EXPERIENCE WITH IMPACTED FOREIGN BODIES IN THE MAXILLOFACIAL REGION AT A NIGERIAN TEACHING HOSPITAL

Abstract

Background

The maxillofacial region has a complex anatomy and is replete with orifices and tissue dead spaces which could harbor foreign bodies. It is important to identify a foreign body impaction when it occurs, as it can be a source of persistent pain, infection and suppuration, it could also further migrate to adjacent regions of the body. The aim of this study is to report the clinical presentation, the prevalence, diagnosis, management and outcome of maxillofacial foreign body impaction in Ibadan, Nigeria.

Methodology

This is a prospective clinic based epidemiological study carried out at the Department of Oral and Maxillofacial surgery, University College hospital, Ibadan, Nigeria. Data of all the patients presenting with foreign body impaction department from January 2008 to July 2013 were recorded into a proforma. The data which included demographics, type of foreign body impaction, predisposing factors, clinical presentation, diagnosis, treatment provided and outcome were analyzed using IBM SPSS version 19.

Results

A total of 5571 patients presented in the clinic during the study period with 16 of the patients presenting with foreign body impaction in the maxillofacial region prevalence rate of 0.29% There were 8 (50%) males and 8 (50%) females with male/female ratio of 1:1.The age ranged from .. to .. with a mean age of 21.89+/-17.047years. Iatrogenically displaced tooth 4 (25%) was the commonest foreign body impacted in the maxillofacial region while the submandibular region 3 (18.8%) was the commonest site. Majority 6 (40%) of the patients had retrieval of the foreign body under local anaesthesia.

Conclusion

Foreign body impactions in the maxillofacial region are not common and are varied in nature. Their management is straightforward when they are impacted in an accessible and superficial site otherwise their diagnosis could be difficult and their management more challenging.

Introduction

The maxillofacial region has a complex anatomy as it represents a crossroad of different systems and apparatus1. This region is replete with orifices and tissue dead spaces in which foreign bodies could be harboured. Despite this anatomical complexity, foreign body impaction is not common in this region and approximately a third of such foreign bodies go unnoticed2. These foreign bodies varies widely, could either be inanimate or animate objects, and often pose a diagnostic enigma due to various factors such as size of the object, nature of object, difficult access, and a close anatomic relation to different vital structures3. It is important to identify foreign body impaction when it occurs, as it can be a source of persistent pain, infection and suppuration, it could also further migrate to adjacent regions of the body4^-9. Majority of previous studies on foreign body impactions in the maxillofacial region have been case reports4,5,10^-13, the present study aims to determine the clinical prevalence, diagnosis, management and outcome of maxillofacial foreign body impactions in a Nigerian population.

Patients & Methods

Data on all the patients managed at the Oral and Maxillofacial Surgery unit of the University College Hospital, Ibadan, Nigeria for foreign body impaction from January 2008 to July 2013 which included their demographics, clinical features, type of foreign body impaction, predisposing factors, treatment provided and outcome were recorded in a proforma. The data were analyzed using IBM SPSS version 19.

Results

Sixteen cases of foreign body impactions were seen in 5,571 patients who attended the oral and maxillofacial surgery clinic during the study period giving a prevalence of 0.29%. There was an equal gender presentation, the mean age was 21.89+/-17.047 years. The foreign body most commonly impacted in the maxillofacial region was an iatrogenically displaced tooth usually occurring as a complication of tooth extraction as shown in Table 1, Figure1 and Figure2. Other foreign bodies retrieved form the patients include broken pen, cockroach, stick, fishbone and scrap of newspaper (Table 1, Figure3). Displaced tooth was commonly associated with attempt at extraction of a molar tooth and the submandibular region is the commonest site for this impaction (Figure1). Majority of the patients (40%) required local anaesthesia for the retrieval of the foreign body, while 33.3% had the foreign body retrieved under general anaesthesia. (Figure4).

Table 1. Age, gender, site and predisposing events to foreign body impaction.

Cases	Age (years)	Gender	Foreign body	Site	Predisposing event
1.	16.0	Female	Bamboo sticks	Orbito-antro-cervical	RTA
2.	8.0	Male	Biro cover	Retromolar	Play
3.	23.0	Male	Molar tooth	Submandibular	Extraction
4.	45.0	Female	Molar tooth	Submandibular	Extraction
5.	36.0	Male	Molar tooth	Antrum	Extraction
6.	24.0	Female	Molar tooth	Antrum	Extraction
7.	53.0	Female	Incisor tooth	Upper Lip	RTA
8.	4.0	Male	Broken pen	Cheek	Fall
9.	6.0	Male	Wooden stick	Palate	Fall
10.	3.0	Female	Newspaper	Nose	Play
11.	2.5	Female	Foil paper	Nose	Play
12.	21.0	Male	Cotton wool	Ear	While cleaning
13.	20.0	Female	Cotton bud	Ear	While cleaning
14.	45.0	Male	Fish bone	Tongue	Eating
15.	34.0	Female	Cockroach	Ear	During sleep
16.	0.7	Male	Plastic drain	Submandibular	Drain insertion

Figure 1. Molar tooth displaced into the submandibular space with associated cellulitis.

Figure 2. Displacement of a molar tooth fragment into the maxillary antrum during a tooth extraction.

Figure 3. Some of the foreign bodies retrieved from patients (broken pen, cockroach and a scrap of newspaper).

Figure 4. Mode of anaesthesia.

Nothing was done in a single case as patient could not afford the cost of treatment and was eventually lost to follow up.

Discussion

The main finding of this study is that displacement of tooth into tissue spaces, though an uncommon complication of tooth extraction, is the commonest type of foreign body impaction in the maxillofacial region14. Several studies have reported displacement of teeth into various areas of the maxillofacial region such as the infratemporal fossa, submandibular space, buccal space, pterygomandibular space, maxillary antrum and the lateral pharyngeal space14^-19. Alexander and Attia19 reported that iatrogenic displacement of teeth is commonly associated with attempted removal of impacted third molars. It is therefore important to discuss this possibility with the patient in the preoperative informed consent discussion19. These accidental displacements comprise the majority of the foreign body impaction in this study and therefore concerted effort must be made to ensure that the tooth that is being extracted is kept in view at all times. Failure to ensure this might lead to inadvertent displacement of the tooth or its part into the soft tissue or the oropharynx. As seen in this study, such displacement frequently require retrieval under general anaesthesia, this is a major morbidity for the patient and could often be avoided if the operator is cautious. Tooth extraction should be done cautiously with mindfulness of the regional anatomy and consciousness of the fact that displacement of the tooth being extracted can occur as a complication of the procedure. Though iatrogenic displacement of teeth into tissue spaces is seldom life-threatening. Failure to resolve the problem in a timely fashion can result in serious psychological, physiologic, and medico-legal sequelae. Also, the patient might be unable to raise funds for surgical intervention and may therefore decide to leave the displaced tooth in situ. This was the case in one of the patients in this study. Anticipation and prevention are therefore keys in management of this complication19.

Foreign bodies are frequently associated with trauma and depending on the event of the trauma, composition and location of foreign bodies may vary considerably20. Foreign body impaction following facial trauma may be missed during examination and usually requires a high index of suspicion by the examining clinician21. When a foreign body impaction is suspected, such as when there are teeth that are unaccounted for and may be within the adjacent soft tissue, imaging should be employed to confirm possible impactions. This was the scenario in one of our patients (Fig. 5), where a central upper incisor was traumatically impacted wholly within the substance of the upper lip during a road traffic crash.

Intraglossal foreign body impaction is uncommon and they are almost exclusively fish bone impactions22^-24. The diagnosis when presentation is usually early and is relatively straightforward as this is aided by the patient’s history of a fish bone impaction. Diagnosis may however become difficult if the fish bone impaction had been asymptomatic, chronic and eventually complicated by other lesions such as a severe fascial space infection or presents as tumour-like growths22,24. This is the case in one of the participants in the study who presented with a tumor-like growth on the tongue, the growth was histologically diagnosed as pyogenic granuloma. However, diagnosis of fish bone impaction was aided by the patient’s insistence that injury to his tongue occurred while he was eating fish and previous attempts to retrieve the fish bone had failed, the fish bone was subsequently removed under local anaesthesia.

Stationeries form a small percentage of foreign body impactions and occur mainly among children25. The common sites for stationary impaction are the nose and the ears. Two of the cases reported in this study occurred in the oral cavity and the incidences happened during play and where the impactions occurred towards the posterior aspect of the oral cavity (retromolar and cheek) as shown in Fig. 6.

Impaction of insects in the maxillofacial region is uncommon. When seen, the most commonly reported site for insects impaction is the ear26. Live insects in the ear, commonly small cockroaches, are annoying due to discomfort created by loud noise and movement26. In the present study, a cockroach crawled into the patient’s ear while she was asleep. As the insect was alive when patient reported to the hospital, it had to be incapacitated to facilitate its retrieval thus the need to drown it in olive oil before retrieval. Insect impaction within the oral cavity has been reported as cases of oral cavity myiasis, which refers to the growth of parasitic organisms (usually the larvae) in living or dead tissue27,28. Predisposing factors for this type of foreign body impaction has been reported as mouth breathing, lip incompetence, malnutrition and neurodegenerative diseases28. Animate foreign body impaction was noticed particularly in animal rearing populations28. None of the cases reviewed in this study presented with intra-oral animate foreign body impaction.

Foreign bodies impacted in the vicinity of vital structures need to be imaged adequately to facilitate their retrieval without inadvertent injury to the adjacent vital structures. The importance of appropriate imaging becomes paramount especially when the foreign body is deeply embedded. Non-metallic objects pose a significant challenge to imaging. Wooden and plastic objects tend not to be radio-opaque unless they have been impregnated with contrast material to aid their image acquisition. Therefore, the retrieval of these wooden and plastic foreign bodies can be hampered by these imaging challenges 29^-32. Due to the acoustic difference between wood and soft tissues, studies have shown that wooden foreign bodies could be easily identified using ultrasonography due to their accentuated echogenic acoustic shadow. Thus, echography has proved to be an effective modality for the detection of wooden foreign bodies, especially when it is located superficially and it is not overlapping with bone or gas3. Wooden objects may also be visualised on CT scans after they have absorbed fluid from the surrounding tissues30. Plain radiographs do not appear to play appreciable role in the imaging of wooden or other non-metallic objects but are better utilised for metallic objects. CT has been reported to be the best method for the detection of foreign bodies of a metallic origin and it is routinely used for foreign body detection as it provides accurate details of the size and shape of the foreign body3. It also provides information on the exact localization of the foreign body, a prerequisite for successful surgical removal20. Digital volume tomography (DVT) was reported to be as suitable as CT for the detection of highly radio-opaque foreign bodies, and has an advantage of considerably lower level of exposure to radiation20. MRI on the other hand appears useful in defining the location and surroundings of non-metallic ectopic objects especially the T2 weighted images. MRI should however be avoided when there is suspicion of a metallic foreign body that is completely enveloped by tissue because the magnetic field may cause movement of the metallic object causing damage to adjacent structures3. Ultrasound may play a role in determining the consistency of the foreign body but the exact relationship with surrounding vital structures may be lacking. It is also examiner-dependent and it is more technique sensitive compared to the CT20. Retrieval under endoscopic guidance or image guided navigation system is fast, effective and minimally invasive, availability of such systems could reduce the morbidity associated with dissection necessary for exposing the foreign body33. They are however not available for use in our patients as they are expensive to acquire.

Foreign bodies in the maxillofacial region should preferentially be removed under general anaesthesia when they are deeply impacted. However, when radiological investigations confirm the superficial location of the impacted object, retrieval under local anesthesia is indicated. Following successful retrieval of an impacted foreign object, the resultant wound should be thoroughly explored, copiously irrigated with sterile saline solution, and sutured in layers. Immediate closure of the residual wound should however be avoided if there is evidence of an ongoing infective process. Prophylactic antibiotics and anti-tetanus should be administered3 In this study the management of an impacted foreign body depended on the anatomical location. The presence of vital structures within its vicinity raised the need for caution in the treatment plan for its retrieval. The exact treatment was based on the nature of the foreign body, the site of impaction and the facility available.

In conclusion, foreign body impactions in the maxillofacial region are not common and are varied in nature. Their management is straightforward when they are impacted in an accessible and superficial site otherwise their diagnosis can be difficult and their management very challenging.

Conclusions

In conclusion, foreign body impactions in the maxillofacial region are not common and are varied in nature. Their management is straightforward when they are impacted in an accessible and superficial site otherwise their diagnosis can be difficult and their management very challenging.

Figure 5. Maxillary incisor displaced into the upper lip following trauma.

Figure 6. Broken pen imparted into the cheek following a fall (before and after retrieval).