Case of the Month – July 2012

This month we are featuring Sky Nickells a young Siberian Husky who fell foul of an unusual foreign body.

Sky presented with a very sore mouth and a swelling under her tongue and the side of her face.  She was very brave for her examination but her mouth was obviously sore and she had a fluid swelling just behind her jaw extending down her neck.  Her temperature was high and her lymph nodes were very enlarged.

It was suspected that she had an abscess.  Overnight she was given a high level of pain relief whilst the area on the side of her neck was hot compressed in an effort to get the abscess to burst.  With 12 hours of intensive bathing the abscess stubbornly still had not erupted so she was admitted that morning and prepared for an anaesthetic.

Under a general anaesthetic poor Sky had an enormous abscess – it extended under her tongue to the edge of her incisors and all the way down the back of her throat to her sub-mandibular lymph nodes and tonsillar tissue.  This had then started to swell outwards onto the side of her neck. 

There was no sign of a stick injury or hole. X-rays showed no evidence of a radiodense foreign body.

The abscess was drained with needle and examined under the microscope confirming lots of pus and bacteria.  Abscesses normally develop due to foreign material being present, much like a splinter in your finger.  The pus inside an abscess is a mix of dead and live white blood cells trying to fight off the infection.  As an abscess becomes bigger and starts to ‘point’ it is effectively stretching the soft tissues and one area will become thin and weak.  As the pressure builds this area will then start to die and split allowing the abscess to burst.  In doing so it is natures way of trying to force out the foreign body that caused the problem in the first place.

With Sky the abscess had been allowed to get so large due to there being a lot of space for it to swell.  However there was a small area under her tongue that was showing signs of pointing so rather than lance the abscess on the side of the neck (where there are a lot of important structures like the Jugular) it was lanced under the tongue.  

An inch long incision was made and a sterile saline solution was flushed through the abscess.  Masses of pus and thick material was obtained.  The abscess extended over 15 cm down the throat.  At this point no obvious foreign body had been found.  However with continual searching eventually ‘pop’ a tiny grass seed was found!  As usual there are a selection of photographs below for those who are not squeamish.

The grass seed was so tiny and being plant material would not show up on x-ray.  It was presumed that whilst chewing and playing in the garden it must have entered the soft tissues under the tongue and then over time as the body recognised it as being foreign the abscess had formed.

Once the abscess site was clean the whole was sutured under the tongue to prevent food material from entering the site.  Sky recovered very quickly from the anaesthetic and the first thing she did was eat some lunch!  She went home on a continuation of painkillers and antibiotics and has made a full recovery!

Thankfully this type of foreign body in the mouth is incredibly rare and we were very lucky to find it.  Often with such small bodies these cases can grumble on for ages and often need referral for an MRI investigation to find them.  Happily this was not the case with Sky!