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Year : 2014  |  Volume : 25  |  Issue : 1  |  Page : 111-114
A 'pen' in the neck: An unusual foreign body and an unusual path of entry

1 Department of Cleft and Craniofacial Surgery, Plastic and Reconstructive Surgery, Amrita Institute of Medical Sciences, Cochin, Kerala, India
2 Department of Radiology, Plastic and Reconstructive Surgery, Amrita Institute of Medical Sciences, Cochin, Kerala, India
3 Department of Head and Neck Surgery, Plastic and Reconstructive Surgery, Amrita Institute of Medical Sciences, Cochin, Kerala, India

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Date of Submission13-Jan-2013
Date of Decision09-Sep-2013
Date of Acceptance30-Nov-2013
Date of Web Publication21-Apr-2014


Penetrating injuries to head and neck region with varying objects have been reported in the literature. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10] Majority of these injuries occur in interpersonal violence or bomb blasts or road traffic accidents. Despite the improvement in imaging technologies and surgical methods, penetrating injuries to head and neck with impacted foreign bodies are very challenging due to the proximity to vital structures and/or difficulties in accessing them for the removal. [1] Following injury the normal anatomy could be altered because of edema or tissue destruction, which makes the diagnosis or retrieval more difficult. [3] Parapharyngeal or prevertebral space is an unusual place for lodgment of foreign bodies and in these cases the usual point of entry is the oral cavity, cheek or neck. Here, we report a case of a ball point pen extending to the prevertebral region at the level of C1-C2 vertebrae from point of entry at the suprazygomatic region in the temporal fossa.

Keywords: Foreign body penetration, paraphryngeal space, prevertebral region

How to cite this article:
Rao LP, Peter S, Sreekumar K P, Iyer S. A 'pen' in the neck: An unusual foreign body and an unusual path of entry. Indian J Dent Res 2014;25:111-4

How to cite this URL:
Rao LP, Peter S, Sreekumar K P, Iyer S. A 'pen' in the neck: An unusual foreign body and an unusual path of entry. Indian J Dent Res [serial online] 2014 [cited 2019 Oct 15];25:111-4. Available from:
Penetrating foreign bodies in the neck, in general, require urgent surgical exploration and retrieval may be quite challenging depending on many factors such as the size of the object, the location and the surrounding anatomical structures. A high index of suspicion should be kept in mind, while exploring for foreign bodies to detect more than what is clearly visible in the scans. This is very important in cases where the impacted body is made up of different materials with varying radiodensity.

   Case Report Top

The present case report is about a 15-year-old boy who was referred to our unit, with a history of penetrating injury to the left side temporal region, in March 2010. He had allegedly fallen onto a pen held upright by his friend and the pen broke while attempting retrieval and part of it got retained inside the body. Remaining part of the pen was not brought along and patient and bystanders were very vague in giving the dimensions of the broken part which could have remained inside.

On examination, the boy was conscious, oriented and hemodynamically stable. There was a 5 mm puncture wound in the left temporal region about 2 cm lateral to the lateral canthus of eye [Figure 1]. There was mild edema in the left temporal region and difficulty in opening the mouth widely. The skull X-rays showed a 15 × 5 mm triangular radio opaque shadow in the prevertebral region at C1-C2 level [Figure 2]. As the shape of the object corresponded well with the metallic end portion of a ball point pen, it was assumed that the tip was retained inside the body.
Figure 1: Lateral view which shows the puncture wound in the suprazygomatic region lateral to lateral canthus

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Figure 2: Lateral (a) and AP (b) skull X-rays showing the retained metal portion in proximity to C2 spine

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Since the impacted object was metallic in nature, it was decided to obtain computed tomography (CT) scan for the patient. Scan revealed a hyperdense shadow of about 16 × 5 mm in size, in the left post-styloid compartment of parapharyngeal space at the level of C1-C2 vertebrae, almost reaching the lateral wall of oropharynx, just anterior to the carotid [Figure 3]. The object did not seem to have violated any vital structure in the neck. There was a well-defined tract in the soft tissues leading to the metallic part from skin surface, which was considered as the path through which the pen entered the tissue [Figure 4].
Figure 3: (a and b) Axial and coronal sections showing the impacted hyperdense foreign body in the post-styloid compartment of left parapharyngeal space

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Figure 4: (a-h) The white arrowhead shows the path of entry of the pen from suprazygomatic region, passing medial to the zygomatic arch, through the sigmoid notch in a slightly inferior direction to reach the spine region of C1-C2 vertebrae

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Parents and patient refused immediate exploration of neck on the pretext of board examination of standard X. They were explained about the chances of migration of the foreign body and penetration into vital structures or persistent infections. Patient was strictly advised to return within a week, when the exams would be over. The patient did not turn up for his appointment at the end of the week and attempts to contact him yielded no results.

Patient reported back to us in December 2010, 9 months after the incident, with history of persistent pus discharge from the wound in the left temporal region for last 3 months, which did not responded to various courses of antibiotics he was prescribed from local hospital. On examination, he had copious pus discharge from the puncture wound in the suprazygomatic region. Mouth opening was reduced to 15 mm.

He underwent magnetic resonance imaging (MRI) scan with contrast which revealed a magnetic susceptibility artefact in the prevertebral soft-tissues at C1/C2 vertebra to the left side obscuring the details of C2 vertebra.

Left lateral wall of oropharynx appeared swollen with obliteration of adjacent parapharyngeal space. There was a well-defined tract leading to the magnetic susceptibility artifact from the skin surface, of 5mm diameter. The tract showed a hypointense margin, which was again considered to be the path of entry remaining patent because of infection and pus drainage [Figure 5].
Figure 5: (a-f) Magnetic resonance imaging with contrast. The white arrowheads in fi gures a to e show the pus fi lled tract with hypointense margin. The white arrowhead in fi gure f shows the magnetic susceptible artifact

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The patient was taken in for exploration and foreign body retrieval under general anesthesia. Pus was aspirated from the suprazygoamtic puncture wound with a suction catheter passed through the wound. Left Risdon's incision was placed and deepened to subplatysmal level. Posterior belly of digastric was retracted down. Stylohyoid muscle was identified and traced back to styloid process. The styloid was freed of its muscle attachments to reach medial and posterior to the styloid process to the post-styloid part of parapharyngeal position of the foreign body as identified from radiological pictures. The metallic pen tip could be identified by bidigital palpation and retrieved by blunt dissection [Figure 6]. Further dissection in the area revealed the plastic portion of the pen in the area. As the plastic part was grasped with a hemostat, to our surprise, its movement could be felt very clearly near the entry wound in the supra zygomatic region. This aroused the suspicion of a larger portion being retained in tissue. The entry wound on the face enlarged, the plastic part of about 3.5 cm length was identified and retrieved [Figure 7], [Figure 8], [Figure 9]. The tract was excised and wound closed in layers. Post-operative recovery was uneventful. Mouth opening returned to normal.
Figure 6: The metal tip in the poststyloid compartment of paraphryngeal space

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Figure 7: The entry wound enlarged to expose the plastic portion of pen

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Figure 8: The retrieved plastic portion and metal tip of pen and the enlarged entry wound

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Figure 9: The retrieved parts assembled

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   Discussion Top

Though soft-tissue injuries to the head and neck are very common penetrating injuries resulting in the impaction of foreign bodies are still a very scary situation for the patient or the attendants. They are usually secondary to a gunshot or stab wound. [2] There have been reports of impacted chopsticks [4] even. However retention of a fractured pen is not reported.

In almost all cases, the impaction of foreign bodies in the neck in the prevertebral or parapharyngeal region occurred with penetration through oral cavity, cheek or neck. [2] In our case, the path of entry was from suprazygomatic region, passing medial to the zygomatic arch, through the sigmoid notch in a slightly inferior direction to reach the spine region of C1-C2 vertebrae. The metallic portion of the pen had lodged just anterior to the carotid.

The diagnosis of penetrating neck trauma with an associated foreign body in situ, is generally quite obvious from history or clinical examination. However, identifying a foreign body can be very challenging at times, especially in cases where the impacted body is very thin or radiologically not very clear. [5]

Precise localization of the foreign object is essential for complication-free removal. Both CT and MRI have been described as useful techniques for detecting the presence of a foreign body in the soft tissues of the neck [6] and provide sufficient information to enable location of the foreign body and determination of the relation between the foreign body and major vessels.

The retention of the plastic portion of the pen, which measured about 3.5 cm in length completely took us by surprise as its presence was not suspected, probably because the CT/MRI values of the retained plastic was hardly discernible and the thickness was less than a millimeter. The tract seen in the tissues was considered the entry path of pen, remaining patent because of persistent pus discharge. A study by Wakisaka et al., [2] opined that in such cases portion of the nonmetallic foreign body, present outside the body could be subjected to tomography, to accurately determine the CT values of the foreign body. This information would have definitely allowed us to adjust CT window settings to allow visualization, facilitating accurate size and site determination. However in this case, it was not possible, even if it was considered since the remaining portion was not made available.

There is currently no consensus among surgeons regarding the management of cervical foreign bodies. There are advocates for both "mandatory" explorations [7] and exploration in "selected" cases. [8] Asensio et al., [9] in their study have performed a thorough review of the literature on the subject of "mandatory exploration versus selective exploration". They found no advantage of one approach over the other. Proponents of mandatory exploration favor removal of foreign bodies at the earliest as they are known to migrate [10] and can cause secondary complications such as hemorrhage or hematoma, infection and neurovascular compromise. In our case, the part of pen remained inside acted as a port of entry to contaminants/infection to deeper tissues.

To conclude, pre-operative imaging is very important in deciding upon the surgical approach for the retrieval of impacted foreign bodies and CT and MRI are equally efficient. In spite of having both CT and MRI, we failed to notice the presence of the plastic portion of pen in the scans. It is also advantageous to have the portion of foreign body which has remained outside imaged to know its imaging properties. This would help in identifying the impacted foreign body especially in case of non-metallic objects.

   References Top

1.Siessegger M, Mischkowski RA, Schneider BT, Krug B, Klesper B, Zöller JE. Image guided surgical navigation for removal of foreign bodies in the head and neck. J Craniomaxillofac Surg 2001;29:321-5.  Back to cited text no. 1
2.Wakisaka H, Takahashi H, Ugumori T, Motoyoshi K, Takagi D. A case of a wooden foreign body penetrating the oral cavity and reaching the posterior neck. Inj Extra 2010;41:92-6.  Back to cited text no. 2
3.Reiss M, Reiss G, Pilling E. Gunshot injuries in the head-neck area-basic principles, diagnosis and management. Schweiz Rundsch Med Prax 1998;87:832-8.  Back to cited text no. 3
4.Park SH, Cho KH, Shin YS, Kim SH, Ahn YH, Cho KG, et al. Penetrating craniofacial injuries in children with wooden and metal chopsticks. Pediatr Neurosurg 2006;42:138-46.  Back to cited text no. 4
5.Hersman G, Barker P, Bowley DM, Boffard KD. The management of penetrating neck injuries. Int Surg 2001;86:82-9.  Back to cited text no. 5
6.Shankar L, Khan A, Cheung G. Head and Neck Imaging. 1st ed.. New York: McGraw-Hill; 1998. p. 15-36.  Back to cited text no. 6
7.Khan MS, Kirkland PM, Kumar R. Migrating foreign body in the tracheobronchial tree: An unusual case of firework penetrating neck injury. J Laryngol Otol 2002;116:148-9.  Back to cited text no. 7
8.Obeid FN, Haddad GS, Horst HM, Bivins BA. A critical reappraisal of a mandatory exploration policy for penetrating wounds of the neck. Surg Gynecol Obstet 1985;160:517-22.  Back to cited text no. 8
9.Asensio JA, Valenziano CP, Falcone RE, Grosh JD. Management of penetrating neck injuries. The controversy surrounding zone II injuries. Surg Clin North Am 1991;71:267-96.  Back to cited text no. 9
10.Landis BN, Giger R. An unusual foreign body migrating through time and tissues. Head Face Med 2006;2:30.  Back to cited text no. 10

Correspondence Address:
Latha P Rao
Department of Cleft and Craniofacial Surgery, Plastic and Reconstructive Surgery, Amrita Institute of Medical Sciences, Cochin, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-9290.131159

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]


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