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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 22  |  Issue : 1  |  Page : 66-69

Migrated aural foreign body in parapharyngeal space


Department of ENT-Head Neck Surgery, Apollo Hospitals, Bhubaneswar, Odisha, India

Date of Web Publication16-Feb-2016

Correspondence Address:
Surya Kanta Pradhan
Department of ENT-Head Neck Surgery, Apollo Hospitals, 251, Sainik School Road, Unit-15, Bhubaneswar - 751 005, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-7749.176501

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  Abstract 

Foreign bodies in ear are very frequently encountered by an otorhinolaryngologist. They should be diagnosed and removed immediately. Otherwise it may cause complications like tympanic membrane perforation, chondritis, ossicular necrosis, facial palsy, inner ear injury or it may migrate to adjacent structures. It may migrate to subcutaneous tissue or middle ear. Migration of aural foreign body to parapharyngeal space is very rare and never been reported in literature. We are reporting this type of very unusual migrated foreign body which was recovered from the parapharyngeal space by a small incision endoscopic assisted approach after 8 years if insertion.

Keywords: Aural foreign body, Parapharyngeal space, Three-dimensional computed tomography scan, Transcervical approach


How to cite this article:
Pradhan SK, Gupta S. Migrated aural foreign body in parapharyngeal space. Indian J Otol 2016;22:66-9

How to cite this URL:
Pradhan SK, Gupta S. Migrated aural foreign body in parapharyngeal space. Indian J Otol [serial online] 2016 [cited 2020 Mar 29];22:66-9. Available from: http://www.indianjotol.org/text.asp?2016/22/1/66/176501




  Introduction Top


Foreign body in ear, nose, and throat is very common in clinical practice, and the incidence is gradually increasing. Mostly, children introduce foreign bodies while playing with it. However in adults, most of the foreign bodies are of an accidental cause. Foreign bodies may be organic, i.e., vegetables, nuts, and food particles, or inorganic i.e., metal balls and pencils. Sometimes, live foreign bodies such as insects are seen in adults as well as children. Most of the time, it is easy to remove foreign bodies from nose and throat, but in ear, foreign bodies are always tricky. Organic and chemical foreign bodies such as button batteries are very dangerous and should be addressed promptly. Some foreign bodies migrate from the site of insertion to nearby structures. Mostly, nasal foreign bodies migrate to nasopharynx or oropharynx and oral foreign bodies to adjacent spaces, i.e., submandibular space, parapharyngeal space, and retropharyngeal space. However, aural foreign bodies rarely migrate because of the bony external canal which prevents the migration to subcutaneous tissue and surrounding structures. It can cause tympanic membrane perforation and migrate to middle ear. We are presenting a very rare case of migrated foreign body from ear to parapharyngeal space which was removed after 8 years by transcervical approach with the help of endoscopes.


  Case Report Top


A 12-year-old girl presented to the Department of Otorhinolaryngology and Head and Neck Surgery, Apollo Hospitals, Bhubaneswar, with severe pain over the right side neck and ear. She was having a history of accidental insertion of a metallic ball in the right ear 8 years back. She was operated twice for removal of the foreign body, but those procedures were unsuccessful. On examination, her general condition was good. There was a postaural scar over the right side. Both the tympanic membranes were normal. The nose, throat, and neck were normal. After all the examinations to find the cause of neck pain and locate the lost foreign body, computed tomography (CT) scan of neck and temporal bone with three-dimensional (3D) reconstruction was done. The scan showed metallic round foreign body of diameter 8 mm in the right parapharyngeal space, it was medial to the right temporomandibular joint and anterior inferior to the right middle and external ear. It was located anterior to the base of the styloid process. The jugular foramen and carotid opening were just posteromedial to it. Focal erosion of the inner part of the anterior wall of the right external ear was noted. The ossicles were absent and there were signs of previous mastoidectomy [Figure 1].
Figure 1: Three-dimensional computed tomography scan showing the proper location of the foreign body

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As the foreign body was near the great vessels and roof of the parapharyngeal space, transcervical approach with the assistance of endoscopes was planned. Curvilinear incision was given over the right side of the neck at the level of the hyoid. Subplatysmal flaps were elevated. Submandibular gland was excised to gain access. The digastric muscle was identified; hypoglossal nerve was dissected and saved. The carotid artery and jugular vein were secured with vascular straps. With the assistance of endoscope, dissection continued toward styloid process lateral to the constrictors. The FB was localized and confirmed by the C-arm [Figure 2] and [Figure 3].
Figure 2: Intraoperative photograph showing the tunnel for endoscopic assisted removal of the foreign body

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Figure 3: Intraoperative photograph showing pointer localizing the foreign body and temporomandibular joint

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It was surrounded by fibrous tissue. It was dissected from the skull base and surrounding structures. Gradually, it was removed through the neck. Postoperative CT scan was done to confirm the removal of foreign body. The patient was discharged and followed up regularly [Figure 4] and [Figure 5].
Figure 4: Postoperative photograph of the foreign body with measuring scale

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Figure 5: Postoperative check C-arm image showing successful removal of the foreign body

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  Discussion Top


Foreign body in ear is more common as compared to the nose and throat. Children of age group 0–5 years are most commonly affected followed by 6–10 years.[1] Some of the children may present with ear discharge and severe otalgia mimicking otitis externa, but most of the children are asymptomatic. Few patients give the proper history of foreign body insertion. Children introduce foreign bodies because of curiosity while playing with it, but adults get these accidentally while cleaning or itching.[2] Some insects get impacted in the ear and cause a lot of discomfort because of their movement and sound.[3] The first attempt is the best attempt for the removal of foreign bodies. However, most of the time, patients present to the nonprofessionals who make the situation more difficult. It should always be removed by experts with proper instruments.[4]

The foreign bodies in ear are always impacted because of the narrow passage. For uncooperative children, it is always better to perform under general anesthesia for proper immobilization and to avoid complications,[5] but for adults, it can be done without anesthesia. The equipment required for the removal of foreign body ear are microscope, micro forceps, angled picks, and syringing instruments. The best position for removal is lying down over the table, but it can be done in sitting position. It should be properly visualized before removal to avoid any complications. Complication rate is very remote in expert hands; no complication was recorded in 87.5% cases.[6] However, Singh et al. recorded 77% complication rate.[7] The early complications are bleeding, ear infection, perforation of the tympanic membrane, facial nerve palsy, and inner ear trauma.[8],[9],[10] The late complication includes granulations, infection, and impaired hearing. Different foreign bodies behave differently, but foreign bodies such as button batteries can cause serious complications within a short span of time because of the leakage of strong alkali such as potassium and sodium hydroxide causing tissue damage. One of the rare complications is migration of the foreign body from the area of insertion.[11],[12]

Usually, nasal and oral foreign bodies migrate to the adjacent structures.[13] Aural foreign bodies can migrate to the surrounding structures and subcutaneous tissue. Superficial foreign bodies migrating from the subcutaneous tissue to the external auditory canal were also reported.[14] Migration from ear to parapharyngeal space is never been reported. Most of the foreign bodies recovered from the parapharyngeal space are due to penetrating injuries and some are due to migration. Because of the complex anatomical structure, it is always a challenge to retrieve foreign body from this space. This space is like an inverted pyramid having skull base as its base and greater cornu of hyoid as its apex. The lateral walls were formed by pterygoid muscle and lateral wall of the pharynx. It is divided into pre- and post-styloid space. It contains vital structures such as internal jugular vein, internal carotid artery, IX–XII cranial nerves, and sympathetic chain which can be damaged due to penetrating or migrating foreign bodies.[15] The different surgical approaches for parapharyngeal space are transcervical, intraoral transtonsillar, transparotid, and transmandibular. However, for foreign body removal, small incision with transcervical and transoral approaches was preferred. One should be very careful while working in this space to avoid complications. In our case, the foreign body might have migrated from ear to parapharyngeal space through the eroded anterior external ear canal which was very unusual. In the literature, there was no description about such migration. The diagnosis was confirmed by the 3D CT scan and all the vital structures were identified. As it was close to the great vessels, we have approached through the neck and proceeded to parapharyngeal space under endoscopic guidance after securing the vital structures. With blunt dissection and proper visualization, it was removed safely without any complications.

Children presenting with ear discharge and pain should be examined carefully by an otolaryngologist and simple investigations such as X-ray mastoid should be done to see radiopaque foreign bodies. CT scan should be done for radiolucent and lost foreign bodies. After diagnosis, its removal should be performed under proper visualization and immobilization. Following removal, the tympanic membrane and eroded parts of the ear should be examined thoroughly. Migrated foreign bodies should be located precisely by using different radiological investigative modalities for proper planning of the surgery. Because of fibrosis, surrounding structures should be separated by blunt dissection to prevent bleeding. All the remnants of the foreign body should be removed and patients should be followed up regularly until discharge and pain subsides. As a method of prevention, all the parents should be educated about safe handling of small balls and batteries.


  Conclusion Top


The incidence of foreign bodies in ear is increasing due to increased use of toys and equipment. Early diagnosis and management minimizes the rate of complications. All the emergency doctors should be educated to diagnose these types of foreign bodies and only otolaryngologist should be consulted for uncomplicated removal.[16],[17] After removal of the foreign bodies, all the patients should be followed up until symptoms subside. We would like to highlight that a lost foreign body from ear can migrate to adjacent structures and rarely to parapharyngeal space. Migrated foreign body has the potential to cause life-threatening complications. Hence, it should be investigated properly and removed promptly.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Chiun KC, Tang IP, Tan TY, Jong DE. Review of ear, nose and throat foreign bodies in Sarawak General Hospital. A five year experience. Med J Malaysia 2012;67:17-20.  Back to cited text no. 1
    
2.
Kroukamp GR, Loock JW. Foreign bodies in the ear. Scott-Brown's Otorhinolaryngology, Head and Neck Surgery. 7th ed., Vol. 3. New York, USA: Hodder Arnold; 2008. p. 3370-2.  Back to cited text no. 2
    
3.
Kroukamp G, Londt JG. Ear-invading arthropods: A South African survey. S Afr Med J 2006;96:290-2.  Back to cited text no. 3
    
4.
Irfan M. Ear foreign body: Tackling the uncommons. Med J Malaysia 2012;67:352.  Back to cited text no. 4
    
5.
Ansley JF, Cunningham MJ. Treatment of aural foreign bodies in children. Pediatrics 1998;101 (4 Pt 1):638-41.  Back to cited text no. 5
    
6.
Al-Juboori AN. Aural foreign bodies: Descriptive study of 224 patients in Al-fallujah general hospital, Iraq. Int J Otolaryngol 2013;2013:401289.  Back to cited text no. 6
    
7.
Singh GB, Sidhu TS, Sharma A, Dhawan R, Jha SK, Singh N. Management of aural foreign body: An evaluative study in 738 consecutive cases. Am J Otolaryngol 2007;28:87-90.  Back to cited text no. 7
    
8.
Kavanagh KT, Litovitz T. Miniature battery foreign bodies in auditory and nasal cavities. JAMA 1986;255:1470-2.  Back to cited text no. 8
    
9.
Capo JM, Lucente FE. Alkaline battery foreign bodies of the ear and nose. Arch Otolaryngol Head Neck Surg 1986;112:562-3.  Back to cited text no. 9
    
10.
Premachandra DJ, McRae D. Severe tissue destruction in the ear caused by alkaline button batteries. Postgrad Med J 1990;66:52-3.  Back to cited text no. 10
    
11.
Tang IP, Singh S, Shoba N, Rahmat O, Shivalingam S, Gopala KG, et al. Migrating foreign body into the common carotid artery and internal jugular vein – A rare case. Auris Nasus Larynx 2009;36:380-2.  Back to cited text no. 11
    
12.
Yamavakava K, Dohgomri H, Furusawa T, Sode Y, Netsu K. Migration of foreign body from mouth to nose. Signa vitae 2009:4:33-4.  Back to cited text no. 12
    
13.
Chung SM, Kim HS, Park EH. Migrating pharyngeal foreign bodies: A series of four cases of saw-toothed fish bones. Eur Arch Otorhinolaryngol 2008;265:1125-9.  Back to cited text no. 13
    
14.
Viswanatha B, Dutta R, Anilkunar R, Sumatha D. Migration of a foreign body from post aural area to the external ear canal. The Internet Journal of Otorhinolaryngology 2008;10. Available from: https://ispub.com/IJORL/10/2/4034.  Back to cited text no. 14
    
15.
Zhao YF, Liu Y, Jiang L, Liu J, Chen XQ, Shi RH, et al. A rare case of a glass fragment impacted in the parapharyngeal space associated with neurovascular compromise. Int J Oral Maxillofac Surg 2011;40:209-11.  Back to cited text no. 15
    
16.
Thompson SK, Wein RO, Dutcher PO. External auditory canal foreign body removal: Management practices and outcomes. Laryngoscope 2003;113:1912-5.  Back to cited text no. 16
    
17.
Barney D, Kass D, Hahn B. Lost foreign body in the ear. J Emerg Med 2013;45:e223-4.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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