To which specialist should a female patient with a 10 mm triangular glass fragment retained in the mid‑neck soft tissue after a motor‑vehicle accident be referred for removal?

Referral Recommendation for Retained Glass Foreign Body in Mid-Neck

Refer this patient to an interventional radiologist for ultrasound-guided or CT-guided removal of the retained glass fragment, or alternatively to a head and neck surgeon (otolaryngology) or trauma surgeon if interventional radiology is unavailable.

Algorithmic Approach to Specialist Selection

First-Line Option: Interventional Radiology

• Ultrasound-guided removal is the preferred minimally invasive approach for superficial soft tissue foreign bodies like glass fragments 1
• Glass is highly echogenic and well-visualized on ultrasound, making it ideal for this technique
• The procedure can be performed in an outpatient setting under local anesthesia in 15-30 minutes 1
• Success rate is excellent (100% in published series) with minimal complications 1

Pre-Removal Imaging Requirements

Before any removal attempt, obtain CT angiography (CTA) of the neck to:

• Precisely localize the 10 mm glass fragment in three dimensions
• Critically assess proximity to vital structures (carotid artery, internal jugular vein, vagus nerve, esophagus, trachea) 2
• Rule out vascular injury or pseudoaneurysm formation from the original trauma
• Guide the safest approach for extraction

CTA is the gold standard imaging modality for penetrating neck injuries with sensitivity of 90-100% and specificity of 98.6-100% for detecting vascular and aerodigestive injuries 2

Alternative Surgical Options if Interventional Radiology Unavailable:

Head and Neck Surgeon (Otolaryngology):

• Expertise in neck anatomy and vital structure preservation
• Appropriate if the fragment is near aerodigestive structures
• Can manage any unexpected airway or esophageal complications

Trauma Surgeon:

• Experienced in penetrating neck injuries
• Appropriate for complex cases requiring open exploration
• Essential if CTA reveals vascular involvement requiring surgical repair

Key Clinical Considerations

Why Not Leave It Alone?

Even after one year, retained foreign bodies carry ongoing risks:

• Chronic inflammation and infection
• Migration toward vital structures
• Delayed vascular erosion or pseudoaneurysm formation
• Persistent pain or functional impairment
• Medicolegal implications of retained foreign body 3

Critical Pitfalls to Avoid:

1. Never attempt blind surgical exploration without precise imaging localization—this leads to failed removal, increased tissue trauma, and potential injury to vital structures 4

2. Do not proceed without vascular imaging—the mid-neck contains the carotid sheath structures, and proximity to the external carotid branches must be assessed 4

3. Avoid MRI for initial imaging due to concern for metallic foreign bodies that may have been missed 2

4. Plain radiographs alone are insufficient—while glass is radiopaque, they don't provide adequate anatomic detail for safe removal planning 2

Advantages of Image-Guided Removal Over Traditional Surgery:

• Minimally invasive with smaller incisions (often closed with Steri-Strips rather than sutures) 1
• Real-time visualization prevents injury to surrounding structures
• Outpatient procedure under local anesthesia
• Lower cost and faster recovery
• Repeatable if initial attempt unsuccessful without precluding subsequent surgical removal 1
• For small or deep fragments, 3D CT guidance provides exceptional accuracy 5

If the Fragment is Near Major Vessels:

The surgical team should be prepared for emergency vascular control before extraction:

• Exposure and preparation of the external carotid artery for potential ligation 4
• Availability of vascular surgery backup
• This may necessitate open surgical approach rather than image-guided removal

Practical Next Steps:

1. Order CTA of the neck with contrast (unless contraindicated)
2. Contact interventional radiology to review imaging and assess feasibility of image-guided removal
3. If interventional radiology declines or is unavailable, refer to head and neck surgery or trauma surgery based on the anatomic location and proximity to vital structures revealed on CTA
4. Ensure antibiotic prophylaxis (amoxicillin-clavulanate for 7 days) is prescribed post-removal 1