What is the best course of treatment for a 15-year-old patient with a history of choking on pepperoni, presenting with tongue swelling, pain, and a palpable bump under the tongue, despite a previous x-ray showing no foreign body or emphysema?

Sublingual Mass with Intermittent Swelling After Choking Episode

This patient requires urgent referral to otolaryngology for direct visualization and palpation of the floor of mouth, with consideration for CT imaging if examination is incomplete or concerning findings are present. 1

Immediate Clinical Assessment

Perform a thorough oral cavity examination now:

• Remove any dentures and use gauze to grasp the tongue to facilitate inspection of lateral tongue surfaces and floor of mouth 1
• Palpate the entire floor of mouth bilaterally to identify any masses, ulcers, or retained foreign material 1
• Assess for limited tongue mobility, which may indicate deeper pathology 1
• Examine for intraoral swelling, ulceration, or asymmetry under the tongue and in sublingual spaces 1

Differential Diagnosis Considerations

The intermittent swelling pattern suggests several possibilities:

• Retained foreign body (pepperoni fragment or bone) despite negative initial X-ray—plain radiography has false-negative rates up to 47% for esophageal foreign bodies and 85% for food bolus 2
• Obstructed salivary duct (submandibular or sublingual gland) causing intermittent sialadenitis
• Ranula (mucous retention cyst from sublingual gland)
• Traumatic injury to sublingual structures from the choking episode

Imaging Strategy

If your oral examination is incomplete or reveals concerning findings, obtain CT imaging:

• CT scan has 90-100% sensitivity for detecting foreign bodies compared to plain radiography's poor sensitivity 2
• CT is essential for evaluating non-radiopaque objects and assessing complications 2
• The negative X-ray one month ago does not exclude a retained foreign body 2

Urgent Referral Indications

Refer to ENT urgently (within 24-48 hours) if:

• You cannot adequately visualize or palpate the entire floor of mouth 1
• Any mass, ulceration, or asymmetry is detected on examination 1
• Symptoms persist despite conservative management 2
• The patient develops dysphagia, odynophagia, or difficulty managing secretions 1

The base of tongue and deep sublingual spaces cannot be fully examined without flexible laryngoscopy or mirror laryngoscopy, which requires specialist evaluation 1

Red Flags Requiring Emergency Evaluation

Send to emergency department immediately if:

• Complete inability to swallow saliva (suggests complete obstruction) 2
• Fever, persistent chest pain, breathlessness, or tachycardia (suggests possible perforation or deep space infection) 2
• Rapidly progressive swelling affecting airway 1

Conservative Management While Awaiting Specialist Evaluation

If examination is reassuring and symptoms are mild:

• Advise soft, moist, low-acidity diet 1
• Warm saline mouth rinses three times daily 1
• Avoid manipulation of the area
• Schedule ENT follow-up within one week maximum

Critical Clinical Pitfall

The most important pitfall here is assuming the negative X-ray rules out a foreign body. Given the persistent symptoms one month after the choking episode, the intermittent nature of swelling (suggesting possible duct obstruction or mobile foreign material), and the poor sensitivity of plain radiography for food-related foreign bodies, this patient needs direct visualization by an otolaryngologist and likely CT imaging if not already performed 2, 1. The one-month duration makes simple trauma less likely and increases concern for a retained foreign body or secondary complication requiring intervention.