|Year : 2016 | Volume
| Issue : 1 | Page : 79-81
The head of a broken toothbrush in the parapharyngeal space: A rare case report
Department of E.N.T., Calcutta National Medical College, Kolkata, West Bengal, India
|Date of Submission||21-Sep-2014|
|Date of Acceptance||03-Jul-2015|
|Date of Web Publication||25-Feb-2016|
Uttarpara Housing Estate, Flat - 1C/11, 88 B G.T. Bhadrakali, Hooghly - 712 232, West Bengal
Source of Support: None, Conflict of Interest: None
| Abstract|| |
While brushing her teeth, the toothbrush of a 4-year-old female child was broken, and about 5.4 cm of it including the head was left behind in her mouth. The head of the toothbrush penetrated the lateral pharyngeal wall and got strongly impacted into the left parapharyngeal space due to the presence of bristles. The broken end of the handle was just protruding into the pharynx and was very difficult to locate. It led to a life-threatening condition. The head of the toothbrush was removed safely by endoscopic approach and the patient recovered without any complication.
Keywords: Foreign body, parapharyngeal space, throat, toothbrush
|How to cite this article:|
Goswami S. The head of a broken toothbrush in the parapharyngeal space: A rare case report. J Indian Soc Periodontol 2016;20:79-81
| Introduction|| |
We frequently get patients with the lodgment of foreign bodies in the aero-digestive tract. A variety of foreign bodies such as a fish bone, pill capsule, sewing needle, and others have been reported. Faust and Schreiner  reported a case of accidental swallowing of a whole toothbrush in a 27-year-old woman, which was lodged in the esophagus. Mendis and Thorne  reported two cases of bean sprout impaction in the pharynx.
In the present case, the child was playing while brushing her teeth. She suddenly fell forward with the toothbrush in her mouth. As a result, the handle of the toothbrush broke, and the head of the broken toothbrush penetrated the lateral pharyngeal wall and entered the left parapharyngeal space. The reason behind reporting this case is its rarity and the difficulty it posed in its management.
| Case Report|| |
A 4-year-old female child came to the emergency of a medical college with the history of accidental impaction of the head of a toothbrush while brushing her teeth. The handle of the toothbrush was broken, and the head along with the adjacent part of the handle remained in her throat. She was unable to expel it out from her mouth. Instead, she tried to swallow it repeatedly and eventually got it stuck in her throat.
Her parents took her to the emergency of a nearby health center but, unfortunately, no dentist was posted there. The patient would have been relieved immediately if the service of a dental surgeon was available. The general physician took no risk and after initial supportive treatment with parenteral analgesics and antibiotics, he referred the patient to a higher level medical institution, where proper medical facilities are available.
On the next day, she was brought to the emergency of a medical college with odynophagia, swelling on the left side of the neck and fever. As it was not a dental college, the patient was admitted under the Department of Otolaryngology. Joint effort of a dental surgeon and an otolaryngologist would have been the best, but due to infrastructural constraints, the otolaryngologist had no other option.
She was complaining of pain in the throat and was unable to open her mouth completely or take food and drinks. She was restless and was having mild respiratory distress. Her temperature was 102°F, and she was mildly dehydrated.
On examination, there was edema of the uvula and the left lateral wall of the oropharynx including both pillars of the left tonsil. Bloodstained saliva was found in the oropharynx, but there was no mucosal injury. There was a swelling on the left side of neck posteroinferior to the angle of the mandible which was extremely tender. As the patient was a child and was in distress, the indirect laryngoscopic examination was not possible. The patient was unable to cooperate for flexible pharyngolaryngoscopy.
Plain radiograph of the neck and chest revealed no significant abnormality. Computed tomography (CT) scan of the neck [Figure 1] revealed the head of the toothbrush with its bristles occupying the left parapharyngeal space.
|Figure 1: Axial computed tomography scan of the neck passing through the C2 level, showing the head of the toothbrush with the bristles, occupying the left parapharyngeal space|
Click here to view
The patient was administered intravenous fluid, broad spectrum antibiotics, corticosteroid, and others to improve her condition before the operation. Taking a decision about the approach for its removal was a little difficult. It was decided that the toothbrush should be tried to be removed by endoscopic approach first, and if it failed, the external approach would be adopted.
The patient was operated under general anesthesia. A Boyle Davis mouth gag was introduced. The oral cavity and the oropharynx were cleaned by suction. Initially, the toothbrush could not be located. There was a moderate degree of edema involving the left lateral wall of the oropharynx and hypopharynx extending toward the laryngeal inlet. After a thorough examination, the broken end of the handle, which was light yellow in color, was found to be protruding inside the left pyriform fossa from its lateral wall. However, the exposure of the foreign body was not satisfactory. The Boyle Davis mouth gag was removed, and a rigid hypopharyngoscope was introduced. The entry point of the toothbrush was located. The head along with the bristles was found to be embedded inside the left parapharyngeal space. The handle of the toothbrush was grasped with a foreign body removing forceps and pulled gently, but the head was found to be strongly impacted within the soft tissue of the neck due to the presence of the bristles in it. The entry point in the left lateral pharyngeal wall was carefully widened a little by using a blunt probe, and the head was gradually disimpacted. After that, the toothbrush was removed by gently pulling, as well as rotating it slightly in either direction to free it from the surrounding soft tissue. It was done slowly with utmost care to avoid injury to the adjacent important structures. On measurement, the toothbrush was found to be 5.4 cm long including the broken part of the handle and 1.8 cm broad at the head [Figure 2].
After removal of the toothbrush, the wound in the left lateral pharyngeal wall was carefully inspected. There was no significant injury to the other adjacent important structures. The wound was apposed by applying stitches with absorbable suture material.
To eliminate the risk of respiratory obstruction in the postoperative period, a tracheostomy was done as a preventive measure. A Ryle's tube was introduced for feeding in the postoperative period.
The patient was kept on intravenous fluid on the day of operation. Ryle's tube feeding was started from the next day. The patient recovered quickly. On the fifth postoperative day, the tracheostomy tube was removed, and the wound was closed. The Ryle's tube was also removed on the same day, and the patient was allowed oral feeding. The patient was discharged 7 days after the operation.
| Discussion|| |
Foreign bodies in the upper aero-digestive tract are frequently encountered by an otolaryngologist. Fish bone is the most common foreign body found in the eastern part of India. Fish bones usually get lodged in the oral cavity, oropharynx, or hypopharynx and are easily removed by forceps with or without local anesthesia. Sometimes other types of foreign bodies are also found but a toothbrush is not a common foreign body in the aero-digestive tract.
Faust and Schreiner  reported a case of accidental swallowing of a whole toothbrush by an adult woman aged 27 years, suffering from bulimia nervosa, while trying to induce vomiting with the handle of it. The toothbrush was lodged in the esophagus and was removed safely by endoscopy. Oza et al. reported a case of implantation of a broken toothbrush medial to the ramus of the mandible in a child following an injury with a cricket ball. Moran  reported a case where a toothbrush was embedded in the buccal soft tissues that needed to be removed under general anesthesia. Sagar et al. reported a case of life-threatening penetrating oropharyngeal trauma caused by a toothbrush in a child.
In most of the cases, removal of foreign bodies in the throat does not pose any significant problem. However, sometimes they penetrate the adjacent soft tissues and get impacted in difficult and potentially dangerous areas. In the present case, the handle of the toothbrush broke [Figure 3] while the child was brushing her teeth and about 5.4 cm of it including the head was left behind in the throat. The child was unable to expel it out from her mouth and tried to swallow it. Instead of going down, the head of the toothbrush gradually penetrated the left lateral pharyngeal wall and entered the left parapharyngeal space. Because of the presence of the bristles, the head of it got impacted there.
|Figure 3: Side view of the toothbrush with sharp broken edge (5.4 cm × 1.8 cm) after removal|
Click here to view
Because of potential complications such as pressure necrosis, perforation, and spread of infection, prompt removal of foreign bodies in the aero-digestive tract is recommended. Most intraluminal foreign bodies can be removed safely by endoscopy. Parapharyngeal space and other extraluminal foreign bodies have the added risk of injury to the adjacent neurovascular structures of the neck, and an external approach may be more suitable. This is particularly important where the foreign body is sharp or is irregular in shape. Burduk  advocated the external exploration of the neck as the method of choice for removal of big parapharyngeal space foreign bodies. However, in the external approach, there is a chance of formation of a pharyngocutaneous fistula.
If some part of the foreign body is inside the lumen and is directly accessible as in this case, an endoscopic approach under general anesthesia may reasonably be tried. However, the surgeon should not be overzealous, and if any difficulty is encountered, it should be removed by an external approach.
I acknowledge the Department of Health and Family Welfare, Government of West Bengal, India. I acknowledge the patient and his relatives for their help. I further acknowledge the nursing and other staff for their help in the management of the case.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hsu CL, Chen CW. A prolonged buried fish bone mimicking Ludwig angina. Am J Otolaryngol 2011;32:75-6.
Baxter EL, Rubin AD. Retained pill capsule remnant in pyriform sinus. Ear Nose Throat J 2010;89:E19-20.
Arora S, Sharma JK, Pippal SK, Sethi Y, Yadav A, Brajpuria S. An unusual foreign body (sewing needle tip) in the tonsils. Braz J Otorhinolaryngol 2009;75:908.
Faust J, Schreiner O. A swallowed toothbrush. Lancet 2001;357:1012.
Mendis D, Thorne S. Bean sprout impaction in the pharynx: Two cases of this unusual foreign body. Ear Nose Throat J 2009;88:E14-6.
Oza N, Agrawal K, Panda KN. An unusual mode of injury-implantation of a broken toothbrush medial to ramus: Report of a case. ASDC J Dent Child 2002;69:193-5, 125.
Moran AJ. An unusual case of trauma: A toothbrush embedded in the buccal mucosa. Br Dent J 1998;185:112-4.
Sagar S, Kumar N, Singhal M, Kumar S, Kumar A. A rare case of life-threatening penetrating oropharyngeal trauma caused by toothbrush in a child. J Indian Soc Pedod Prev Dent 2010;28:134-6.
Burduk PK. Parapharyngeal space foreign body. Eur Arch Otorhinolaryngol 2006;263:772-4.
[Figure 1], [Figure 2], [Figure 3]