An Unusual Penetrating Injury of the Cheek

Foreign bodies in the cheek, face or oral cavity may be the result of traumatic injuries, self-inflicted or iatrogenic dental or surgical procedures. Penetrating pencil and pen injuries have been reported in the literature, most commonly in children, with the head and neck being the most common site. 1 Injuries from pens and pencils can be severe or even fatal. 2

Case Report
A 35-year-old male presented to the emergency room with a lead pencil penetrating his right cheek, through and through, about 5 mm inferior to Stenson’s duct, with the lead tip just touching the palatoglossal arch and soft palate. The pencil was self-inflicted. The patient had a psychiatric history but was otherwise healthy. The patient was informed of the risks and complications and consented to its removal. The extraoral and intraoral areas were prepped, local anesthetic infiltrated, the throat was protected with a gauze, and the pencil was removed. The wound was thoroughly irrigated and the small fragments of glossy yellow pencil coating in the area and within the wound track were removed. The wound was closed in layers and the patient was released. He was given pain medication and antibiotics. He went on to an uneventful postoperative course with no residual nerve weakness, swelling or inflammation in the area.

Discussion
This unusual injury is likely under reported but several cases have been published with pencils penetrating the neck, oropharynx, vertebrate, transnasal-orbital and intracranial regions. 1,2,3,4 The pencil was easily removed in this case with knowledge of the associated anatomy and potential complications in this region of the face. Radiographs or CT scans may be required if the pencil or pen was close to vital structures, penetrated the bone or fractured during the injury.

Patients suffering from self-inflicted injuries of this nature may require counselling and supportive care. After the extraction of the object, it is important to thoroughly inspect and irrigate the penetrating injury because retained lead or neglected foreign bodies may result in granulation tissue, indurations, inflammation and or fibrotic scars. 5,6 OH

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References
1. Fisher SB, Clifton, MS, Bahatia AM. Pencils and pens: an under –recognized source of penetrating injuries in children. Am Surg 2011: 77(8),1076-80
2. Van Duinen, MTA. The transorbital intracranial penetrating injry; a review of the literature. Springer Science+Business Media DC, Kluwer Academic Publisher, 2000
3. Al-Otaibi, F Baeesa, S. Occult orbital penetrating pencil injury in a child. Case Reports in Surgery 2012;2012:716791
4. Rao, LP,et al. A ‘pen’ in the neck: an unusual foreign body and unusual path of entry. Indian J Dent res 2014:25(1) 111-114
5. Fukunaga Y et al. Pencil-core granulama of the face Report of two rare cases. J Plast Reconstr Aesth Surg 2011: 64, 1235-1237
6. Sinha, SN. Foreign body (Lead Pencil) in the maxillary sinus. J Laryngol Otol. 1968;82(5)473-476.

About the Author
Dr. Bruce Pynn is Oral Health’s editorial board member for oral and maxillofacial surgery. He maintains a private practice in Thunder Bay, ON. He is an Associate Professor, North Ontario School of Medicine, Lakehead University, and Chief of Dentistry, Thunder Bay Regional Health Sciences Center. President, Ontario Society of Oral and Maxillofacial Surgery.