Needle in the Haystack: Wire Bristle Foreign Body Presenting Deep Within the Tongue Base

Abstract

Objectives:

To report a case of ingested wire bristle embedded within the extrinsic musculature of the tongue requiring a transcervical approach for removal and to provide a revised algorithm for the management of ingested wire bristles.

Methods:

The clinical record of 1 patient who ingested a grill brush wire bristle was reviewed. A literature review was also conducted to refine a treatment algorithm for managing ingested wire bristles.

Results:

We present a case of a 53-year-old male who accidentally ingested a grill brush wire bristle. After multiple unsuccessful endoscopic attempts at removal, the wire bristle migrated deep into the extrinsic musculature of the tongue, necessitating a transcervical approach for adequate visualization and retrieval.

Conclusions:

This is the first case reported of a wire bristle migrating deep into the tongue musculature that was successfully removed via a transcervical approach. Our proposed algorithm provides a comprehensive approach to the management of ingested wire bristles, specifically in cases where endoscopic retrieval is not feasible.

Introduction

The accidental ingestion of wire bristles from grill brushes has become increasingly prevalent in medical literature and media. In recent years, the CDC issued an editorial note warning of the risk associated with grilling brushes, and brush-related injury data continue to be reviewed by the Consumer Product Safety Commission. ¹ In fact, an estimated 1700 Americans presented to an emergency department between 2002 and 2014 after ingesting wire brush bristles. ² Complications of foreign body ingestion are broad, but wire bristles especially have led to devastating injuries, including lingual abscess, penetrating esophageal injury, and colonic perforation. ^{3 -5} Despite these major complications, wire bristles present a unique clinical challenge to the otolaryngologist due to their small size and nonspecific presenting symptoms.

A wide range of approaches to removal of wire bristles from the upper aerodigestive tract has been described in the literature. Wong et al presented an algorithm for diagnosis and removal of wire brush bristles. ⁶ In nearly all of these reports, the wire bristle was located in a location within the upper aerodigestive tract amenable to endoscopic, minimally invasive retrieval. Penetration of the wire bristle through the pharyngeal lumen and migration into the neck requiring an open approach has previously been described. ⁷ To our knowledge, however, there are no reports of a wire bristle becoming so deeply embedded within the extrinsic musculature of the tongue that a transcervical approach was required. We present our experience in successfully locating and removing a wire bristle deep in the extrinsic tongue musculature via a transcervical approach and propose revisions to the previously described algorithm for management of ingested wire bristles.

Case

A 53-year-old male presented to an outside hospital after experiencing odynophagia and foreign body sensation following preparation and ingestion of steak. In the emergency department, a lateral soft neck x-ray demonstrated a linear metallic foreign body present within the tongue base, and subsequent computed tomography (CT) with contrast demonstrated a linear foreign body located in the lingual tonsillar tissue, consistent with a wire bristle (Figure 1A). Within 24 hours, he was taken to the operating room (OR) by a general otolaryngologist for direct laryngoscopy, but the foreign body was not visualized. The patient was discharged on antibiotics and a course of corticosteroids and referred to laryngology. Subsequent in-office laryngoscopy revealed a faint submucosal linear metallic shimmer along the tongue base, and the patient continued to complain of foreign body sensation and otalgia. Twelve days after the incident, the patient returned to the OR for microscopic suspension laryngoscopy. Therefore, focused dissection at the suspected site of the foreign body was performed using needle tip bovie cautery; however, after several hours of dissection assisted by fluoroscopy, the foreign body could not be extracted. The procedure was aborted, and immediate postoperative CT confirmed that the needle migrated deeper into the tongue base, now located 1-cm deep from the mucosal edge of the tongue base (Figure 1B).

Figure 1.

A, First CT demonstrating a linear foreign body in the lingual tonsillar tissue. B, Second CT after unsuccessful microscopic suspension laryngoscopy confirming foreign body migration to deep within the tongue base. CT indicates computed tomography.

Given the location of the foreign body deep within the tongue musculature, the patient was referred to Head and Neck Surgery for further evaluation. After discussion, the decision was made to allow 2 to 3 weeks for the foreign body to potentially migrate to a location more amenable to transcervical recovery. Computed tomography imaging was obtained once more, revealing the foreign body to have migrated anteriorly into the left sublingual space, between the genioglossus and hyoglossus muscles (Figure 2). Reviewing the imaging, it was felt that a transcervical submandibular approach would be the most direct. A standard submandibular approach was employed using a Risdon incision. The submandibular gland was retracted superiorly and the mylohyoid muscle medially, exposing the hypoglossal nerve overlying the hyoglossus muscle. The hypoglossal nerve was skeletonized, preserving its branches, and the hyoglossus muscle was divided, exposing the genioglossus. Intraoperative fluoroscopy demonstrated the foreign body to be within the field of dissection at the location of the hypoglossal nerve (Figure 3). After extensive dissection, no foreign body could be recognized. A hockey stick ultrasound probe was then used to examine the genioglossus muscle (Figure 4); this revealed a linear foreign body superficially within the genioglossus beneath the level of the hypoglossal nerve. Despite this, additional dissection failed to yield the foreign body. To help provide stability to the tongue base, a Deaver retractor was placed intraorally. After additional dissection through the genioglossus, the leading edge of the foreign body was palpated and visualized. The object was grasped with a fine tonsil hemostat and removed. Inspection of the object was consistent with a wire grill brush bristle, measuring approximately 2 cm in length with a diameter of approximately 0.1 mm (Figure 5). At the end of the operation, the hypoglossal nerve was visibly intact, and the patient had normal tongue mobility. His postoperative course was uncomplicated, and the patient was discharged home the morning after surgery with resolution of symptoms.

Figure 2.

Final CT demonstrating foreign body in the genioglossus and hyoglossus muscles. CT indicates computed tomography.

Figure 3.

Intraoperative fluoroscopy image revealing foreign body in the area of the hypoglossal nerve.

Figure 4.

Hockey stick ultrasound probe. ⁸

Figure 5.

Metallic wire bristle extracted from patient.

Discussion

The accidental ingestion of wire bristles from metallic grill brushes has been reported numerous times within the literature. This situation is frequent enough to have warranted the development of a treatment algorithm in previous publications. As opposed to prior cases, which have primarily focused on endoscopic removal of wire bristles from the lingual tonsils, palatine tonsils, or pharyngeal lumen, the wire bristle in our case had migrated deep into the extrinsic musculature of the tongue, necessitating an open, transcervical approach for removal.

In review of the recent literature, it is common for the first attempt at removal of these foreign bodies to be unsuccessful. ^6,9 However, with wire bristles most commonly becoming embedded within the oropharynx, only a small number of reported cases have required open neck exploration for removal. ⁹ In those cases, the foreign body had migrated through the pharyngeal or esophageal lumen into the soft tissue of the neck. In one similar case in which the wire bristle was located deep within the tongue musculature, the bristle was unable to be located and was left in situ, despite open attempts. ³ To our knowledge, our case is the first in which a wire bristle migrated deep into the extrinsic musculature of the tongue was successfully removed via a transcervical approach.

The previously proposed algorithm for management of wire bristle foreign bodies was followed in this case. ⁶ However, the algorithm fails to address cases of foreign body located in the base of tongue unable to be retrieved endoscopically. In our case, the patient’s initial imaging studies localized the foreign body to the tongue base. After 2 unsuccessful attempts at endoscopic retrieval under general anesthesia, the foreign body migrated deeper into the tongue base musculature, rendering endoscopic removal impossible. On retrospective review of these 2 failed endoscopies, the patient was intubated in the standard endotracheal fashion using a Macintosh blade. We suspect that the pressure of the laryngoscopy blade on the tongue base may have inadvertently pushed the foreign body deeper, accounting for the inability of the foreign body to be retrieved endoscopically. Therefore, in cases in which the foreign body can be identified on flexible fiberoptic laryngoscopy but not removed under local anesthesia, or in cases where the foreign body appears to be embedded in or located just under the surface of the lingual tonsils, we advocate for a fiberoptic intubation to minimize the risk of unintended manipulation of the tongue base.

In the OR, localizing these thin wire bristles can prove to be extremely challenging. We recommend that multiple imaging modalities be available for use intraoperatively. Intraoperative CT or image-guided surgical navigation would provide the most accurate, 3-dimensional visualization of a foreign body relative to the field of dissection. Currently, image-guided navigation is a commonplace for sinus and skull base surgery, but application of image-guided navigation and augmented reality to transoral surgery remains in the developmental phase and is not widely available for use. ¹⁰ In our case, intraoperative CT was not available for use. The use of intraoperative x-ray and fluoroscopy has well-demonstrated utility in identifying and localizing radio-opaque foreign bodies. However, when working in a very narrow field of dissection, the C-arm fluoroscope proves to be bulky and cumbersome. Additionally, the images provided by fluoroscopy are 2-dimensional. With the diameter of these wire bristles measuring mere micrometers and embedded in a sea of muscle fibers, the lack of real-time 3-dimensional visualization is limiting. In our experience, the hockey stick ultrasound probe proved to be the most useful tool in helping to successfully locate the wire bristle. While a traditional breast ultrasound probe was too bulky to place through the Risdon incision, the hockey stick ultrasound probe, with its shape and small size, was able to fit into the small plane of dissection.

In our case, the wire bristle was located obliquely within the genioglossus. Even though the foreign body was easily visualized using the hockey stick ultrasound, during actual dissection it proved extremely difficult to locate and remove. We found that placement of a Deaver retractor into the oral cavity helped stabilize the tongue base and prevent the foreign body from shifting medially during dissection. This finally allowed for the sharp edge of the wire bristle to be palpated and was key to successful removal. The submandibular approach provides full visualization of the hypoglossal nerve and lingual artery, allowing for their preservation.

Since the publication of a treatment algorithm for managing wire bristle foreign bodies in 2016, there have been several reports of utilizing the da Vinci surgical robot to retrieve wire bristles embedded in the lingual tonsillar tissue. A transoral robotic surgical (TORS) approach provides inherent advantages compared to conventional suspension microlaryngoscopy, as the da Vinci endoscope provides a 3-dimensional view of the lingual tonsillar tissue, and the robotic instruments provide a wide range of movement. In the cases of successful foreign body removal using the da Vinci robot, the wire bristles were located either within the lingual tonsillar tissue or at the surface of the interface between the base of tongue musculature and lingual tonsil. In our case, the foreign body was located more than 1-cm deep to the surface, within the tongue musculature. We propose that for wire bristles located within the lingual tonsils or within 5 mm of the surface on CT imaging, a TORS approach is the best option in the case of failed laryngoscopy. However, once the foreign body has migrated more than 1 cm into the tongue musculature, an open approach is preferred. An updated algorithm for managing wire bristle foreign bodies is proposed (Figure 6).

Figure 6.

Updated algorithm for management of wire bristle ingestion.

Additional measures that have not been previously described but could help minimize time spent in the OR include preoperative CT-guided needle localization by interventional radiology with focal injection of a radiotracer, methylene blue, or other substance. These methods could help minimize dissection through the tongue musculature and have been shown to decrease operative time and radiation use when employed to identify foreign bodies in soft tissues. ¹¹

Conclusion

Ingested wire grill brush bristles can be difficult to remove. In one study, 38% of patients required more than 1 attempt at removal and 22% required open neck exploration. ⁹ With this in mind, identifying a direct and secure surgical approach is key in preventing further trips to the OR and patient morbidity. Although robotic-assisted removal of wire bristles has succeeded in extracting wire bristles embedded in the tongue base, its limited availability and scope may require an otolaryngologist to proceed with a transcervical approach, which we demonstrated to be safe and effective. In addition, the use of hockey stick ultrasound is a cheap, accessible, and efficient way to localize the foreign body. Hockey stick ultrasound-guided identification proves to be advantageous in cases where other imaging modalities fail to help expose the ingested wire bristle intraoperatively and should be considered when using a transcervical approach to access the base of tongue. Our revised algorithm provides a stepwise method to treating ingestion of wire brush bristles, specifically in cases where endoscopic or robotic-assisted methods are not feasible.