PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 36 no. 2 July – december 2021 PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 36 no. 2 July – december 2021 PhiliPPine Journal of otolaryngology-head and neck Surgery 3736 PhiliPPine Journal of otolaryngology-head and neck Surgery PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 36 no. 2 July – december 2021 PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 36 no. 2 July – december 2021 CASE REPORTS Philipp J Otolaryngol Head Neck Surg 2021; 36 (2): 36-39 c Philippine Society of Otolaryngology – Head and Neck Surgery, Inc. Approach to a Sewing Needle in the Parapharyngeal Space: A Case Report Vishaka Bettadahalli, MS (ENT), MRCSEd (ENT)1,2 Rahul Bhargava, MS (ENT), DNB1,3 Sunil Kumar, MS (ENT), DNB1 1Department of ENT and Head Neck Surgery Lady Hardinge Medical College 2Department of ENT The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust 3SMI Saroj Medical Institute, Delhi Correspondence: Dr. Vishaka Bettadahalli Department of ENT The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust Gayton Road, King’s Lynn, PE30 4ET United Kingdom Phone: +4474 4800 3822 Email: vishakab.l@gmail.com The authors declared that this presents original material that is not being considered for publication or has not been published or accepted for publication elsewhere or in part, in print or electronic media; that the requirements for authorship have been met by all the authors, and the author believes that the manuscript represents honest work. Disclosures: The authors signed a disclosure that there are no financial or other (including personal) relationship, intellectual passion, political or religious beliefs, and institutional affiliations that might led to conflict of interest. Creative Commons (CC BY-NC-ND 4.0) Attribution - NonCommercial - NoDerivatives 4.0 International ABSTRACT Objective: To describe a unique situation of a sewing needle lodged in the parapharyngeal space and elucidate the problems encountered in its successful removal. Methods: Design: Case Report Setting: Tertiary Private Hospital Patient: One Result: A 24-year-old male tailor accidentally swallowed a sewing needle that pierced the oropharyngeal wall and was wedged in the parapharyngeal space. After a thorough physical examination, 70 degree rod endoscopy, radiography and doppler ultrasonography and intraoperative C-arm X-ray for intraoperative localization and as a guide for extraction all yielded less than optimal guidance. Although an intra-oral approach was initially taken, the transcervical approach provided the best access. Conclusion: Removal of a sharp foreign body in the parapharyngeal space should be considered a surgical emergency owing to its close proximity to vital structures and the potential for serious complications. Identifying the exact location may require a variety of imaging modalities, and foreign body extraction may entail multiple surgical approaches. Keywords: Foreign body; sewing needle; parapharyngeal space; surgical emergency Although common in the pediatric population, aero-digestive foreign bodies are infrequent in adults. Commonly encountered pharyngeal foreign bodies are coins, batteries, fishbones, chicken bones, buttons, dentures, pins and earrings.1 Foreign bodies in the parapharyngeal space are mainly dental needles, suture needles, broken implants, a third molar and broken toothbrush.1–3 A sewing needle piercing the pharyngeal wall to lodge in the parapharyngeal space is a very uncommon foreign body.3–5 There have been instances of needle and fishbone PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 36 no. 2 July – december 2021 PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 36 no. 2 July – december 2021 PhiliPPine Journal of otolaryngology-head and neck Surgery 3736 PhiliPPine Journal of otolaryngology-head and neck Surgery PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 36 no. 2 July – december 2021 PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 36 no. 2 July – december 2021 CASE REPORTS foreign bodies migrating into the posterior cervical space, lodging in deep neck spaces, posterior pharyngeal wall, hypopharynx, thyroid gland and even piercing the carotid reported in the literature.6–8 We report the case of a foreign body sewing needle embedded in the parapharyngeal space. CASE REPORT A 24-year-old male tailor was referred from a secondary care center to our tertiary care ENT emergency with complaints of accidental displacement of a sewing needle into his mouth while he was holding it between the lips. He complained of a pricking sensation in his right tonsillar fossa with odynophagia for 6 hours. There were no other symptoms such as pain associated with neck movements or any neck swellings. After a thorough examination, the oral cavity, oropharynx and neck were unremarkable. The foreign body was neither seen nor could it be palpated in the tonsillar fossa or base of the tongue. A 70-degree rod endoscopy of the oropharynx, hypopharynx and larynx did not reveal any foreign body. A plain soft tissue neck X-ray showed a metallic sewing needle lying obliquely in the right parapharyngeal region opposite C1-C3 vertebra with its eye superiorly near the skull-base and the sharp end towards the tonsillar fossa. (Figure 1) Doppler ultrasonography of the neck revealed the needle lying close to the great vessels in the parapharyngeal space. (Figure 2) Considering the symptoms, the nature of the foreign body and potential complications, an urgent removal was planned. Under general anesthesia, futile attempts were made to palpate the right tonsillar fossa and the base of the tongue. The anteroposterior image from the C-arm suggested that the sharp end could be embedded in the tonsillar fossa. (Figure 3) Therefore, right unilateral tonsillectomy was done, and the tonsillar fossa was explored to see and palpate the needle. However, nothing was palpated and the incision was extended over the retromolar trigone and anterior pillar to provide better exposure of the parapharyngeal space but the needle was not traced. Intraoperative C-arm guidance was also used to delineate the needle in the parapharyngeal space (Figure 3), but we could not locate the needle with accuracy since it did not provide a 3-dimensional picture. Thereafter, a transcervical approach was undertaken through a horizontal neck crease incision. The anterior border of the sternocleidomastoid and posterior belly of the digastric were identified and soft tissue dissected to approach the parapharyngeal space. A curved mosquito forceps was used as a marker during the C-arm imaging to locate the site of the needle. (Figure 4) However, the needle still could not be located. Angular mandibulotomy was performed and the ramus of the mandible was retracted anteriorly for better exposure. Once the ramus of the mandible was retracted anteriorly we were able to locate the needle medial to the styloid process at the skull-base. (Figure 5) The 4.2 cm needle was removed carefully without any vascular or neurological complications. (Figure 6) The mandibulotomy was fixed with mini plates and the wound closed in layers. The postoperative period was uneventful and the patient was discharged on the 4th postoperative day. DISCUSSION Fishbone and chicken bone are the most commonly encountered pharyngeal foreign bodies in adults.2,9,10 A sharp metallic foreign body migrating into the parapharyngeal space has seldom been reported in the literature.3,6,10 To the best of our knowledge, based on a search of PubMed (MEDLINE; PubMed Central), Google Scholar, Scopus, and Index Medicus using the search terms “parapharyngeal space,” “sewing needle,” “needle,” and “sharp foreign body,” this is only the second case of a sewing needle migrating into the parapharyngeal space posing a threat to major vessels in the neck. The parapharyngeal space is an inverted pyramidal-shaped space lateral to the constrictor muscles of the pharynx with its base at the skull-base and apex at the greater cornu of the hyoid bone. It is a potential space which is filled with loose connective tissue and neurovascular bundle. Its major contents are the carotid sheath and its contents, sympathetic chain, glossopharyngeal, hypoglossal, accessory nerves and a part of the maxillary artery.6,10 A foreign body in the parapharyngeal space can cause injury to these vital structures. A sharp foreign body can migrate into this space and further into other spaces. It is postulated that the contraction of the pharyngeal musculature and the movement of the viscera are responsible for the migration of sharp objects in these spaces.3,4,8,10,11 A foreign body lodged in the parapharyngeal space can lead to deep neck abscess, jugular vein thrombosis, internal carotid artery aneurysm, and fistula.8,9,12 A sharp foreign body can migrate through the pharynx into other surrounding spaces. Therefore, any sharp foreign body should be treated as a surgical emergency. Migration of foreign body through carotid and jugular vein and injury to the cranial nerves has been reported earlier in the literature.4,8 Foreign body sensation in the throat, dysphagia, odynophagia, neck swelling and pain associated with neck movements are the frequently encountered symptoms.9 Dyspnea has been seen in cases with delayed presentations involving the hypopharynx and retropharyngeal area.9 A plain X-ray should be the first investigation ordered in such cases. Sometimes a small piece of chicken bone or fishbone and a radiolucent foreign body might be missed in a plain X-ray. Doppler ultrasound may help in identifying the relation of the vital structures in the neck to the foreign body as in the present case. PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 36 no. 2 July – december 2021 PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 36 no. 2 July – december 2021 PhiliPPine Journal of otolaryngology-head and neck Surgery 3938 PhiliPPine Journal of otolaryngology-head and neck Surgery PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 36 no. 2 July – december 2021 PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 36 no. 2 July – december 2021 CASE REPORTS The parapharyngeal space can be reached externally through transcervical, submandibular and transparotid approaches.10,13 In the present case, we removed the needle through a transcervical approach with angular mandibulotomy since we were unable to locate the needle using a transoral approach. The external approach provided good exposure compared to the transoral approach. The external approach also provided better control over the surgical field in the event of any vascular injuries. Angular mandibulotomy and anterior retraction of the mandibular ramus provided better exposure of the parapharyngeal space. The external approach has been recommended as the method of choice for removal of large foreign bodies of the parapharyngeal space by Burduk, providing good exposure to the neurovascular structures in the space.12 Although an intra-operative C-arm could be used for guidance to localize the site of the foreign body, it was not much help to us in this case, perhaps also because we seldom use the C-arm in ENT at our center. Further paraphernalia associated with its use was also very cumbersome. There is no consensus regarding the usage of C-arm guidance for such cases in the literature.3 While a preoperative CT scan may help in localizing the site, approximating the size and its relation to the adjacent structures in a radiolucent foreign body,12 significant scatter artifacts are a limitation of CT for metallic objects. In retrospect, an intraoperative X-ray with application of markers to determine the relative position and distances of the foreign body in the surgical field may have been simpler and more helpful. Sharp foreign bodies embedded in the parapharyngeal space are extremely rare. This report highlights the difficulties faced by the surgeons in managing such a case in a setting with limited resources. Hopefully, readers will be able to easily identify these and plan well to manage such cases. Even though this report may not add any new Figure 1. Lateral plain soft tissue neck X-ray showing the sewing needle opposite C1-3 vertebrae Figure 3. Intraoperative C-arm image (anteroposterior) showing needle with sharp end in right tonsil fossa (asterisk) Figure 2. Doppler ultrasonogram showing the needle (2-head arrow) and its relation to great vessels (asterisk) Figure 4. Intraoperative C-arm image (lateral) with curved mosquito forceps marker Figure 5. Needle in parapharyngeal space, medial to tip of styloid process (arrow); ramus of mandible retracted anteriorly (asterisk); posterior belly of digastric reflected posteriorly (lower retractor) Figure 6. Needle after extraction, measuring 4.2cm PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 36 no. 2 July – december 2021 PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 36 no. 2 July – december 2021 PhiliPPine Journal of otolaryngology-head and neck Surgery 3938 PhiliPPine Journal of otolaryngology-head and neck Surgery PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 36 no. 2 July – december 2021 PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 36 no. 2 July – december 2021 CASE REPORTS REFERENCES 1. Arora S, Sharma JK, Pippal SK, Sethi Y, Yadav A, Brajpuria S. An unusual foreign body (sewing needle tip) in the tonsils. Braz J Otorhinolaryngol. Nov-Dec 2009;75(6):908. DOI: 10.1016/s1808- 8694(15)30558-9; PubMed PMID: 20209296. 2. Goswami S. The head of a broken toothbrush in the parapharyngeal space: A rare case report. J Indian Soc Periodontol. Jan-Feb 2016;20(1):79-81. 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Management of a sharp foreign body should be considered a surgical emergency owing to its close proximity to vital structures and the potential for serious complications. Identifying the exact location may require a variety of imaging modalities, and foreign body extraction may entail multiple surgical approaches.