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Abstract
A young adult male patient presented with the history of a retained foreign body in the oral cavity. The object in question was a stapler pin that got accidentally lodged while the patient tried removing food particles from his mouth 28 days earlier. Aside from intermittent pain upon digital palpation on the right side of the floor of his mouth, he was asymptomatic. Clinical examination was unremarkable. Plain radiography and a computed tomogram revealed a linear foreign body in the right submandibular gland. The patient underwent a submandibular gland excision, during which a 2 cm long stapler pin was retrieved. This case highlights that not all foreign bodies cause inflammatory reactions as a telltale sign of their presence.
- Ear, nose and throat/otolaryngology
- Otolaryngology / ENT
- Mouth
- Head and neck surgery
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Background
Accidentally ingested foreign bodies of the aerodigestive tract are a common yet challenging occurrence faced by otolaryngologists worldwide. All age groups are affected; however, their preponderance is higher among the paediatric population.1 The situation’s complexity increases when the foreign body under question is not readily detectable on clinical examination or any acute symptoms are absent. Adding to the nuisance is the presence of sharp foreign bodies that can potentially migrate to distant sites, cause catastrophic complications and are associated with the most significant mortality.2 The literature review suggests that foreign bodies of the submandibular gland or duct are a rarity. Two possible mechanisms have been proposed for such foreign bodies, that is, retrograde migration via the Wharton’s duct or penetrating trauma, which are highly debated in our surgical arena.3 This case was noteworthy because the foreign body was unintendedly lodged at the unusual location Instead, it was one of the first reports where a foreign body from the oral cavity has migrated to the substance of the submandibular gland by repeated digital palpation.
Case presentation
A man in his early 20s presented with a 28-day-old history of using an open stapler pin to scrape off a stuck food particle from his teeth. The pin accidentally slipped off his fingers during the act while he made multiple attempts to retrieve it using his fingers. However, it disappeared within a few seconds. He visited a nearby hospital where he was clinically examined, but no such object was found. He then reported 28 days later to the outpatient department of our tertiary care centre with the only complaint of intermittent episodes of dull aching, non-radiating pain on digital palpation of the right side of his floor of mouth.
There was no history of fever, oral bleeding, pain or neck swelling while chewing food or peri-prandial discomfort. A complete head-and-neck examination, including fibre-optic laryngoscopy, was done. The oral cavity showed no signs of penetrating trauma (figure 1). Wharton’s duct opening appeared normal. Tenderness was present on deep palpation of the anterior floor of the mouth on the right side. The neck examination revealed no erythema of the overlying skin, tenderness or lymphadenopathy.
Picture showing oral cavity of the patient.
Investigations
A plain radiograph was obtained, which revealed a linear radio-opaque object below the ramus of the mandible and above the hyoid bone (figure 2). The precise location could not be discerned based on the X-ray alone; therefore, a contrast-enhanced computed tomogram was ordered. Computed tomography of the face showed a metallic object within the right submandibular gland, thus, pin-pointing our target location and simultaneously ruling out concurrent infections (figures 3 and 4).
Plain radiograph showing radio-opaque foreign body.
Sagittal view of computed tomography showing foreign body in submandibular gland.
Axial view of computed tomography; arrow showing foreign body within the gland substance.
Differential diagnosis
Neurogenic pain/neuralgia, Submandibular gland sialadenitis, Sialolithiasis
Treatment
After obtaining informed written consent, he was taken up for right submandibular gland excision via transcervical approach under general anaesthesia.
Outcome and follow-up
A 2 cm long metallic stapler pin was retrieved intraoperatively, partly located within the gland and partially within the submandibular duct (figures 5 and 6). In the immediate postoperative period, no complications were noted. Hence, he was discharged after being observed for 2 days. The patient was followed up 5 months following the procedure. He continues to be asymptomatic.
Retrieved foreign object.
Picture depicting the foreign body post excision of gland.
Discussion
We highlighted the case of an invisible yet present foreign body in the submandibular gland and its silent migration. Although foreign bodies from the digestive tract have been reported several times, the exact incidence remains unknown. The most common ones include fish bones from the pharynx.
We report a case of the stapler pin from the submandibular gland, which penetrated through the floor of the mouth or migrated via the Wharton’s duct. Submandibular duct cannulation by a foreign body is rare since the duct puncta size is relatively small, and there is continuous salivary efflux to the oral cavity.4 The underlying mechanism in our case remains unclear. Repeated digital manipulation by the patient may have caused the object to migrate via a trans-mucosal route.
Localisation of such objects can be challenging if they are not visible on clinical examination. Plain radiographs can pick up metallic foreign bodies. However, non-metallic foreign bodies may require additional investigations. Ultrasonography and computed tomography have been employed successfully5 before planning a surgical exploration. Cross-sectional imaging may serve as a valuable asset in resolving the deadlock in situations where a mismatch exists between the history claimed by the patient and the clinical examination performed by the physician.
Sharp foreign bodies always carry the potential to migrate beyond their primary site. Reports of unusual complications caused by migration to the common carotid artery,6 internal jugular vein, sternocleidomastoid muscle and thyroid gland7 have been cited in the annals of literature. Moreover, foreign bodies can induce inflammatory reactions leading to sialadenitis or even act as a nidus for the formation of sialolithiasis in chronic cases.8 Deep neck space infections and vascular pathologies as sequelae of unrecognised foreign bodies are also known entities cited in the literature.9 Fortunately, the patient presented early and did not develop any of these complications in our case. With the advent of newer technologies like sialendoscopy, retrieving such intraluminal foreign objects with greater ease may be possible. The access to Wharton’s duct mainly depends upon the accuracy of preoperative localisation. The intraoral approach risks duct stenosis, lingual vasculature and nerve damage and further distal object migration.10 The overall high requirement for surgical expertise may restrict its usage.
However, in chronic cases, the possibility of glandular and duct fibrosis should be considered, and a sialoadenectomy along with duct excision by a cervical incision may award permanent relief and reduce risk of future complications.11
Patient’s perspective
‘I was cleaning my teeth with the stapler pin that day. I remember I had straightened the pin before using it. I got distracted for a moment and lost it. I tried to remove it by my tongue movements and using my fingers. I checked in the mirror to locate it somewhere but could not see anything. I visited a doctor nearby. He examined my mouth and throat and said no such object was visible. I felt that something was still pricking inside whenever I touched the area on the right side of my mouth. I was still apprehensive and unsure, so I went to a higher centre for a second look.’
Learning points
A patient’s consistent reporting of symptoms warrants a thorough investigation, even when clinical examinations appear normal.
Always consider the possibility of foreign body migration, especially with sharp objects and when symptoms are intermittent or subtle.
Advanced imaging techniques like computed tomography can be invaluable for precise localisation as well as to rule out complications.
Ethics statements
Patient consent for publication
Footnotes
Contributors HV supervised the findings, formulated the surgical plan, verified the manuscript and encouraged the entire team for working towards the desired goal. VB identified the case, was involved in postoperative care of the patient and wrote the manuscript. VM supervised the surgery and wrote the manuscript. MDB performed the main surgery.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.