Volume 10, Issue 8, August – 2025 International Journal of Innovative Science and Research Technology

ISSN No: -2456-2165 https://doi.org/10.38124/ijisrt/25aug931

Foreign Body in the Left Sub-Masseteric Region

Masquerading as a Chronic Parotid Fistula: A
Rare and Intriguing Case Report
Dr. Abdul Haseeb Quadri1; Dr. Souvik Roy2*
1
Professor, 2IIIrd Year Postgraduate Student
1,2
Department of Oral and Maxillofacial Surgery, Subbaiah Institute of Dental Sciences, Shivamogga, India.

Corresponding Author: Dr. Souvik Roy2*

Publication Date: 2025/08/25

Abstract: Oral and maxillofacial surgeons often encounter foreign bodies. They may present a diagnostic challenge, due to
many factors such as the size of the object, the difficult access, masked by structures and a close anatomical relationship of
the foreign body to vital structures. We report a rare case of a chronic parotid fistula caused by an occult wooden foreign
body, emphasizing the importance of thorough history and clinical examination in diagnosis.

Keywords: Foreign Body, Surgical Exploration, Superficial Parotidectomy.

How to Cite: Dr. Abdul Haseeb Quadri; Dr. Souvik Roy (2025) Foreign Body in the Left Sub-Masseteric Region Masquerading as
a Chronic Parotid Fistula: A Rare and Intriguing Case Report. International Journal of Innovative Science and Research
Technology, 10(8), 1147-1150. https://doi.org/10.38124/ijisrt/25aug931

I. INTRODUCTION the diagnostic challenges posed by occult foreign bodies and

underscores the importance of accurate, meticulous history
The presence of foreign bodies deeply embedded in elicitation and maintaining a high index of suspicion in
facial tissues poses a significant challenge for maxillofacial trauma cases, even when initial findings appear
surgeons. Studies indicate that nearly one-third of foreign unremarkable.
bodies are overlooked during initial assessments. Following
facial trauma, foreign bodies—including grit particles, Surgical removal was the treatment of choice for
wooden splinters, thorns, pebbles, and glass fragments—may resolution. This case highlights the diagnostic challenges
become embedded within deeper soft tissues. posed by deeply embedded foreign bodies and emphasizes
the need for heightened clinical suspicion, thorough wound
These retained objects often evade initial detection and evaluation, and consideration of advanced imaging in trauma
may only be identified incidentally during radiographic cases where retained objects may not be immediately
evaluation or upon the subsequent development of clinical apparent. The importance of meticulous debridement during
manifestations such as localized pain, purulent discharge, or initial wound management and maintaining vigilance for
sinus tract formation. Road traffic accidents are a leading delayed presentations is underscored.
cause of such injuries in the maxillofacial region, yet many
cases go unrecognised initially. [1] II. CASE REPORT

This case report describes a delayed diagnosis of a A 24-year-old male presented to the emergency
deeply embedded foreign body in the facial region following department with a laceration in the left parotid region
maxillofacial trauma. Despite initial evaluation, the foreign following a fall onto wooden debris while walking. Initial
body was not detected during routine history-taking and examination revealed a 3×1 cm soft tissue laceration without
clinical examination, and the absence of overt suspicion evidence of deep penetration by a wooden fragment or
precluded further radiographic investigation at that stage. damage to the parotid gland and duct. The wound was
However, persistent signs and symptoms of a parotid fistula thoroughly debrided and primarily closed using Polyglactin
prompted advanced imaging, including CT and MRI, which 3-0 sutures.
ultimately revealed a radiopaque foreign body near the left
ramus, lodged beneath the masseter muscle. This highlights

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Volume 10, Issue 8, August – 2025 International Journal of Innovative Science and Research Technology
ISSN No: -2456-2165 https://doi.org/10.38124/ijisrt/25aug931

One month later, the patient returned to our outpatient

department with persistent pus and serous discharge from the
same site. Despite conservative management over five
months, symptoms remained unresolved, prompting a clinical
diagnosis of parotid fistula. Further evaluation with CT and
MRI of the facio-maxillary region revealed a 1.5×1 cm
radiopaque mass along the left ramus, situated beneath the
masseter muscle. These findings emphasize that meticulous
history collection serves as a crucial determinant in selecting
appropriate diagnostic tools, where early CT imaging might
have revealed the pathology at its initial presentation.

The patient subsequently underwent superficial

parotidectomy with surgical exploration under general
anaesthesia, leading to the successful removal of an
embedded wooden fragment.

Fig 3 Surgical Removal of Foreign Body Embedded Within

the Masseter Muscle

III. DISCUSSION

Maxillofacial surgeons often face difficulties in

clinically diagnosing foreign bodies during initial
examinations, with approximately one-third of cases being
overlooked initially.[4] Initial clinical assessments frequently
miss embedded foreign bodies, which typically become
apparent only during follow-up visits for unresolved
symptoms. Diagnostic imaging aimed at evaluating osseous
injuries often serendipitously reveals these retained objects.
Predisposing factors include polytrauma presentations
(notably high-velocity collisions), where acute stress
responses or intoxication-related cognitive impairment
frequently hinder accurate patient history documentation.

Retained foreign bodies following penetrating trauma

Fig 1 Preoperative Marking for Flap Reflection present a significant diagnostic challenge. Clinicians should
suspect their presence in cases of chronic wound drainage,
persistent sinus tracts, or abscesses with sterile cultures. The
presence of recurrent inflammatory symptoms, including
swelling and pain, warrants consideration of occult foreign
body retention in the differential diagnosis. Wooden foreign
bodies are particularly difficult to diagnose, as they often
result from minor trauma (e.g., small pricks) and are rarely
visible during clinical examination. Only 15% of wooden
foreign bodies are detectable on plain radiographs, leading to
frequent misdiagnosis.[5] In contrast, denser materials such as
grit, pebbles, stones, and glass fragments are more readily
identified via conventional radiography. For radiolucent
organic materials such as wooden objects, bamboo splinters,
and thorns, cross-sectional imaging modalities including CT
and MRI demonstrate superior diagnostic capability
compared to conventional radiography.

In the present case, radiographic confirmation of the

wooden foreign body was achieved exclusively through
computed tomography. CT imaging continues to represent
the diagnostic gold standard for identification of deeply
embedded foreign objects. If a wooden fragment is suspected
Fig 2 Gland Dissection with Careful Preservation of Facial but not visualized on CT, MRI should be performed.
Nerve Branches

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Volume 10, Issue 8, August – 2025 International Journal of Innovative Science and Research Technology
ISSN No: -2456-2165 https://doi.org/10.38124/ijisrt/25aug931

Additionally, ultrasound imaging serves as a well-established  Superficial examination and plain radiographs have well-
modality for foreign body localization documented shortcomings in detecting organic foreign
bodies, with reported miss rates as high as 85% for
Foreign bodies penetrating facial tissues often harbor wooden objects. [7,8]
significant microbial contamination due to their typically  Deeply embedded foreign bodies often evade visual
unclean nature. The presence of these contaminated objects detection during primary wound inspection, particularly
in the facial region frequently leads to infection, as evidenced when masked by tissue edema or located beneath muscle
by numerous case reports in the literature. Clinical layers.
manifestations may include substantial sinus tract formation
and persistent purulent discharge, representing serious  Essential Diagnostic Protocol:
complications that underscore the importance of prompt  Meticulous wound exploration with thorough
diagnosis and removal. debridement remains the cornerstone of initial
management, as it may reveal foreign material that would
The management of facial trauma requires particular otherwise go unnoticed.
vigilance regarding embedded foreign bodies. Standard  A high index of suspicion should be maintained for all
protocol should include radiographic evaluation of deep penetrating facial injuries, especially those involving
facial lacerations to detect potential foreign material in organic materials or high-velocity mechanisms.
underlying tissues. This becomes especially crucial when the
mechanism of injury involves wooden or bamboo objects, as  Advanced Imaging Indications:
these materials present unique diagnostic challenges.  When clinical suspicion persists despite negative initial
findings, CT imaging should be considered the diagnostic
Previous clinical reports emphasize the necessity of modality of choice, offering superior sensitivity for both
maintaining a high index of suspicion for retained radiolucent radiopaque and radiolucent foreign bodies.[9]
foreign bodies, particularly in cases where the injury  MRI may serve as an alternative for suspected wooden
mechanism suggests possible penetration by such materials. fragments that remain undetected on CT, particularly in
The diagnostic difficulty is compounded by the variable soft tissue-rich anatomical regions.[10]
radiopacity of different foreign materials: while metallic or
mineral objects are typically radiographically apparent,  Proactive Diagnostic Approach:
organic materials like wood often evade detection on  Surgeons should maintain a low threshold for obtaining
conventional imaging. advanced imaging in cases of:
 Persistent symptoms (pain, swelling, discharge)
 These Considerations Highlight the Need for a Systematic  Dubious injury mechanisms (wood, bamboo)
Approach to Facial Trauma Evaluation, Incorporating:  Deep or complex wound configurations

 Thorough history-taking regarding the nature of the This case exemplifies the diagnostic challenges posed
injuring object by retained foreign bodies and emphasizes the need for a
 Comprehensive physical examination of wound tracts systematic, multimodal approach to evaluation. The
 Appropriate imaging modalities based on suspected combination of thorough clinical assessment, appropriate
foreign body composition imaging selection, and timely intervention remains
 Early intervention when foreign body retention is paramount in preventing the long-term complications
suspected associated with missed foreign bodies.

The potential for serious infectious complications and IV. CONCLUSION

chronic wound issues necessitates this comprehensive
approach to ensure optimal patient outcomes in cases of facial This case illustrates the diagnostic pitfalls in
trauma with suspected foreign body retention. maxillofacial trauma when a patient’s history is incomplete
or overlooked. Despite inconclusive initial exams and
In the present case, both clinical examination and imaging, the patient’s persistent symptoms—rooted in
conventional radiography failed to detect the retained foreign undisclosed details of the injury—necessitated advanced
body, underscoring the limitations of these standard imaging, ultimately revealing a retained wooden fragment.
diagnostic approaches. It was only through computed The scenario highlights three key lessons: (1) organic foreign
tomography (CT) imaging that the embedded wooden bodies often escape detection due to their radiolucent nature
fragment was successfully identified, highlighting the critical and gaps in patient-reported history, (2) CT imaging is critical
role of advanced diagnostic modalities in such challenging when symptoms and clinical suspicion conflict with initial
scenarios. findings, and (3) delayed intervention risks complications,
particularly when early clues are missed. These findings
 This Case Reinforces Several Important Clinical underscore the importance of meticulous history-taking,
Considerations: especially in penetrating injuries involving organic materials.
A proactive diagnostic approach—integrating patient
 Limitations of Initial Assessment: narratives, targeted imaging, and timely intervention—is vital
to avoid missed diagnoses and ensure optimal outcomes.

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Volume 10, Issue 8, August – 2025 International Journal of Innovative Science and Research Technology
ISSN No: -2456-2165 https://doi.org/10.38124/ijisrt/25aug931

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