Case Report
Ultrasound-guided removal of impalpable, radiolucent vegetative foreign bodies embedded into facial soft tissues of a toddler

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Abstract

Otolaryngologists frequently encounter children with foreign bodies retained inside the lumen of their upper aerodigestive tract. However, total capture in the soft tissues happens rarely, and could be clinically, as well as radiographically, silent. Ultrasonography is a safe and effective imaging modality, aiding both diagnosis and surgical treatment. We report on a 14-month girl with chronic, fluctuating cheek edema and erythema, induced by an impalpable, radiolucent bundle of organic fibers embedded intramuscularly. Foreign body identification and atraumatic removal were facilitated by real-time ultrasound scanning.

Introduction

Pediatric surgical subspecialties deal everyday with retained foreign bodies. Otolaryngologists are especially accustomed to treating children with foreign items inserted into the various cavities of the head and neck region, due to the inherent curiosity of infants and toddlers to probe their body orifices [1]. Consequently, foreign bodies entirely embedded among the facial soft tissues, as opposed to intraluminal ones, might pose an out-of -the-ordinary challenge to the ENT physician.

Whereas the contribution of history and physical examination is unquestionably essential to a successful foreign item localization in adults, such situations in the uncooperative pediatric population call particularly for imaging studies. Radiographs, be it plain or soft-tissue, traditionally constitute the first-line defense in the management of children with a suspected foreign body, as they are ubiquitous, inexpensive, and can be obtained instantly. However, unless the item in question is radiopaque (e.g. metal, stone, glass), it is likely not to be visualized. In fact, 95% of plastic or organic retained foreign bodies will escape detection by plain x-rays [2]. Computed tomography is far more sensitive, although in case of wood or vegetative material, the density of the foreign fragment is similar to that of the surrounding soft tissues [3]. Needless to mention the burden of ionizing radiation on the delicate growing structures of the head and neck in a young child. In addition, magnetic resonance imaging, despite being superior in terms of soft tissue depiction, lacks the necessary spatial resolution for the discrimination of small organic particles, is expensive and not available in every institution [4]. On the other hand, ultrasonography is a readily accessible, cost-effective, radiation-free imaging technique, capable of identifying radiolucent foreign bodies measuring less than 1 mm in any dimension. Not only that, but the real-time acquisition of images allows constant visualization of the foreign body during surgical exploration [5]. Here we report the case of a toddler with an intramuscularly-embedded radiolucent foreign body of the cheek, which was discovered and removed utilizing high-resolution ultrasound.

Section snippets

Clinical report

A 14-month old female patient was brought to the otolaryngology clinic by her adoptive parents, because of episodic right-sided cheek swelling, along with mild erythema, for the last 4 months. The child had been adopted at the age of six months, and no past medical history was available. No trauma event had been noticed since the adoption, either. The toddler was well-nourished, calm, with no clinical signs of generalized sepsis. Physical exam, both facial and intraoral, demonstrated moderate

Discussion

The present report illustrates a rare clinical scenario, where the medical history and physical exam offer little or no help to the diagnostic workup. To our knowledge, this is the first case report describing ultrasound-assisted removal of a foreign body from the head and neck region of a patient at such a young age. With regard to toddlers, all information is provided by the caregivers; still, an episode of foreign body insertion into one's oral cavity might go unnoticed. As far as physical

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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