Delayed Presentation of Submucosal Retained Toothbrush from Self-Inflicted Injury in Patient with Schizophrenia

Abstract

Foreign body ingestion occurs in not only children but also adults, particularly those with history of neurologic disease, alcohol use, or psychiatric disease. We present the case of a 40-year-old male with schizophrenia who presented to the emergency room with a long history of pharyngeal foreign body sensation which had recently progressed to include trismus, odynophagia, and dyspnea. Flexible laryngoscopy demonstrated fullness of the right posterior pharyngeal wall and computed tomography (CT) showed a linear opaque foreign body extending from the level of the oropharynx to the thyroid ala. Further history elicited that he stabbed himself in the pharynx two years prior with a toothbrush following a command hallucination. The toothbrush was removed uneventfully via an external approach. The patient was discharged with psychiatry follow-up. This case is unusual due to the submucosal location of the foreign body and the length of retention. It demonstrates the atypical nature which patients with comorbid psychiatric illness may present following foreign body injury and the use of an external surgical approach for the removal of a retained foreign body based on CT reconstruction.

Clinical Approaches to Migrating Ingested Foreign Bodies in the Neck

“…The CT scan is essential to evaluate the status of the foreign body and nearby structures before any surgical attempt. 1,3,4,6,8,10,11,[13][14][15]18,19 For foreign bodies with complications or that are close to great vessels and vital organs, an external approach is preferred. Consultation of cardiothoracic and/or cardiovascular surgeons is recommended in cases of mediastinitis and pulmonary and cardiovascular penetration.…”

“…[1][2][3] Muscle contraction, horizontal orientation, patient manipulation, and tissue reaction may contribute to the migration. [1][2][3][4][5][6][7][8][9] These migrating foreign bodies are rare; however, they may cause severe complications such as penetration of vessels, deep neck infection, esophageal perforation, retropharyngeal abscess, and thyroid abscess. 2,3,5,7,[9][10][11][12][13][14][15] Immediate diagnosis, visualization, and removal of migrating foreign bodies on endoscopy under local anesthesia can be very difficult.…”

“…[3][4][5]10,11,14 In addition, some cases presented with subtle or bizarre manifestations such as cervical mass or cutaneous fistula without oropharyngeal complaints. [5][6][7][8]10,16,17 There are several techniques to retrieve a migrating foreign body in the neck, including the endoscopic and percutaneous approaches. The aim of our report is to describe these procedures with 2 unusual cases, review literature, and propose an algorithm to determine the initial surgical management of migrating ingested foreign bodies.…”

“…3-5,10,11,14 In addition, some cases presented with subtle or bizarre manifestations such as cervical mass or cutaneous fistula without oropharyngeal complaints. 5-8,10,16,17…”