Management of Retained Glass Fragment in Anterior-Lateral Neck (Two Years Post-Injury)
Initial Assessment and Imaging
For a retained glass fragment in the neck from a remote injury two years ago, obtain CT imaging without contrast to precisely localize the foreign body and assess its relationship to critical neurovascular structures before attempting removal. 1
Imaging Strategy
CT without contrast is the optimal modality for evaluating retained glass foreign bodies in the neck, as it provides precise localization and excellent visualization of the relationship to surrounding vascular and aerodigestive structures 1
Radiographs can detect glass fragments but are inconsistently reliable, particularly if fragments are small or obscured by adjacent osseous structures 1
Ultrasound has limited utility in the neck due to overlying soft tissue, cervical collars, or skin changes, and provides limited evaluation of deeper structures and zone I/III injuries 1
MRI should be avoided if metallic contamination is possible, though it can be valuable for assessing soft-tissue complications if glass composition is confirmed 1
Critical Anatomic Considerations
Assess proximity to major vascular structures including the carotid artery, internal jugular vein, and vertebral arteries using CT or CT angiography 1
Evaluate for cranial nerve involvement, particularly if the patient reports dysphonia, dysphagia, or sensory deficits 1, 2
Determine relationship to the spinal canal and cord, as glass fragments can penetrate deeper than the entry wound suggests 3, 4, 5
Management Decision Algorithm
Indications for Removal
Surgical removal should be pursued if:
- The fragment is causing symptoms (pain, nerve compression, recurrent infection) 1, 2
- The fragment is in proximity to critical neurovascular structures with risk of delayed injury 2, 5
- There is evidence of soft-tissue infection or granulomatous reaction 1
- The fragment is mobile or migrating 2
Timing Considerations for Delayed Removal
The two-year delay may actually be advantageous for surgical removal because retained foreign bodies become surrounded by a fibrous envelope over time, which can reduce the risk of active bleeding during extraction 2
A case report demonstrated that delayed exploration (3 weeks post-injury) of a glass fragment in the parapharyngeal space allowed fibrosis to surround the foreign body, facilitating safer removal without active bleeding 2
Spinal immobilization is crucial if there is any concern for craniocervical junction involvement to prevent secondary neurologic or vascular damage 5
Surgical Approach
Preoperative CT angiography is essential if the fragment is near major vessels to map vascular anatomy and plan the safest surgical corridor 1, 5
Direct surgical exploration through an appropriate incision based on CT localization is the standard approach 2, 5
Intraoperative imaging or navigation may be helpful to ensure complete fragment removal, as multiple pieces may be present 5
Dural repair with autograft is necessary if there is penetration into the subarachnoid space 5
Key Clinical Pitfalls
Do not assume the fragment location based on the entry wound alone—glass can travel significant distances from the laceration site 3
Multiple fragments may be present—use multi-slice CT to determine the accurate number and positions of all glass pieces 6, 5
Incomplete assessment can result in unexpected hazards—always obtain complete imaging before intervention 5
Consider infection risk—retained foreign bodies trigger granulomatous reactions and can develop soft-tissue infections requiring removal 1
Conservative Management
Observation may be appropriate only if:
- The fragment is completely asymptomatic 1
- It is remote from critical structures on imaging 1
- There is no evidence of infection or inflammation 1
- The patient declines intervention after informed discussion of risks
However, given the neck location with proximity to vital structures, surgical consultation for removal is generally recommended rather than indefinite observation 1, 2, 5