An interesting case of Foreign body retrieval
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A 38-year-old man presented to A&E with a right-sided focal fluctuant swelling to the submandibular and submental area which crossed the midline. The neck was diffusely swollen. He had dysphonia, odynophagia, and dyspnoea. He was tachycardic and tachypnoeic and gave a history of intermittent dental abscess from the lower right quadrant further to a dental extraction many years ago. On previous occasions, this had usually resolved with courses of antibiotics. Medically the patient had a history of recreational drug use and was a heavy smoker. A provisional diagnosis of impending airway loss secondary to spreading dental sepsis from the 46 regions was made.

Routine blood showed raised WBC (21.2), neutrophils (19.7), CRP (456), lactate (2.1), and urea 8.3 mmol/L, demonstrating significant cervicofacial infection. An OPG revealed a foreign body (FB) in the 46 regions. Urgent theatre arrangements were made in order to stabilize the airway and achieve immediate abscess drainage and attempt foreign body removal. The abscess was drained via an extraoral and intraoral approach. The FB was not retrievable with blunt dissection.

Post-operatively, a CT scan was carried out to locate the FB with plans for elective retrieval. With the patient's airway now safe, on questioning, he admitted attempting to clear the lower right molar socket of debris with an interdental brush and we hypothesized the FB to be its metallic core. Whilst the patient initially improved, worsening clinical signs and neck swelling necessitated a repeat CT. This demonstrated a spreading fascial space infection with further collections extending to the right anterior neck, retrosternal, and anterosuperior mediastinum. The position of the FB remained unchanged.

In spite of having pre-op 3D scans, locating the FB proved to be challenging intraoperatively. Ultimately, a marker needle, in conjunction with an intra-operative C-arm and parallax technique, allowed FB position triangulation. Blunt dissection was carried out around the needle to successfully retrieve the interdental brush.

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