547106

research-article2014
AORXXX10.1177/0003489414547106Annals of Otology, Rhinology & LaryngologyOkumura et al

Case Report
Annals of Otology, Rhinology & Laryngology

Unique Migration of a Dental Needle

2015, Vol. 124(2) 162­–167
© The Author(s) 2014
Reprints and permissions:
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DOI: 10.1177/0003489414547106

Successful Removal by an Intraoral aor.sagepub.com

Approach and Simulation for Tracking

Visibility in X-ray Fluoroscopy

Yuri Okumura, MD1, Hiroshi Hidaka, MD, PhD1, Kazumasa Seiji, MD, PhD2,
Kazuhiro Nomura, MD, PhD1, Yusuke Takata, MD, PhD1,
Takahiro Suzuki, MD, PhD1, and Yukio Katori, MD, PhD1

Abstract
Objectives: The first objective was to describe a novel case of migration of a broken dental needle into the parapharyngeal
space. The second was to address the importance of simulation elucidating visualization of such a thin needle under X-ray
fluoroscopy.
Methods: Clinical case records (including computed tomography [CT] and surgical approaches) were reviewed, and a
simulation experiment using a head phantom was conducted using the same settings applied intraoperatively.
Results: A 36-year-old man was referred after failure to locate a broken 31-G dental needle. Computed tomography
revealed migration of the needle into the parapharyngeal space. Intraoperative X-ray fluoroscopy failed to identify the
needle, so a steel wire was applied as a reference during X-ray to locate the foreign body. The needle was successfully
removed using an intraoral approach with tonsillectomy under surgical microscopy. The simulation showed that the dental
needle was able to be identified only after applying an appropriate compensating filter, contrasting with the steel wire.
Conclusion: Meticulous preoperative simulation regarding visual identification of dental needle foreign bodies is
mandatory. Intraoperative radiography and an intraoral approach with tonsillectomy under surgical microscopy offer
benefits for accessing the parapharyngeal space, specifically for cases medial to the great vessels.

Keywords
compensating filter, needle migration, parapharyngeal space, surgical microscope, X-ray fluoroscopy

Introduction breakage when local anesthetic was employed for infiltra-

Breaking a needle during the administration of local anes-
thesia in oral surgery is now a rare complication.1-3 Other
foreign bodies are also only rarely encountered in the para-
pharyngeal space during daily medical practice, and only a
small number of cases have been reported to date.4-7 In the
event of a foreign body in the parapharyngeal space, ade-
quate responses are required because of the location in close
proximity to the great vessels and nerves.5,6 No previous
reports appear to have described migration of a broken nee-
dle into the parapharyngeal space, with the exception of a
recent report by Ho et al3 reporting intraoral migration into
the posterior cervical space, presumably after drifting
through the parapharyngeal space.
First, we report an extremely rare case of migration of a
needle foreign body into the parapharyngeal space after
tion anesthesia for the removal of a lower right wisdom
tooth. Intraoperatively, the broken needle was unable to be
identified on X-ray fluoroscopy (C-arm). We therefore con-
ducted an experiment using the same settings applied intra-
operatively, to clarify the causes underlying the failure of
C-arm fluoroscopy to identify the needle.
1
Department of Otolaryngology–Head and Neck Surgery, Tohoku
University Graduate School of Medicine, Sendai, Japan
2
Department of Diagnostic Radiology, Tohoku University Graduate
School of Medicine, Sendai, Japan
Corresponding Author:
Hiroshi Hidaka, MD, PhD, Department of Otolaryngology–Head and
Neck Surgery, Tohoku University Graduate School of Medicine, 1-1
Seiryomachi, Aoba-ku, Sendai 980-8575, Japan.
Email: ZAY00015@nifty.com
Okumura et al 163

Figure 1.  (A) Axial contrast-enhanced computed tomography (CT) after the first surgery at the previous hospital showing a foreign
body in the parapharynx (arrow). (B) Three-dimensional reconstructed CT, revealing migration of the foreign body (arrow). (C, D)
Intraoperative facial X-ray, revealing the foreign body (arrowheads) located 10 mm anterior [(C) lateral view] and 7 mm lateral [(D)
frontal view] to a steel bar placed in the tonsillar fossa as a reference.

Case Report of Dental Needle
Migration Into the Parapharyngeal
Space
A 36-year-old man underwent dental treatment, including
removal of the right mandibular wisdom tooth. The dentist
applied infiltration anesthesia using an electric dental anes-
thesia machine equipped with a dental injection needle (31-
G; Terumo, Tokyo, Japan). When a second injection with
the bent needle was performed firmly at a greater depth, the
needle broke and pierced medially into the submucosal
area. Although the wisdom tooth was removed, the dentist
failed in attempts to locate the broken tip of the needle.
X-ray revealed a foreign body, and the patient was thus
referred to a general hospital, where computed tomography
(CT) revealed a foreign body situated adjacent to the exter-
nal carotid artery. Although the patient complained of swell-
ing of the right cheek and trismus at that stage, symptoms
gradually improved.
One month after fracture of the needle, dentists at another
hospital performed surgery to extract the foreign body
under general anesthesia by incising the anterior palatoglos-
sal arch without conducting tonsillectomy. However, they
experienced difficulty detecting the needle tip, presumably
due to its small size, and identification and removal of the
needle failed once again. Postoperative CT showed that a
foreign body remained (Figure 1), and the patient was
referred to our department.
164 Annals of Otology, Rhinology & Laryngology 124(2)
Figure 2.  (A, B) Photographic findings at surgery, showing blunt dissection of the tonsillar fossa (A), revealing the needle foreign
body (arrow) (B). (C) Retrieved broken dental needle. (D) Illustration showing the direction of needle migration and the relationship
to the tonsillar fossa.
As he had not described any symptoms at the first visit,
we decided to prepare a metal detector, X-ray, and X-ray
fluoroscopy. We then performed a second operation under
general anesthesia using an intraoral approach, and the
whole procedure was performed under surgical microscopy.
We first performed tonsillectomy on the affected side and
then made a blunt dissection into the musculature of the
tonsillar fossa by using Kelly forceps and bipolar scissors
(see supplemental video clip, available at http://aor.sagepub.
com/supplemental). At that time, we could not identify any
foreign bodies despite the use of an Implant-Finder
(Degussa AG, Huerth, Germany) and X-ray fluoroscopy
(Mobile C-arm: BV Endure; Philips, Amsterdam, the
Netherlands). The Implant-Finder is a metallic detector rou-
tinely used for identifying fixtures under the gingival
mucosa during secondary implant operations. However,
this instrument was unable to locate the foreign body
because of the presence of the metal mouth gag. Again,
X-ray fluoroscopy failed to identify the foreign body
because the surgeon (H.H.) and radiological technicians did
not consider using a compensation filter to avoid halation.
We thus applied a K-wire (diameter, 2 mm), as a steel
wire used in osteosynthesis, onto the posterior palatine arch
as a reference bar to determine the location of the foreign
body, because this wire would be consistently visible under
X-ray fluoroscopy. Intraoperative facial X-ray revealed the
location of a foreign body 10 mm anterior and 7 mm lateral
to the bar (Figures 1C and 1D), and the foreign body was
then identified buried in inflammatory granulation tissue
(Figures 2A and 2B). Extraction was performed with for-
ceps (Figure 2C), and the tonsillar fossa wound was loosely
sutured. After confirming the absence of overt bleeding, the
operation was completed (Figure 2D). The patient was dis-
charged 7 days postoperatively without any complications.
Materials and Methods
To clarify issues contributing to the failure to identify the
needle under X-ray fluoroscopy, we evaluated the visibility
of a 31-G dental needle (Terumo) and a K-wire with a diam-
eter of 2 mm under the mobile C-arm (BV Endura; Philips).
The dental needle, K-wire, and X-ray fluoroscopy settings
were all identical to those used in the present case (Figures
3A and 3B). A human skull and tissue material (PBU-50;
Kyoto Kagaku, Kyoto, Japan) were used as a head
phantom.8
Results
Without applying a compensating filter, the dental needle
was unable to be identified, although the K-wire was clearly
visualized (Figure 3C). However, after applying a compen-
sating filter (Z-00112; GE Healthcare Japan, Tokyo, Japan),
the dental needle was visible (Figure 3D).
Okumura et al 165

Figure 3.  (A, B) Overview of the simulation under C-arm to address visualization of the K-wire (arrow) and the 31-G dental needle
(arrowhead) near the head phantom. (C) In contrast to visualization of the K-wire (arrow), the needle could not be identified,
presumably due to halation by air. (D) After applying a compensating filter, both the K-wire (arrow) and needle (arrowheads) were
able to be visualized.

Discussion and viscera results in migration of the foreign body deeper

Foreign bodies in the head and neck region are frequently
encountered in association with dental therapy, in the form
of broken implants, teeth, probes, and injection needles.1-3
Specifically, broken needles are encountered as a result of
attempts to induce local anesthesia for tooth removal, and
the patient may remain unaware of the presence of the
object for a long time.9 The most common site for loss of a
broken needle is the pterygomandibular area during inferior
alveolar nerve block.1,10 Cases involving broken dental nee-
dles located in the parapharyngeal space do not appear to
have been reported previously, so this represents the first
case reported in the literature.
In terms of the parapharyngeal space, foreign bodies
such as a toothbrush, a metallic fragment, and a glass piece
have been reported and have typically entered the deeper
tissues of the neck through the mucous membranes of the
oral cavity and pharynx.5,6,11 Movement of the neck muscles
into areas adjacent to the great vessels and nerves of the
neck, and prompt provision of adequate management has
been advocated to avoid potential risks.6 Fatal cases in
which foreign bodies migrated through the common carotid
artery or internal jugular vein or caused injury to cranial
nerves have been reported on rare occasions.5,6,12
Surgical manipulation, including use of needles to induce
local anesthesia, should always be performed with great
care to avoid potential fracture, according to prior knowl-
edge of the weak area.1,9 Needle fragility and susceptibility
to breakage with repeated injections have also been
documented.13-15
The present patient underwent the first surgery by the
primary dentist 1 month after onset. This was presumably
because he had not experienced any clinical symptoms and
had been hesitant to undergo surgery. Moreover, several
previous reports have discussed retained needles secondary
to intravenous drug use revealing no delayed complications
166 Annals of Otology, Rhinology & Laryngology 124(2)
and have noted that deferring surgical intervention may be
reasonable for asymptomatic patients, to avoid further
morbidity.3
Hazards to the surgeon attempting to manage needle
migration include those inherent in seeking a small sharp
object and potential morbidity attributed to puncture or lac-
eration of vessels.3,15 Although the Implant-Finder and
X-ray fluoroscopy were prepared before surgery, both failed
to identify the foreign body. We therefore applied a steel
K-wire and conventional X-ray as a reference to locate the
foreign body.
Although several previous studies have reported C-arm
fluoroscopy as reliable in detecting broken dental nee-
dles10,14,16,17 intraoperatively, C-arm fluoroscopy failed to
visualize the broken 31-G needle in this case, likely due to
the very small size of the needle.
The following 3 factors were considered to have poten-
tially been related to the invisibility of the needle in this
case: (1) degradation of the image intensifier for X-ray fluo-
roscopy; (2) halation by air in the oral cavity, as air offers
very low X-ray attenuation; and (3) degradation of image
quality as a result of reduced signal-to-noise ratio, due to
the relatively lower intensity of X-rays used in order to min-
imize radiation exposure to both the operators and patient.
To determine which of the above-mentioned 3 factors
contributed most to the lack of visibility of the needle in this
case, we conducted a simulation focusing on visualization
of the dental needle and K-wire under the same settings,
except that we used a head phantom to simulate the human
head. In contrast to the K-wire, the dental needle was visi-
ble only after applying a compensating filter. Therefore, to
detect small foreign bodies under X-ray fluoroscopy, poten-
tial resolutions could involve preparing an appropriate com-
pensating filter to avoid halation. Again, development of
dental needles that are readily visible under C-arm fluoros-
copy should be encouraged by manufacturing companies.
In most cases of foreign bodies in the parapharyngeal
space, an external neck approach has been used for removal,
because this method allows visualization and complete sur-
gical control of the carotid artery.18,19 Conversely, the intra-
oral approach has been reported as safe and effective, with
no increased risk of vascular injuries, due in large part to
current medical imaging capabilities.19,20 Specifically, this
approach can reduce the surgical burden and should be spe-
cifically advocated for lesions located medial to the great
vessels or close to the skull base.19 We were able to remove
the broken needle using an intraoral approach with tonsil-
lectomy followed by an approximately 5-mm incision in the
soft palate, overcoming the narrow surgical area.21 The
intraoral approach with tonsillectomy may be more direct
and suitable in cases with a lesion located medial to the
great vessels.19 Furthermore, in terms of small foreign bod-
ies such as needles, our present intraoral approach to the
parapharynx followed by ipsilateral tonsillectomy under
surgical microscopy would be an advantageous technique
to delineate relationships with surrounding structures,
including the vessels and lingual branches of the glossopha-
ryngeal nerve.22
Conclusion
We have reported a rare case of a broken needle in the para-
pharyngeal space. Although the patient had not noticed any
symptoms, and no complications of surgery were encoun-
tered in this case, such events have the potential to be life
threatening.
Meticulous preoperative simulation regarding the visual-
ization of needle foreign bodies should be mandatory in the
use of X-ray fluoroscopy. Again, intraoperative X-ray and
the intraoral approach with tonsillectomy under surgical
microscopy offer beneficial effects on an extraction opera-
tion, specifically for cases medial to the great vessels.
Acknowledgments
The authors thank Mr Shigeru Tachibana and Mr Yutaka Dendo
(Department of Radiology, Tohoku University Hospital) for their
technical support.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
Supplementary Material
Supplementary material for this article is available on the AOR
website at http://aor.sagepub.com/supplemental.
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