Electronic Gastroscopy in Identifying Hidden Tonsillar Foreign Bodies: A Case of a Completely Embedded Sunflower Seed Shell

Introduction

Pharyngeal foreign bodies are mainly detected via laryngoscopy. Sunflower seed shells are a common type of pharyngeal foreign body, but complete penetration of the tonsil is rare and easily misdiagnosed. In cases where laryngoscopy fails to detect a foreign body, electronic gastroscopy may provide diagnostic assistance. The following report describes a case in which a pharyngeal foreign body was identified through electronic gastroscopy.

Case Report

A 38-year-old woman experienced throat pain and foreign body sensation after consuming sunflower seeds; she sought treatment at the otolaryngology department on June 1, 2024. Although no foreign body was detected by laryngoscopy, the symptoms persisted. On the afternoon of June 2, she returned for reevaluation, and a repeat examination did not show any foreign body. Apart from throat pain, her overall health was good; she had no fever, no cervical lymphadenopathy, and normal pulse, respiration, and blood pressure. The otolaryngologist considered the possibility of pharyngitis or mucosal abrasion and prescribed acetaminophen (0.5 g per dose, twice daily). However, the treatment did not alleviate her symptoms. By the morning of June 3, the throat pain had worsened, and the patient requested further investigation via gastroscopy. Thus, gastroscopy was performed under intravenous general anesthesia (propofol 500 mg per vial, administered by continuous intravenous infusion [40 mg/10 s]), limited to examination of the throat without exploration of the upper digestive tract. The oropharynx and laryngopharynx were meticulously examined using a transparent cap attached to the endoscope, but no obvious foreign body was observed. After cap removal and lens cleaning, a second examination revealed no abnormalities in the epiglottis or the left and right pyriform fossae. When the endoscope was retracted to the tongue root, a yellow dot approximately 1 mm in diameter was noted on the surface of the right palatal tonsil, suggesting an embedded foreign body. Using foreign body forceps, a yellow fibrous fragment approximately 4 mm in length was successfully extracted. Subsequent examination confirmed that the yellow dot had disappeared and that the tonsillar surface was intact, without evidence of bleeding or purulent discharge (Figures 1, 2). After removal, the patient’s symptoms – including throat pain and foreign body sensation – completely resolved.

Discussion

Pharyngeal foreign bodies are a common emergency in otorhinolaryngology-head and neck surgery, most commonly found in the tonsils, tongue root, epiglottic vallecula, and pyriform fossa [1]. In most cases, foreign bodies can be detected by direct visualization or with specialized instruments such as indirect or fiberoptic laryngoscopy, enabling straightforward identification and removal by the otorhinolaryngologist.

The surface of each tonsil contains multiple crypts that can easily trap foreign material. When a foreign body is forcibly swallowed, it may become completely embedded within the tonsillar tissue, rendering it invisible on the tonsillar surface. Consistent with this mechanism, a previous report described sewing needles embedded in the tonsils [2]. In a large retrospective analysis of 829 pediatric cases of foreign bodies in the ear, nose, and throat, the most frequently affected sites were the nose (58.7%) and ear (20.2%), followed by the mouth, pharynx, or tonsil (12.3%); esophagus (6.2%); and tracheobronchial tree (2.4%). The most common types of foreign bodies identified at each site were beads in the nose (30.8%); beads in the ear (32.1%); fish bones in the mouth, pharynx, or tonsil (56.8%); nuts and peanuts in the tracheobronchial tree (70%); and coins or disc batteries in the esophagus (80.7%) [3]. Moreover, sunflower seeds are among the most common aspirated airway foreign bodies in children [4]. Nevertheless, there have been no documented cases of pharyngeal foreign bodies caused by sunflower seed shells.

A previously reported case of a tonsillar foreign body bears similarity to the present case. A 12-year-old girl sustained a tonsillar injury from a ballpoint pen cap, resulting in laceration over the left tonsil. Although antibiotic treatment temporarily relieved her symptoms, the pain recurred. Upon careful examination, a piece of embedded plastic was identified in the upper pole of the left tonsil, surrounded by an area of inflammation. Under general anesthesia, the bottom plug of a ballpoint pen was successfully removed from the tonsil. The previous case supports the possibility that completely embedded tonsillar foreign bodies may escape initial diagnosis [5].

A unique aspect of the present case is that the patient had a clear history of consuming sunflower seed shells and experienced throat pain while eating them. Although no foreign body was identified during 2 otolaryngology consultations and repeated laryngoscopic examinations, the patient continued to report persistent throat pain, discomfort, and foreign body sensation. This prompted a gastroscopic examination using a transparent cap to enhance observation of the pharyngeal structures. Initially, no foreign body was detected, but during endoscope retraction, a small yellow dot was observed on the surface of the right palatal tonsil. We speculated that the foreign body had completely penetrated the tonsil and that the yellow dot represented either inflammation or the foreign body itself. Using foreign body forceps, the site was carefully explored; we confirmed that the yellow dot was a penetrating fiber from a sunflower seed shell. This case underscores the potential risk of overlooking small or atypical findings. If the tonsils are not examined thoroughly during gastroscopy, or if such findings are misinterpreted as simple inflammation, a penetrated sunflower seed shell may lead to a tonsillar abscess. The key conclusion from this case is that when a patient has a clear history of foreign body ingestion and continues to experience pain or a persistent foreign body sensation, multiple negative nasopharyngeal or endoscopic examinations cannot definitively exclude foreign body retention. Unless all possible causes are excluded, symptoms should not be attributed solely to mucosal inflammation from prior injury. Clinicians should consider the possibility of complete mucosal penetration and carefully inspect all areas of the pharynx, including the tonsils, during endoscopic examination. Any suspicious finding should receive a high index of suspicion and be further explored using foreign body forceps when feasible. This approach may help reduce the risk of foreign body retention and associated complications. An increasing number of early-stage pharyngeal cancers have been detected via electronic gastroscopy, possibly because the high image clarity enables identification of subtle manifestations of hypopharyngeal cancer. Thus, for concealed foreign bodies in the pharynx, electronic gastroscopy – with its clear field of view – can aid in detecting retained foreign material [6]. Similar to the present case, Koito et al. reported an instance in which a fish bone was completely embedded beneath the esophageal mucosa and successfully removed through endoscopic mucosal incision [7]. These examples demonstrate that an endoscope with a clear field of view can serve as an adjunct for detecting and removing completely embedded foreign bodies.

Conclusions

In our case, no foreign body was identified during laryngoscopy because the object had completely penetrated the tonsil. Electronic gastroscopy aided in the detection and management of pharyngeal foreign bodies.