Imaging foreign bodies in head and neck trauma: a pictorial review

Complex-Type Foreign Body Penetrating Injuries of the Craniofacial Region and Surgical Management: A Report of Three Cases

Introduction

Craniofacial penetrating injuries are not a rare sight in the career of oral and maxillofacial surgeons and trainees, but bizarre craniomaxillofacial sharp injuries caused by peculiar foreign bodies to the head and neck region, complicating and obscuring the vital structures, are seldom found. Foreign bodies such as lunch boxes, wooden branches or twigs are peculiarly associated with penetrating/perforating craniofacial severe impaled injuries with dramatic consequences.

Case Report

Three cases are reported, with elaborate descriptions of the site, kind, and severity of the injuries. Cases 1 and 3, wooden impalement injuries into the neck region and sensitive orbital region, respectively, necessitating immediate surgical retrieval as in both cases. In case 2, 4-year old sustained an injury with a sharp rim of the lunch box, obscuring the entire craniofacial region and impeding the primary care and assessment.Cases represent the peculiarity of the injuries caused by unusual foreign bodies and how their uniqueness demanded a different surgical intervention.The need for a multidisciplinary approach is crucial to managing these injuries in areas with a high degree of specialization overlap, such as the craniofacial region.

Conclusion

We give an overview of the diagnosis and treatment of penetrating foreign body trauma encountered in our department. Every foreign body penetrating trauma demands a formulation of a different surgical plan and stands as a challenge for the treating surgeons. Adequate radiology knowledge, detection, vigilant clinical assessment, and tension-free closure are a few of the important aspects for the ideal management of penetrating foreign body trauma.

A serial case study of the combined use of intraoperative CT and surgical navigation system for the removal of small foreign bodies in the maxillofacial region

PURPOSE

The removal of small foreign bodies embedded within the deep soft tissues of the maxillofacial region is a complex and challenging task for maxillofacial surgeons. The purpose of this study was to explore the efficacy of the combination of intraoperative CT and surgical navigation for the removal of small foreign objects in the maxillofacial region.

METHODS

A serial case study was conducted involving all consecutive patients who underwent surgical removal of small foreign bodies in the maxillofacial region. The combination of intraoperative CT and a surgical navigation system was used at a single medical institution from January 2018 to December 2022. Comprehensive data, including patient demographics, characteristics of the foreign bodies, previous surgical interventions, duration of the surgical procedure, and removal success rate were collected for this study. Relevant data were recorded into Microsoft Excel sheet and analyzed using SPSS version 22.0.

RESULTS

Nine patients (6 males and 3 females) were included in this study, with an average age of 37 years. Each patient had previously undergone an unsuccessful removal attempt utilizing conventional surgical methods based on preoperative CT imaging or C-arm guidance at a local healthcare facility. Four patients also experienced unsuccessful attempts with preoperative CT image-based navigation systems. However, by employing the combined approach of intraoperative CT and surgical navigation, the foreign bodies were successfully removed in all 9 patients. The mean duration of the surgical procedure was 59 min, and the average size of the foreign bodies was approximately 26 mm³. Postoperative follow-up exceeding 6 months revealed no complications.

CONCLUSION

The combined use of a surgical navigation system and intraoperative CT represents a potent and effective strategy for the precise localization and subsequent removal of small foreign bodies from the soft tissue structures of the maxillofacial region. This integrative approach appears to increase the success rate of surgical interventions in such cases.

Low-velocity penetrating brain injury: a review of the literature and illustrative case

INTRODUCTION

Low-velocity penetrating brain injury (LVPBI) is a class of brain injury where a foreign object violates the skull and damages the brain. Such injuries are rare and consequently understudied.

CASE

As such, we report an illustrative case of a 29-year-old female with a dense, plastic spike penetrating her right orbit and into her midbrain. After assessment with a CT scan and angiography, the object was removed with careful attention to possible vascular injury. The patient had an uncomplicated post-operative course and received antibiotic and antiepileptic prophylaxis. She was discharged on post-operative day 5, experiencing only mild left-sided weakness.

DISCUSSION

Common concerns regarding LVPBI include infection, post-traumatic epilepsy, and vascular injury. A review of published LVPBI cases over the past 20 years demonstrated that most cases (55.2%) are due to accidents. Of patients undergoing surgery, 43.4% underwent a craniotomy, and 22.8% underwent a craniectomy. Despite the grave nature of LVPBI, only 13.5% of the patients died. Additionally, 6.5% of patients developed an infection over their clinical course.

CONCLUSION

In all, more reported cases further paint a picture of the current state of management and outcomes regarding LVPBI, paving the way for more cohesive guidelines to ensure the best possible patient outcomes.

Artificial intelligence in the detection of non-biological materials

Artificial Intelligence (AI) has emerged as a transformative force within medical imaging, making significant strides within emergency radiology. Presently, there is a strong reliance on radiologists to accurately diagnose and characterize foreign bodies in a timely fashion, a task that can be readily augmented with AI tools. This article will first explore the most common clinical scenarios involving foreign bodies, such as retained surgical instruments, open and penetrating injuries, catheter and tube malposition, and foreign body ingestion and aspiration. By initially exploring the existing imaging techniques employed for diagnosing these conditions, the potential role of AI in detecting non-biological materials can be better elucidated. Yet, the heterogeneous nature of foreign bodies and limited data availability complicates the development of computer-aided detection models. Despite these challenges, integrating AI can potentially decrease radiologist workload, enhance diagnostic accuracy, and improve patient outcomes.

Migrated subcutaneous sharp foreign body in the anterior chest wall: An unusual presentation

Key Clinical Message

Migration of any foreign body can cause potentially life threatening complications and should be reviewed by a multidisciplinary approach for the management. Diagnosis can be challenging; a history of foreign body injury could be suspicious.

Abstract

Foreign body injury to the chest wall can be an emergency situation and require a multidisciplinary approach for the management of the condition. Migration of the foreign body, though rare, can lead to potentially life threatening complications and require a multidisciplinary approach for the localization of the foreign body and subsequent management of the condition. A 50-year-old male presented to the emergency department with the complaint of left sided chest pain. Upon examination, the patient was found to have a penetrating injury 6 years back by a sharp object. Radiological investigations helped in the localization of the migrating foreign body, which was removed with effective surgical intervention. The postoperative chest x-ray was normal, the patient was asymptomatic and thus the patient was discharged on the same day following surgery.

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.

Non-traumatic head and neck emergencies

This review aims to provide pictorial examples of non-traumatic head and neck emergencies one may commonly encounter in the Emergency Department, with a few important, rarer cases for educational purposes. It begins with a brief introduction to compartmental neck space anatomy and how one might approach choosing an imaging modality, moving on to consider a variety of predominantly infective pathologies that may present acutely. It is not a comprehensive overview of all non-traumatic emergencies but will hopefully stimulate interest in the subject and encourage further reading.

The Evolution of Foreign Bodies Management in a Case of Near-fatal Penetrating Neck Injury

Penetrating wounds of the neck with foreign bodies retention are frequent and often life-threatening events, and their management has changed in recent years from an open approach to a conservative approach thanks to the possibility of performing minimally invasive radiologically guided surgery. We present a case of penetrating glass injury to zone III of the neck in which the foreign body go through the parotid region passing near, but without injuring, the facial nerve and the external and internal carotid arteries.

Surgical Removal of an Orthodontic Mini-Screw Displaced Into the Lateral Pharyngeal Space: A Case Report and Review of Pertinent Literature

Oral and maxillofacial surgeons are often faced with the clinical challenge of foreign body displacement into the perioral tissues and soft tissues of the head and neck. This mainly occurs either because of trauma or inadvertently during dental treatment. In addition to the maxillary sinus, iatrogenic foreign body displacement during dental treatment could happen into one of the 16 distinct fascial spaces of the head and neck region. Commonly displaced foreign bodies related to dental treatment include tooth roots or fragments, local anesthetic needles, implants and restorations. The clinical sequelae of a displaced foreign body depend on its size, shape, anatomic location and proximity to vital structures. Although patients may remain asymptomatic for a considerable amount of time, retained foreign bodies result in persistent pain, recurrent infection and scarring of soft tissue due to inflammation, all of which may complicate delayed retrieval. In addition to the history, imaging modalities such as plain radiographs and computed tomography (CT) help in locating the displaced foreign body and its subsequent retrieval. Surgical retrieval may be attempted through intraoral, transcervical and endoscopic approaches. Additionally, surgery may be aided by real-time imaging such as fluoroscopy. The present report aims to detail a case of inadvertent displacement of an orthodontic mini-screw, commonly used as a temporary anchorage device (TAD), into the lateral pharyngeal space, while attempting placement in the mandibular retromolar area. The case report also describes the surgical retrieval procedure of the TAD screw using an intraoral approach and with fluoroscopy guidance using C-Arm radiographic imaging. This case is reported along with the pertinent review of literature, as it not only explains a rare complication of orthodontic mini-screw placement but also details a modality to remove displaced foreign bodies from fascial spaces of the head and neck, which are otherwise directly inaccessible.

Penetrating Neck Injury Involving Wooden Foreign Bodies: Case Report

Although rare, penetrating neck injuries can have grave consequences, and are associated with high mortality rates. Individuals with cervical injuries due to wooden foreign bodies are at an increased risk of developing infectious complications. In this case, a male patient aged 27 years presented with a cervical injury indicative of a penetrating wound caused by a wooden foreign body. Computed tomography (CT) scan revealed no signs of intracranial hemorrhage or fracture. Additionally, cervical CT scan showed no evidence of cervical corpus or longus colli muscle lesions. The medical team suggested a cervical magnetic resonance imaging (MRI) examination; however, the patient's family opted out. Subsequently, the patient underwent wound debridement, which involved the extraction of a fragment of impaling wood. Two days after the procedure, the patient developed a fever and weakness of the shoulder and arm on the ipsilateral side. Following the process of re-education, the family provided consent for MRI examination. A subsequent surgical procedure was performed on the patient based on the MRI findings and clinical presentation. Residual wooden fragments were effectively extracted, resulting in positive progression of the patient's condition.

Unexpected metallic foreign bodies on panoramic scans - a narrative review

BACKGROUND

The digital panoramic radiograph (orthopantomogram, OPG) is the standard radiographic technique for basic diagnostics in dental practice. A correctly taken image provides a good overview of teeth and jaw, whereas radiopaque foreign materials, e. g. metal, can obscure relevant findings.

METHODS

A literature review on unexpected metallic foreign bodies in OPG was performed to determine the spectrum of metallic foreign bodies that may cause radiopaque areas on panoramic radiographs in routine clinical use.

RESULTS AND CONCLUSION

A total of 37 different unexpected metallic foreign bodies were found. They can be categorized as jewelry, clothing, personal protective equipment, medical devices, iatrogenic foreign bodies, and rare incidental findings. Radiopaque foreign materials in the OPG are often relatively easy to recognize as artifacts because of their location, and they are avoidable in most cases. If unclear, a three-dimensional radiograph was helpful for determining the location. Radiopaque areas caused by foreign bodies can lead to misinterpretation or partial or complete non-evaluability and should therefore be avoided.

KEY POINTS

· The OPG is the standard radiograph for dentists, oral surgeons, and oral and maxillofacial surgeons.. · Foreign bodies made of metal can lead to non-evaluability of panoramic radiographs. Based on a review of the literature and exemplary radiographs, this article provides an overview of rare but typical metallic foreign bodies in OPG, thus addressing the problem of the subfield of radiography by making radiologists more familiar with these images.. · The spectrum of unexpected metallic foreign bodies includes unremoved earrings with the typical ghost images on the contralateral side, piercings, hearing aids, acupuncture needles, rare iatrogenic foreign bodies, incidental findings in infants in the nose and external auditory canal, vascular clips after surgical interventions, and ritual subcutaneous foreign materials..

CITATION FORMAT

· Brauer HU, Bartols A, Hellmann D et al. Unexpected metallic foreign bodies on panoramic scans - a narrative review. Fortschr Röntgenstr 2023; 195: 809 - 818.

Fluoroscopy-Guided Metallic Foreign Body Removal: A Report of Three Cases and Literature Review

Ingested foreign objects that become trapped in the upper aerodigestive tract is a common issue that arises in Otolaryngology-Head and Neck Surgery practice. In these circumstances, it is advised to explore the neck using an external method to remove the item. However, locating the foreign body might be challenging. Not all metallic foreign body (MFB) patients require surgery, especially those without symptoms or complications. The standard X-ray and CT images are routinely examined for preoperative assessment and localization. Removal can be accomplished via flexible pharyngo-laryngoscopy or upper gastrointestinal endoscopy. Fluoroscopy is a widely accessible, minimally invasive, but underutilized tool during procedures. It offers an accurate intraoperative assessment of the foreign body in real-time. To allow the planning of a secure extraction pathway, the target should be radiopaque. In this report, we present three unique cases in which we used fluoroscopic imaging for guidance to remove a foreign body in the head and neck region in Prince Sultan Military Medical City in Riyadh, Saudi Arabia. In the first case, a young male presented with a history of foreign body sensation and odynophagia in the throat after eating a (shawarma) sandwich. In the second case, a six-year-old boy presented to the emergency department (ED) with epistaxis after being exposed to an air gun shot to his face. In the third case, a 40- year-old male presented after exposure to an air gun shot to the neck. After identification of the foreign body, all three patients were referred to Otolaryngology-Head and Neck. After radiological images have been done to confirm the presence of foreign objects, all three had a minimally invasive procedure to remove the metallic foreign bodies under fluoroscopic guidance without needing extensive surgery. All the procedures went well with no immediate complications with discharge on the same day. Fluoroscopy-guided removal of foreign bodies related to metabolic forging is a promising technique with several advantages, including real-time visualization, reduced invasiveness, and shorter recovery times. However, it is essential to weigh the benefits against the risks associated with radiation exposure and inherent limitations in detecting non-metallic objects. Further research and clinical studies are needed to optimize this technique and establish evidence-based guidelines for its application in the field of metabolic forging bodies.

Imaging the External Ear: Practical Approach to Normal and Pathologic Conditions

The external ear (EE) is an osseous-cartilaginous structure that extends from the auricle to the tympanic membrane. It is divided into two parts: the auricle (or pinna) and the external auditory canal (EAC). Given the ease of access to the EE, imaging studies are not always needed to make a diagnosis. However, when lesions block visual access to areas deep to the EE abnormality, complications are suspected, or there is lack of response to treatment, imaging becomes essential. A basic understanding of the embryologic development and knowledge of the anatomy of the auricle and EAC are useful for accurate diagnosis of EE lesions. Congenital, traumatic, inflammatory, neoplastic, and vascular conditions can affect the EE. An overview of the anatomy and embryologic development of the EE is presented, with discussion and illustrations of common and uncommon conditions that affect EE structures and a focus on the CT and MRI features that are of interest to radiologists. CT is usually the first diagnostic modality used to evaluate the EAC and is the superior method for demonstrating bone changes. MRI provides excellent tissue characterization and enables one to better define lesion extension and perineural tumor spread. In addition, a flowchart to facilitate the differential diagnosis of EE abnormalities is provided. Online supplemental material is available for this article. ^©RSNA, 2022.

A Metal Badge Embedded in the Forehead: A Case Report of Military Uniform Safety

Foreign body (FB) injury to the head is not uncommon in medical practice. Various objects have been reported in penetrating head injuries. Depth and location of penetration determine the expected complications and management approach. Here, we describe a case of FB injury to the head by the metal badge of a uniform hat and discuss the medical implications of such injuries among a large population of workers at risk. A 23-year-old male presented to the emergency room with the metal badge of his uniform hat embedded in the left side of his forehead after a physical altercation at work. Imaging revealed FB penetrating the soft tissue and minimally embedded in the outer table of the left frontal bone. The FB was removed in the emergency room with no complications. The wound was then cleaned and sutured, and the patient was discharged home with oral antibiotics for one week. Penetrating FB to the head can present significant morbidity to military personnel, and thus a safer design of work uniforms is warranted.

Removal of a Pencil Embedded in a Child’s Foot: A Case Report

The foot is the most common anatomic site for foreign body embedment in both children and adults. An 11-year-old boy boy with a history of autism spectrum disorder (ASD), learning disorder, and attention-deficit hyperactivity disorder (ADHD) was brought to our ED with a pencil deeply embedded in his right foot. The broken portion of the pencil was completely embedded in his right foot, with mild bleeding and it could not be extracted easily. The pencil was eventually mobilized via gentle back-and-forth twisting motion, which allowed successful removal of a significant portion of the embedded pencil.

To establish the presence of a foreign body, as in each X-ray, the affected body part should be imaged in at least two directions. Based on the density of the embedded foreign body, ultrasound imaging should be considered.