Abstract
Foreign body removal in the head and neck region can be a challenging procedure, especially when it comes to a second look procedure with scar tissue. Multiple techniques for pre- or intraoperative localization of foreign bodies are known. Here we present the use of preoperative CT-guided fibroid embolic microcoil placement as a potential option for intraoperative soft tissue foreign body localization by the Otolaryngologist.
1
Introduction
Identification and localization of embedded foreign bodies in the various cavities and soft tissues of the head and neck is a common challenge frequently faced by the Otolaryngologist. Plain x-ray, ultrasound, computer tomography (CT) or magnetic resonance imaging (MRI) are important modalities that can aid in the preoperative localization of the foreign body and the choice of the surgical approach. Wooden foreign bodies can at times be challenging to detect through these conventional imaging techniques and, despite detection, they often pose a challenge to intraoperative tissue correlation and localization. This can lead to an increased risk of residual fragments left in the head and neck tissues and potential subsequent complications. The technique of using CT-guided microcoil localization prior to surgical management has previously been described by Sangha et al. in localization of an intraorbital abscess [ ]. Here, we outline its possible application in the Head & Neck for removal of a residual wooden foreign body in a previously operated and scarred field in close proximity to Stenson’s duct.
2
Case report
A four-year old female presented to our Otolaryngology clinic at a tertiary Children’s Hospital with an approximately two-week history of progressive swelling of her left cheek, associated with intermittent tenderness. This had not improved despite a course of oral antibiotics administered by her primary care physician. On physical examination, she was systemically well and afebrile with a painful, fluctuant swelling over her left cheek without overlying erythema. Intraoral examination revealed a scar over the buccal mucosa with no other obvious abnormalities.
Further inquiry revealed that the patient had previously sustained an intraoral injury from a tree branch after a fall from a tree approximately 1.5 years prior. At the time, she underwent incision and drainage of a buccal abscess as well as subsequent exploration of her left buccal space due to progressive worsening, with ultimate removal of a wooden foreign body.
Ultrasound evaluation during her current presentation revealed a collection in the left cheek with an echogenic structure in the deep superior aspect, suspicious for a possible residual foreign body ( Fig. 1 ). Due to the extent of scarring in the area from the previous procedure as well as its proximity to a number of delicate structures, such as the Stenson’s duct and the facial nerve, decision was made to utilize CT guided microcoil placement to enhance the ability to localize the foreign body at time of surgical removal. The patient was brought into the procedural CT suite and general anesthesia was performed. A noncontrast CT scan demonstrated a complex multilocular collection in the left buccal space along with a 1 cm linear shaped foreign body in the left masticator space. The interventional radiologist preloaded a 22-gauge, 10 cm long Chiba needle (Cook, Stouffville, Ontario, Canada) with a 4 mm diameter by 14 cm Cook Nester 18 fibered microcoil to locate the foreign body under CT guidance ( Fig. 2 ). The coil was deliberately placed adjacent to the foreign body, and deployed along the trajectory of the needle as it was removed such that a portion was left intra-orally at the point of needle entry. A small intra-oral incision was then made over the region of the swelling. The microcoil wire was identified and followed using gentle dissection to efficiently identify a piece of wooden foreign body embedded in a scar capsule in the superior most aspect of the masticator space. The piece of wood was then removed, along with the coil ( Fig. 3 ). At 1-month follow-up, the patient had fully recovered from the infection and the incision had healed well with intact salivary flow from Stenson’s duct.
