Facial pain after choking

A 60-year-old male presented to our emergency department with complaints of facial pain following a choking episode while eating chicken wings. He reported feeling like he was choking and subsequently coughed, after which he began experiencing facial pain and congestion. He was afebrile but had an elevated blood pressure with a normal heart rate. On physical examination, the patient appeared comfortable, had a patent airway, was able to tolerate water and his secretions, but had continuous drainage from his nose. Tenderness was noted in the right maxillary sinus. Due to the patient's acute symptoms of persistent facial pain, congestion, and sinus tenderness, a computed tomography (CT) scan was ordered. The imaging revealed a chicken bone angled and impacted in the ethmoid air cells. Consequently, the patient was transferred to another hospital for evaluation by Ear, Nose & Throat (ENT) specialists and endoscopic removal of the bone. Knowing when to order a CT scan is a crucial skill for any clinician. Each chief complaint presents a range of clues in the patient's history and physical examination that guide the necessity of CT imaging. Specifically, in cases where a parasinus or esophageal foreign body is suspected after choking. In these cases, clinical indicators such as fever, chills, sinus pain, persistent nasal congestion or discharge, loss of smell, bad breath, headache, or toothache should prompt consideration of a CT scan of the soft tissue of the neck. This CT scan, extending from above the ears to below the clavicles, effectively evaluates the sinuses, trachea, and proximal esophagus, proving to be an invaluable diagnostic tool. Finding foreign bodies within the paranasal sinuses are exceptionally rare, typically arising from trauma.1 While multiple case reports document instances of foreign bodies entering the sinuses due to trauma or deliberate self-infliction, this case stands out as a unique presentation following a choking episode. The existing literature underscores the critical importance of promptly removing foreign objects from the nasal sinuses, given their potential to cause severe complications. These complications range from cerebrospinal fluid fistulas1, 2 and optic nerve compression3 to a spectrum of infections, including abscess, empyema, orbital cellulitis, meningitis, and osteomyelitis.4, 5 Modern management favors minimally invasive endoscopic procedures for foreign body removal from the paranasal sinuses (6).6 However, in situations where the precise location of the foreign body remains questionable despite thorough imaging and endoscopic assessment, an open surgical approach may be necessary to ensure complete removal and minimize the risk of complications (6)