual foreign body of skull base by a penetrating injury of oropharynx. J NTR Univ Health Sci 2014;3:276-9

How to cite this URL:
Vemuru KC, Markapuram KK, Tirumalabukkapatnam R, Nara JN. Unusual foreign body of skull base by a penetrating injury of oropharynx. J NTR Univ Health Sci [serial online] 2014 [cited 2023 Mar 22];3:276-9. Available from: https://www.jdrntruhs.org/text.asp?2014/3/4/276/146651

Introduction

Case report

A 55-year-old female patient presented with a history of tooth brush injury during an episode of seizure. Following the seizure episode, she had a brief loss of consciousness. When she regained consciousness, it was noticed that there was profuse bleeding and the tooth brush was struck in her mouth, and it was not possible to remove it. Two hours after the injury, she presented to the emergency room of our hospital. There were blood clots and no bleeding, patient had difficulty in opening mouth, and was unable to speak. She also gestured as having difficulty in swallowing. She is known epileptic on irregular treatment. On examination, patient was conscious, coherent, and vitals were within the normal limits.

There is soft tissue edema in the region of the soft palate, uvula, and right retromolar trigone. Local examination of the oral cavity revealed a retained tooth brush that was piercing the right supratonsillar region measuring 5 cm showing the distal part. The bristles and the proximal segment could not be seen [Figure 1]. Upper left central incisor observed to be moving. Tongue and tongue movements were normal. No other injuries were observed in the oral cavity. Examination of the nose, and ears were normal. There is no respiratory stridor, saturations well-maintained. There was a swelling observed below the right mastoid region extending to the occiput.

Figure 1: Clinical photograph showing the handle of retained tooth brush protruding from the mouth

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Investigations

Computed tomography (CT) of the neck, cervical spine with 3D reconstruction revealed cranial most portion of the brush with bristles in the right posterior cervical space, laceration of the superior constrictor and paraspinal muscles and displacement of the common carotid laterally. Medially, the tooth brush was found grazing the right arch of Atlas after entering into right parapharyngeal spaces through the breach in the pharyngeal wall [Figure 2] and [Figure 3].

Figutre 2: Computed tomography scan axial and sagittal cuts showing the direction and nature of foreign body

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Figure 3: (a-c) Volume rendered images are showing relation of the impacted tooth brush to Atlas and occipital bone, also note the anterior displacement of left upper central incisor

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Management

Immediate surgical exploration under anesthesia was planned. After nasotracheal intubation patient placed in left semi lateral position, oral entry wound of the tooth brush was exposed [Figure 4] and the distal end of tooth brush in the oral cavity was cut and removed at the right retro molar trigone region. Upper left central incisor tooth removed the rest of the oral cavity and oropharynx inspected for other injuries. External approach was planned for removal of proximal head of tooth brush, under CT scan guidance the proximal position of tooth brush was identified as being posteromedial and inferior to right mastoid tip. Incision of about 3 cm is taken along the posterior border of sternocleidomastoid so as to allow for adequate exposure of the tissue. Tip of tooth brush identified by meticulous dissection. The surrounding areas were carefully dissected taking care to avoid damage to arch of Atlas and carotid vessels. Proximal part of tooth brush removed in toto by gentle dissection [Figure 5]. Intra oral wound was closed approximating superior constrictor and faucial pillars by 3.0 vicryl. Mucosal injury was repaired by 2.0 vicryl. Nasogastric tube was placed, and tube feedings were given for 7 days postoperatively. Postoperative period was uneventful and patient recovered. Patient did not develop any postoperative complications and recovered well and regained activities normally without any deficits.

Figure 4: Intraoperative photograph of the surgical exploration of the external wound

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Figure 5: Foreign body tooth brush specimen after successful removal

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Discussion

Tooth brush injuries commonly occur at gingivobuccal sulcus, buccal fat pad, soft palate, anterior faucial pillar, and pharynx. ^[1],[2] Blunt injuries to the oropharynx are often ignored. ^[3],[4] However, sharp injuries of oropharynx are often associated with profuse bleeding. ^[5],[6] Rarely, a blunt injury of oropharynx may occur and may not result in bleeding. In our case, it was a blunt, smooth hard tooth brush that penetrated oropharynx. It is essential to note the history of epilepsy in all such cases as it is probably the precipitating factor due to profound gag reflex associated with oropharynx. ^[7],[8] These ignored innocuous looking injuries have been reported to cause internal carotid artery dissection and thrombosis leading to cerebral infarction and neurological complications. ^[9],[10] Patient may at a later stages present with neurological symptoms immediately or after a lucid interval of 3-28 h after injury. It is, therefore, recommended that any patient with a lateral palate or peritonsillar wound should be admitted and observed for at least 48 h. In severe cases, the tooth brush can penetrate into parapharyngeal space causing sepsis and late complications. It is mandatory to get a CT, preferably with 3D reconstruction, so as not miss an embedded piece deep in the tissues. Imaging also helps us to know the status of the surrounding great vessels, vertebrae, or any developing abscess entering the deep neck spaces causing widespread emphysema within the neck. ^[11]

Penetrating injuries due to a toothbrush may be classified as blunt injury (no mucosal break or perforation) penetrating injury (deep laceration/perforation of the soft tissues, but the toothbrush has been extricated from the wound at the time of presentation) or impalement injury (toothbrush is impacted within the soft tissues) and embedded (head of the toothbrush breaks and retained deep within the tissues). ^[11] In this case, there was no breakage of the head of the toothbrush.

Previous studies indicate intimal injury of carotid, as it is being crushed between vertebrae and head of the toothbrush. This has led to cerebrovascular accidents due to mural and retropharyngeal thrombus formation. In some studies, mediastinitis and retropharyngeal emphysema were reported as dreaded complications. In our study, the foreign body was abutting the arch of Atlas and medial to carotid vessels. Hence, the chance of cerebrovascular accidents is remote. Hence, we propose to classify the penetrating injuries of oropharynx as:

Injury of mucosa
Injury of mucosa and constrictors
Foreign body entering cervical spaces medial to carotid vessels
Foreign body entering cervical space lateral to carotid vessels with compression of great vessels (chance of intravascular mural thrombus likely to be dislodged after removal of foreign body).

Conclusion

Though tooth brush is safe for oral care and hygiene, sometimes it can cause minor injuries to the oral cavity. In rare circumstances, there may be life-threatening penetrating injuries. Management includes prompt diagnosis and careful removal. Always these foreign bodies should be removed under general anesthesia, and careful inspection should be performed to look for any associated injuries. All cases should be screened for epilepsy, previous irradiation, and glossopharyngeal neuralgia when injury is in oropharynx.

Acknowledgments

We sincerely thank our medical director Dr. Subramanyam D.M (Cardiology) for encouragement and support.

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