Broken Hypodermic Needle Retrieval

Background

Local anesthesia is usually associated with few risks or complications, but needle breakage can occur and lead to serious and potentially life-threatening consequences resulting from damage to vital anatomic structures. Immediate extraction of the broken fragment is recommended, and recovery rates are reported to be about 95%. In light of the global pandemic of coronavirus-disease 2019 (COVID-19), measures are in place to reduce the likelihood of infection for patients and medical/dental staff. Exposure is particularly problematic for dentists, maxillofacial surgeons, and ear-nose-throat (ENT) surgeons because of the high viral load in the nasal cavity of infected patients. A dislodged dental needle can become a life-threatening emergency, so planning for an adequate retrieval procedure under pandemic conditions is desirable. A case was presented that used 3-dimensional (3D) navigation to recover a dislodged fractured needle. In addition, a procedure appropriate for pandemic emergencies was offered.

Case Report

Man, 61, was referred by his local dentist for removal of a 30 G broken needle after having anesthesia with the inferior alveolar nerve block technique. The patient was otherwise healthy, in stable condition, and had no pain or discomfort. An orthopantomogram (OPTG), a cephalometric image, and cone beam computed tomography (CBCT) showed the needle was located at the medial side of the ascending ramus near the mandibular foramen (Figure 1 ). The patient wasn’t given any medication and laboratory tests revealed no pathological results. An intraoral approach under general anesthesia was planned for the next day to remove the fragment.

Figure 1.

Orthopantomographic images on the day of initial presentation (A) and 1 day afterward (B). The dislodged fractured hypodermic needle is located at the left ascending mandibular ramus and moved by about 1.5 cm after 1 day. (Courtesy of Schorn L, Sproll C, Depprich R, et al: Navigated recovery of fractured dental injection needles: Case report and suggestions for management during pandemic crises. Case Reports in Dentistry, vol 2021, Article ID 8820381.)

The next day, a second OPTG showed the needle had moved laterally about 1.5 cm. A CT with 0.75 mm slice thickness was taken, and intraoperative 3D navigation was planned. The CT showed needle position to be retroauricular about 2 cm dorsal and 1.5 cm under the left earlobe. The patient was immediately prepped for surgery and instructed to maintain his head position. He was intubated without complications.

The surgery commenced with a 1.5-cm incision on the left parietal side to the periosteum. The calvaria were denuded and a hole predrilled with a 1.1 twist drill. The scull reference array (tripod) was inserted and screwed in place. A previously constructed dental splint with 4 attached registration screws was inserted and registration verified. 3D navigation found the needle within an accuracy of 0.7 mm.

An extraoral incision was made below the left earlobe, with electrocoagulation used to achieve hemostasis. The parotid capsule was dissected with layer-by-layer dissection until the cannula tip was found. The 2.1-cm needle was completely recovered, with repair of the injuries to the parotid capsule and musculature. The wound was closed and the tripod removed. The operation was completed in 32 minutes.

The patient had no complications postoperatively. At the 10-day follow-up, there were no signs of infection, wound dehiscence, or other recognizable pathologic conditions. The sutures were removed and the local dentist followed up through the postoperative period, which was without complications.

Pandemic Plan

When fractured needles are recovered, there is a high risk of infection for patients and staff, so a procedure was developed to reduce the transmission of infective agents to minimal levels. The dentist referring the patient should contact the maxillofacial department before sending the patient over and provide 3D imaging if possible. The patient should be isolated and undergo appropriate testing. Needle detection by ultrasound should be attempted using adequate COVID-19 gear, including respirators, waterproof gowns, eye protection, and gloves. Test results should be shared when they arrive. If the ultrasound detects the needle’s position, sonography-controlled surgical needle recovery should be attempted. If sonography is unable to find the needle fragment, intraoperative 3D visualization (CT or CBCT) should be combined with visual exploration, preferably extraoral, to find the needle fragment. A surface scan using 3D navigation can be attempted if the needle remains elusive.

If the needle’s location cannot be identified, the patient should be closely monitored. If the needle moves toward a potentially life-threatening position, such as the carotid artery, complex but highly accurate 3D navigation with dental splints can be attempted under strict infection-controlled measures.

Discussion

Fractured needles can move quickly, making their immediate recovery extremely necessary. 3D navigation can help in recovering dislodged fractured hypodermic needles, but it must be planned immediately before surgery to ensure the needle hasn’t moved. Planning for removal needs to incorporate pandemic precautions to ensure a safer process for everyone involved.

Clinical Significance.

Preventing needle breakage is more desirable than recovering broken pieces. Several actions can be taken to avoid needle breakage Table 1. Should a needle break occur and the fragment can be seen, forceps or a hemostat should be used to immediately grasp it. It’s important that the patient remain as immobile as possible because the needle fragment can disappear when tissue tension is released.

Table 1.

Eight Crucial Points for Avoiding Needle Breakage

(1)	Explore the patient-specific anatomy
(2)	Use a sufficiently strong and long canula
(3)	Inspect for damage before use
(4)	Avoid prebending or kinking
(5)	Prepare the patient for puncture and avoid sudden movements
(6)	Do nut insert the whole needle
(7)	Puncture only when masticatory musculature is relaxed
(8)	Avoid directional change during needle advancement
(9)	Change the needle for every injection

(Courtesy of Schorn L, Sproll C, Depprich R, et al: Navigated recovery of fractured dental injection needles: Case report and suggestions for management during pandemic crises. Case Reports in Dentistry, vol 2021, Article ID 8820381.)