Hypopharyngeal toothpick-induced granuloma mimicking a pyriform sinus malignancy


Adult foreign body ingestion is a common event. Here we present a case of toothpick ingestion resulting in a granulomatous reaction mimicking a pyriform sinus malignancy. A 55-year-old male nonsmoker presented with a 3-month history of left sided neck pain, odynophagia and dysphagia. CT revealed a heterogeneous enhancement in the left pyriform sinus. Direct laryngoscopy was performed, and biopsy of the mass revealed acute/chronic inflammation and granulation tissue with presence of a plant-based substance consistent with a toothpick. No evidence of malignancy was appreciated. Follow up CT scan at 5 months showed complete resolution of the mass.


Foreign body ingestion occurs commonly. Most objects traverse the gastrointestinal tract unnoticed [ , ]. Common lodging sites within the pharynx include the palatine tonsils, tongue base, vallecula, and pyriform sinus [ , ]. Complications include perforation, ulceration, and impaction along the upper aerodigestive tract [ ].

We present a unique case of a 55-year-old male with three months of dysphagia and left-sided neck pain who presented with a mass suspicious for hypopharyngeal malignancy. He had no recollection of a foreign body ingestion, but ultimately was diagnosed with a toothpick-induced granulomatous reaction. Exemption was obtained from the Vanderbilt University Institutional Review Board for this study.

Case prsentation

A 55-year-old male nonsmoker presented to the Emergency Department with a 3-month history of left-sided constant sore throat, neck discomfort, odynophagia, and new onset fever of 104° Fahrenheit. His labs noted a white blood cell count of 2.76 × 10 3 . CT scan revealed an ill-defined region of heterogeneous enhancement in the left pyriform sinus measuring 1.3 × 0.8 × 2.2cm ( Fig. 1 ) with cervical lymphadenopathy. He was treated for acute pharyngitis with amoxicillin-clavulanic and was referred for outpatient otolaryngology follow up.

Fig. 1

CT Scan showing enhancing mass involving the left pyriform sinus measuring 1.3 × 0.8 × 2.2 cm.

In otolaryngology clinic, flexible fiberoptic laryngoscopy revealed significant left pyriform sinus mucosal edema without an appreciable mass. Direct laryngoscopy with biopsy was recommended. The patient preferred to proceed with observation. He returned one month later with persistent symptoms and an unchanged CT scan and consented to surgery at that time.

Intraoperatively, we encountered a friable mass in the left pyriform sinus. Initial biopsies and frozen section analysis showed inflammatory changes with granulation tissue. Additional specimens were taken due to concern for malignancy. We then encountered a firm and fragmented object consistent with a segment of eroded hyoid bone given the assumed malignant process. Final permanent histopathologic analysis revealed granulation tissue and squamous mucosa with acute and chronic inflammation, negative for dysplasia or malignancy. Interestingly, within the specimen was a plant substance material suggestive of a toothpick ( Fig. 2 ).

Jul 5, 2021 | Posted by in OTOLARYNGOLOGY | Comments Off on Hypopharyngeal toothpick-induced granuloma mimicking a pyriform sinus malignancy
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