What is the management approach for a patient presenting with a foreign body sensation in the oral cavity?

Management of Foreign Body Sensation in the Oral Cavity

For a patient presenting with foreign body sensation in the oral cavity, perform immediate visual inspection and manual examination after cleansing with water or saline, remove any visible foreign objects, and obtain plain radiographs if the sensation persists despite negative visual examination. 1

Initial Assessment and Examination

Critical first steps:

• Cleanse the oral cavity thoroughly with water or saline to enable accurate visualization of any foreign material 2
• Perform systematic visual inspection of the entire oral cavity, including teeth, gingiva, tongue, floor of mouth, and oropharynx 2
• Palpate the oral soft tissues and floor of mouth for embedded objects that may not be immediately visible 3
• Remove ill-fitting dental prostheses or fractured teeth that may be causing the sensation 1, 2

Important caveat: Children and mentally impaired adults may not provide reliable history of foreign body ingestion or insertion, requiring more thorough examination 1

Manual Removal of Visible Foreign Bodies

If a foreign object is visible:

• Manual extraction of visible items in the mouth is appropriate as first-line intervention 1
• Avoid blind finger sweeps, as these can push objects deeper or cause injury 1
• Common foreign bodies in the oral cavity include restorative materials (amalgam, broken instruments, needles), food particles, and accidentally inserted objects like stapler pins or metal fragments 4, 5

Diagnostic Imaging When Physical Examination is Negative

Radiographic evaluation is essential when symptoms persist despite negative visual examination:

• Plain radiographs (anteroposterior and lateral views of the neck, chest, and oral cavity) should be obtained first to identify radiopaque foreign bodies and assess their location, size, and shape 1

• Plain radiography has a false-negative rate up to 47% for general foreign bodies and up to 85% for fish bones, chicken bones, wood, plastic, and glass fragments 1

• CT scan is the definitive imaging modality when plain films are negative but symptoms persist, with sensitivity of 90-100% and specificity of 93.7-100% for detecting foreign bodies 1

• CT should be performed if there is suspicion of complications including perforation, abscess formation, or deep tissue involvement 1

Contrast swallow studies should be avoided as they can coat foreign bodies and impair subsequent endoscopic visualization, and should not delay other interventions 1

Endoscopic Evaluation

Flexible endoscopy is indicated when:

• Persistent symptoms occur despite negative radiographic examination 1
• A foreign body is confirmed on imaging but cannot be removed manually 1
• There is suspicion of esophageal or pharyngeal foreign body causing referred sensation to the oral cavity 1

Timing considerations:

• Emergent endoscopy (within 2-6 hours) for sharp-pointed objects, complete obstruction, or objects causing severe symptoms 1
• Urgent endoscopy (within 24 hours) for other persistent foreign bodies without complete obstruction 1

Symptomatic Management

While investigating or after foreign body removal:

• Recommend warm saline rinses (4 times daily) to reduce inflammation and promote healing 1, 2
• Prescribe alcohol-free antimicrobial mouthwash (0.2% chlorhexidine) to reduce bacterial load and prevent secondary infection 1, 2
• Provide over-the-counter oral acetaminophen or NSAIDs for residual discomfort 1
• Instruct on gentle oral hygiene with soft toothbrush and mild fluoride-containing toothpaste 1, 2
• Advise avoidance of painful stimuli including smoking, alcohol, and spicy or hot foods 1, 2

Special Considerations

Anatomical causes to consider when no foreign body is found:

• Medially displaced superior cornu of the thyroid cartilage can cause persistent foreign body sensation at the hyoid level, requiring surgical correction 6
• Gastroesophageal reflux disease and upper esophageal dysmotility are common non-foreign body causes of this sensation 6
• Retained foreign bodies in submandibular glands or deep soft tissues may not cause obvious inflammatory reactions 3

Critical Pitfalls to Avoid

• Never dismiss persistent symptoms as psychogenic without thorough imaging evaluation, as foreign bodies can remain asymptomatic for extended periods (weeks to months) 3, 7
• Do not rely solely on plain radiographs for radiolucent materials like wood, plastic, or certain food items 1
• Avoid blind instrumentation or finger sweeps that could push objects deeper or cause mucosal injury 1
• Consider chronic retained foreign bodies even in adults, particularly in patients with anatomical abnormalities like Zenker diverticulum 7

Follow-up Instructions

Patients should return immediately for:

• Increasing swelling or difficulty breathing/swallowing 2
• Development of fever or signs of infection 1
• Worsening pain or new symptoms 2