Intraoperative ultrasound-guided retrieval of an airgun pellet from the tongue: a case report

Intraoperative Ultrasound for Removal of a Fishbone Foreign Body Embedded in the Tongue

Background

Ultrasound (U/S) is a dynamic imaging modality with many applications in medicine. In Otolaryngology, U/S is used routinely in the clinic with several evolving applications intraoperatively. Case Report. A 53-year-old male presented to the emergency department with dysphagia, odynophagia, hoarseness, and sensation of foreign body after ingesting fish. A CT scan identified an approximately 2 cm horizontally-oriented foreign body consistent with a fishbone embedded in the left posterolateral tongue. Intraoperative U/S was used to localize and remove the fishbone without complications.

Results

The patient recovered well after surgery and was discharged home on postoperative day 2. No residual foreign body was found on the repeat CT scan.

Conclusion

Our case demonstrates the effectiveness of intraoperative U/S for removal of fishbone foreign bodies from the tongue and serves to inspire future applications of this modality in Otolaryngology.

Air guns and their wider relevance to the dental profession

Crimes involving air guns have declined over the last 16 years in England and Wales; however, still represent a significant occurrence, with 3,028 crimes involving air guns reported in 2019 (just under one-third of all firearm crime). We aim to present points regarding air gun injuries and their wider relevance to the dental profession which have not been covered in previous publications.This article covers air gun licensing in the UK and the relevant safeguarding issues, as well as optimal imaging of suspected retained pellets in the head and neck.Whilst there are numerous case reports of retained air gun pellets found in various regions of the head and neck, only a handful of papers discuss the issues in leaving retained pellets or a surgical approach to removal of these pellets. This article summarises the current approaches and provides a suggested protocol for the management of pellets in the head and neck, as well as highlighting the need for further development in this field.Air gun pellets as retained foreign bodies may be identified on routine examination of the head and neck, both in general dental practice and in oral and maxillofacial surgery departments. This article acts as an overview and guide for dental professionals to gain a wider understanding of these injuries and their management.

Characteristics of Retained Foreign Bodies in the Tongue: A Retrospective Study of 35 Cases

PURPOSE

There are only a few case reports of foreign bodies (FBs) in the tongue. Delayed diagnosis or misdiagnosis is not uncommonly reported. The purpose of this study was to identify the demographic, clinical, and radiological features that might facilitate the diagnosis of retained FBs in the tongue.

METHODS

A retrospective case series was performed. Clinical and imaging data of patients with FBs in the tongue at Wuhan University Hospital of Stomatology were reviewed. The outcome variable was a preliminary, radiological, intraoperative, or pathological diagnosis. Covariates included age, sex, FB-related history, symptoms and signs, duration, and computed tomography (CT) imaging features. Descriptive statistics were computed for each study variable.

RESULTS

Thirty-five patients were included. The sample's mean age was 54.5 ± 11.2 years, included 19 males (54.3%). Eighty percent of the patients reported FB-related history with a mean duration of 4 weeks. More than 70% of the patients presented with tongue swelling. Approximately half of the 35 cases were preliminarily misdiagnosed, and 15 of them were initially suspected to be tumors. After CT examinations, 33 of the 35 cases were diagnosed as FB. Characteristic CT imaging feature of the FB was a radiopaque line. Most FBs were located at the anterior two-thirds and marginal area of the tongue and in an oblique direction. The depth of FB was 0.61 ± 0.42 cm. The superficial ends of most FBs were close to the surface of the dorsum and the tongue margin.

CONCLUSIONS

The possibility of a retained FB should be included in the differential diagnosis of a nonhealing wound or tongue enlargement when a radiopaque line is present on CT images of patients presenting with or without FB-related history. It may be easier to detect a FB in the tongue when a CT imaging postprocessing protocol, including thin-slice reconstruction and multiplanar reformation visualization and careful interpretation, is used.

Ultrasound-Assisted Removal of A Fishbone Stuck in A Tongue in the Emergency Department

BACKGROUND

Foreign body (FB) impaction in the oropharyngeal region-and specifically the tongue-is a common problem in the emergency department that often requires specialty consultation and admission for operative intervention. Over the years, the use of point of care ultrasound (POCUS) has increased ease and success of FB removal in other anatomic regions, but is only rarely reported for extraction of FB from the tongue outside of the operating room.

CASE REPORT

This case demonstrates a unique case of ultrasound-guided removal of a fishbone from the tongue in the emergency department after blind attempts failed. Operative intervention and admission were initially avoided; however, because of initial failed attempts and blind dissection before the use of POCUS, the patient presented a day later requiring admission for postprocedural tongue swelling and edema. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians should be aware that POCUS may assist in FB localization in the tongue.

Intraoperative ultrasound to facilitate removal of a submucosal foreign body

A 61-year-old man with a history of fish bone ingestion and poorly localized symptoms was seen. His clinical examination was unremarkable, but CT demonstrated a foreign body deeply embedded within his tongue. Intraoperative ultrasound (US) guidance facilitated identification of a bone, allowing a needle to be placed as a guide to dissection. Repeat US scanning through the incision permitted precisely targeted surgery. CT and US are the most effective imaging techniques for localizing fish bones. Intraoperative US can be used to accurately locate a submucosal fish bone in mobile tissue such as the tongue, and focused, image-guided dissection can reduce surgical tissue trauma.

A contribution to the discussion on the safety of air weapons

Firearms legislation in the UK stems from the Firearms Act 1968 with its definition of a firearm as a lethal barrelled weapon of any description. The Act allows certain exceptions to be held without licence, most notably air weapons although these are limited by The Firearms (Dangerous Air Weapons) Rules 1969 and related regulations to below 12ft lb (16.3J) for air rifles and below 6ft lb (8.1J) for air pistols. Despite this there are occasional fatalities, typically 1 or 2 each year in the UK, from legally owned air weapons. In the USA there are over 20,000 visits each year to emergency departments due to injuries from air weapons and paintball guns. Despite this, limited research appears to have been carried out into the safety of air weapons and the present study tries to address this. Fresh samples of animal tissue were obtained from an abattoir or butcher and were embedded in ballistic gelatin. Pig heart, lung, liver and shoulder were used. By firing pellets into gelatin alone and into the combination of the gelatin and animal tissue it was possible to compare gelatin as a model for these tissues. The depth of penetration was similar but the residual track appeared to remain more open in the animal tissue. Pellets penetrated completely through the organ, with total penetration of gelatin and organ being typically around 10-15cm. Samples of pig, cow and chicken skin were placed in contact with the gelatin or embedded in the gelatin to simulate the effect of skin on penetration into a body. Chicken skin had no effect, pig skin stopped the pellet and cow skin was perforated by the pellet. If cow skin was embedded in the gelatin there was little effect on the total amount of penetration, but cow skin on the front surface of the gelatin reduced penetration by about 30%. Computed tomography was used to examine the pellet track and to calculate the volume of damage produced. However, due to the similar densities of gelatin and organ a technique had to be developed to differentiate phases. A barium salt paste was applied to outer surfaces and iodine solution or barium nitrate solution containing red food colouring was injected into the pellet track to enhance the contrast of the track. The track through the gelatin tended to enclose itself whereas the track through the organ remained more open, presumably due to the inhomogeneity of the fibrous nature of the tissue. Pellets were also fired at construction materials (wood, plasterboard and brick) and computed tomography used to determine the volume of damage created. Pellets perforated single layers of wood and plasterboard and would embed in a second layer. However, if the two layers were in contact the pellet did not penetrate the first layer. An air rifle pellet could therefore perforate house construction materials, although the resultant kinetic energy would be low and further damage would be limited. Some of the possible physical parameters are discussed that might help predict the degree of damage caused, but from this study it is not possible to define a limit which could be proposed as safe.

Ultrasonographically supported removal of foreign bodies of the eye lid and parapharyngeal space in a 13-year-old boy subjected to shot injuries in early childhood

Background: B-scan ultrasonography is widely used in diagnostics of head and neck pathologies. Ultrasonography can be applied intraoperatively to identify foreign materials.

Case report: This case report describes the ultrasonographic identification of foreign bodies of the eye lid and parapharyngeal space in an adolescent who was injured several years ago, obviously a victim of domestic violence. B-scan ultrasonography (small part transducer, emission frequency: 7.5 MHz) proved to be a reliable tool to locate the foreign bodies. Ultrasound imaging facilitated the decision-making of the surgical approach and thus reduced the surgical exploration time.

Discussion: B-scan ultrasonography is a valuable tool in oral and maxillofacial surgery. The use of B-scan ultrasonography in the head neck region requires the capacity of the surgeon to fuse the ultrasonographic picture with the topography of the head and neck. The advantages and limitations of B-scan ultrasonography in the head and neck region concerning foreign body identification are briefly discussed.

Effects of hemodialysis therapy on sit-to-walk characteristics in end stage renal disease patients

Patients with end stage renal diseases (ESRD) undergoing hemodialysis (HD) have high morbidity and mortality due to multiple causes; one of which is dramatically higher fall rates than the general population. In spite of the multiple efforts aiming to decrease the high mortality and improve quality of life in ESRD patients, limited success has been achieved. If adequate interventions for fall prevention are to be achieved, the functional and mobility mechanisms consistent with falls in this population must be understood. Human movements such as sit-to-walk (STW) tasks are clinically significant, and analysis of these movements provides a meaningful evaluation of postural and locomotor performance in elderly patients with functional limitations indicative of fall risks. In order to assess the effects of HD therapy on fall risks, 22 sessions of both pre- and post-HD measurements were obtained in six ESRD patients utilizing customized inertial measurement units (IMU). IMU signals were denoised using ensemble empirical mode decomposition and Savistky-Golay filtering methods to detect relevant events for identification of STW phases. The results indicated that patients were slower to get out of the chair (as measured by trunk flexion angular accelerations, time to peak trunk flexion, and overall STW completion time) following the dialysis therapy session. STW is a frequent movement in activities of daily living, and HD therapy may influence the postural and locomotor control of these movements. The analysis of STW movement may assist in not only assessing a patient's physical status, but in identifying HD-related fall risk as well. This preliminary study presents a non-invasive method of kinematic measurement for early detection of increased fall risk in ESRD patients using portable inertial sensors for out-patient monitoring. This can be helpful in understanding the pathogenesis better, and improve awareness in health care providers in targeting interventions to identify individuals at risk for fall.

Entrapment of an air gun pellet between the thyroid cartilage and the lining mucosa in a patient with a penetrating neck injury: a case report

Introduction

Air guns, either modern or traditional models, are powerful weapons that are capable of causing serious or life-threatening injuries.

Case presentation

Here, we present a case of an air gun pellet injury, with the pellet trapped between the thyroid cartilage and the lining mucosa of a 58-year-old Iranian man.

Conclusion

Entrapment of air gun pellet between thyroid cartilage and the lining mucosa, as presented in our case, may cause diagnostic challenges through the clinical presentation of slight odynophagia.

Tooth embedded in tongue following firearm trauma: report of two cases

Injuries caused by projectiles from firearms involve diverse patterns of dentoalveolar trauma due to the different types of wound and extent of tissue damage. This article reports two cases in which tooth fragments were embedded in the tongue following aggression from a firearm projectile in the facial region. Radiographs confirmed the presence of foreign bodies, which were surgically removed under local anesthesia. When dentoalveolar trauma occurs in facial injuries, both hard and soft tissues must be carefully examined to avoid overlooking embedded tooth fragments not located immediately in the soft tissue.

Wooden foreign body embedded in the zygomatic region for 2 years

We report a case of retained wooden foreign body in the zygomatic region which posed a considerable diagnostic difficulty and was the source of persistent draining sinus and other distressing symptoms. The patient was not aware of the foreign body in the maxillofacial region. In such cases a thorough history of the patient is of utmost importance. The case has been described to highlight the problems associated in managing unlikely foreign bodies at unusual facial sites when there is a possibility that radiolucent material is embedded in the wound.

An investigation into the behaviour of air rifle pellets in ballistic gel and their interaction with bone

Although air weapons are considerably lower in power than other firearms, there is increasing concern that serious injuries can result from their misuse. The present study was therefore carried out to improve understanding of the terminal ballistic behaviour of air rifle pellets. Pellets were fired into ballistic gel under a variety of conditions. The pellets penetrated further than anticipated from their low cross-sectional density, and Bloom number was not necessarily a good guide to gel behaviour. Pellet penetration into the gel decreased with increasing gel concentration, and appeared to be linear at higher concentrations. Pointed pellets penetrated up to 50% further than rounded pellets. Power and range affect penetration, but other factors are also important, and power alone is not a simple guide to potential penetration. Test firings were also carried out firing pellets into ballistic gel that contained sections of animal bone. Computed tomography (CT) and visual observation were employed to record the interactions. CT scanning showed potential as a tool for examining pellet damage. The bone appeared to be undamaged, but the pellets were severely deformed on impact. If the pellet strikes the bone at an angle, less energy is absorbed by the impact and the pellet fragments may ricochet and cause further damage in the gel. A tentative model is proposed for estimating the energy absorbed by the impact.

Clinical use of navigation based on cone-beam computer tomography in maxillofacial surgery

Image-guidance in maxillofacial surgery is based predominantly on computed tomographic (CT) images. Its main disadvantage is the considerable amount of radiation to which the patient is exposed, and dental metal artefacts. Recently, a new class of devices based on the concept of cone-beam computed tomography (CBCT) has been introduced for maxillofacial imaging, which we have investigated. In a clinical study, the first seven patients to be operated using a navigation system based on CBCT images, were evaluated. In all cases patient to image recording was uneventful and the surgical objective was reached. The guidance given by the navigation system was helpful. CBCT is an alternative to conventional CT, gives a lower dose of radiation, and costs less. Limitations in the quality of the images and the size of the field of view may restrict its use. It is suitable for image-guided surgery using a navigation system as long as the images show enough of the relevant anatomy and pathology.

Carotid artery injury from an airgun pellet: a case report and review of the literature

Historically airguns were powerful weapons. Modern models, though less lethal, are still capable of inflicting serious or life threatening injuries. Current United Kingdom legislation fails to take into the account the capacity for airguns to maim and kill. We believe that airguns should be governed by the same law that applies to firearms. We present a case of a potentially fatal airgun injury to the neck. The airgun pellet caused a defect in the anterior wall of the external carotid artery, which required rapid access and surgical repair. We discuss the mechanism of airgun injury and review the literature in terms of investigation and management.

Ultrasound guided removal of an airgun pellet from a patient's right cheek

This case report describes the use of real-time intraoperative ultrasonography to guide the removal of an airgun pellet embedded in the right cheek of a 20-year-old man. This patient had previously undergone two unsuccessful surgical attempts to have this pellet removed via blind exploration. Through the use of ultrasonography, the pellet's positional relationship throughout the procedure was accurately defined with respect to important soft and hard anatomical structures, as well as to the surgical instruments used, enabling its very efficient removal. This technique is safe, easy, cost effective and accurate, and thus minimizes post-operative morbidity and the risk of surgical complications.

Conventional radiographs: are they still the standard in localization of projectiles?

The penetration of air gun pellets in facial soft tissue can cause major problems during the removal of foreign bodies, although conventional radiography, computed tomography, image-guided surgical removal, and ultrasound have been applied to facilitate the procedure. It was the aim of the present case report to introduce a modified intraoperative method for the localization of air gun pellets, based on the use of radiopaque markers in conventional radiographs. A 66-year-old patient attempted to commit suicide by using an air gun. The pellet hit the right temporal region. A computed tomographic (CT) scan was acquired to localize the foreign body. The first attempt to remove the pellet through the penetrating wound failed. Because of a dislodgement of the pellet, the CT scan could no longer be used for the localization of the air gun pellet. As the air gun pellet was positioned under the zygomatic arch, ultrasound was unable to identify its position. Successful intraoperative localization of the projectile was performed after fixation of radiopaque markers to the skin in the region of the estimated localization, with conventional radiographs in 2 planes, acquired with a mobile dental x-ray device. Although the markers remained attached to the patient as reference makers, the air gun pellet was removed easily. The use of radiopaque markers in conventional radiographs in 2 planes allows fast, intraoperative localization of radiopaque foreign bodies within soft tissue. The procedure can be carried out with a conventional x-ray device that should be available in every oral and maxillofacial practice. The use of reference markers should be considered a standard procedure for the localization of radiopaque foreign bodies in the head and neck.

Snookered! Facial infection secondary to occult foreign body

A case is presented of a man suffering from a severe purulent temporofacial infection that was secondary to an occult foreign body. The patient had been impaled on a 13 cm section of snooker cue and was entirely unaware of its presence despite the size. The management of this case is presented and discussed.

Novel use of ultrasound-guided surface marking of head and neck tumors invading facial skin

Malignant tumors of deep head and neck structures can invade skin, but the tumor periphery is difficult to assess clinically. The surgeon's dilemma is achieving tumor clearance with safe margins while at the same time minimizing skin loss on the face. We show, in 2 cases involving the face, that high-resolution diagnostic ultrasound was superior to CT scan in demonstrating the periphery of the tumor. The tumor was distinguished from surrounding edema by its lower echogenicity and homogeneous echotexture. The maximum contour of the tumor was marked on the skin surface with ink under ultrasound guidance. The ink marking aided excision and reconstruction planning. Subsequent histology showed the surgical margins were clear of tumor. The patients remained tumor-free for more than 3 years. Ultrasound imaging therefore shows good potential for planning surgical resection with a safe margin and for aiding decisions on donor site and type of flap for reconstruction.

Image-guided removal of foreign bodies

Foreign bodies are common in the head and face. We investigated the use of image-guided navigation systems for the removal of foreign bodies in 10 patients between 1998 and 2004. In all cases foreign bodies were retrieved. There were no major complications. Image-guided removal of foreign bodies is safe and valuable.

[Incorporation of multiple foreign bodies due to borderline personality disorder]

BACKGROUND

Autoaggressive behaviour is one of the pathognomonic characteristics in patients with borderline personality disorder. Clinical symptoms of such behaviour can be the self-induced incorporation of foreign bodies. In the head and neck area, this form of autoaggressivity causes primary or secondary infectious complications with different clinical manifestations. Below follows a description of diagnosis, therapy and follow-up of such a case, comparing our own findings with the corresponding literature.

CASE REPORT

A 24-year-old woman with manifest borderline personality disorder was referred to the Department of Maxillofacial Surgery after developing a swelling in the infra-auricular region. After antibiotic therapy failed to reduce inflammatory symptoms, local revision was performed including excision of two metallic foreign bodies. Comprehensive radiological evaluation identified multiple foreign bodies in the head and neck region and lower arms. A total of 76 metallic foreign bodies was removed surgically. During early surgical follow-up and subsequent psychiatric treatment, the patient incorporated new foreign bodies.

DISCUSSION

The case reported represents a pattern of foreign body incorporation which is unusual based on review of the literature but characteristic for patients with borderline personality disorder. Diagnostics and therapy require an individual concept which only can be implemented in close co-operation with psychiatrists. Secondary clinical benefit derived from surgical diagnostics and therapy as well as the possibility of autoaggressive relapse have to be taken into consideration.

A new approach using intraoperative ultrasound imaging for the localization and removal of multiple foreign bodies in the neck

An innovative method of using ultrasound imaging intraoperatively is reported. Multiple radiopaque and radiolucent foreign bodies within soft tissues were localized in theatre using high resolution ultrasonography. Depth of injury and vessel status were also ultrasonically assessed. Surgical removal of all foreign bodies was aided by intraoperative ultrasound guidance. In addition, this new approach of using intraoperative ultrasonography was pivotal in confirming the removal of all foreign bodies from the wound at the time of the operation.