A 40-year-old male with a 20-year history of schizophrenia presented to the emergency department with long history of pharyngeal foreign body sensation which had progressed over one month to include sore throat, odynophagia, and dyspnea. Physical exam revealed asymmetric prominence of the right posterior oropharyngeal wall and trismus with maximal interincisural distance of two centimeters. There were tenderness, edema, and erythema of the right submandibular triangle without palpable mass.\nFlexible laryngoscopy showed fullness of the right posterior pharyngeal wall without mucosal abnormality, resulting in anterior displacement of the right aryepiglottic fold. This was encroaching on the airway but not causing critical airway stenosis. A computed tomography (CT) scan of the neck with contrast was obtained. This demonstrated a linear opacity extending from the oropharynx to the right thyroid ala. Reconstructed 3D images showed a uniform mass consistent with a foreign body (). Further psychiatric history was obtained and revealed a history of auditory hallucinations that had on several occasions led to suicide attempts, including one attempt two years ago in which the patient stabbed himself in the pharynx with a broken toothbrush handle. Prompt removal was recommended given risk for infection and airway compromise.\nThe patient was transorally intubated over a flexible bronchoscope and then underwent direct laryngoscopy. Swelling of the right posterior oropharynx and hypopharynx was noted (). An anterolateral neck incision was made and subplatysmal flaps were raised. The mass was easily palpated overlying the right thyroid ala, and blunt dissection allowed entry into the fibrous capsule surrounding the foreign body (). The capsule was opened, and the foreign body was removed. The length corresponded exactly to the length of the foreign body on the CT (). A sample was obtained for bacterial culture, the wound was irrigated, and a drain was placed. The patient was extubated and given a soft diet.\nVisual inspection and pathologic analysis confirmed that the foreign body was indeed a toothbrush handle. Cultures from the area grew heavy mixed bacteria including anaerobes. After an uneventful postoperative stay, the patient was discharged without complications. Discharge planning included psychiatry follow-up.
Mr. S is a 31-year-old, single, unemployed gentleman from a low socioeconomic Tamil-speaking background, who first came to psychiatric hospital in 2003 at the age of 17 years within 10 days of onset of symptoms of psychosis and mania. He was treated with tablet risperidone up to 4 mg/day. He responded well and even went back to school. After 9 months of regular treatment, he stopped medicines. Two months after stopping of medicines he had relapse of psychotic symptoms including Schniderian first rank symptoms without any mood symptoms. His diagnosis was revised to paranoid schizophrenia. He failed trials of tablet risperidone 8 mg/day, tablet olanzepine 25 mg/day, a course of 10 sittings of electroconvulsive therapy, and injection fluphenazine decanoate depot 100 mg intramuscular every month. He did not show significant improvement. He was started on tablet clozapine and the dose was gradually built up to 450 mg/day by 2007. He was on regular follow-up for 9 years during which he had fluctuations in psychiatric symptoms but was managing well without any physical health issues.\nIn 2016, he developed pain in the left lumbar region following trivial trauma (while using a crowbar) and later developed a swelling in the region for which incision and drainage were done at a primary health center. When the ulcer did not heal for about 3 months, he was referred to a surgical department of a teaching hospital for further management. The non-healing ulcer in the incision site of left lumbar gradually had increased in size and was associated with passage of air through the ulcer while defecating or straining. There was no history of abdominal distension, vomiting, obstipation, hematemeis, malena, or fever. Physical examination revealed a soft non-tender abdomen.\nRoentgenogram of abdomen and ultrasonography investigations revealed a foreign body in the abdominal cavity just below the diaphragm without any other features of obstruction or perforation. Contrast-enhanced computer tomography and magnetic resonance imaging revealed a linear foreign body forming a fistula communicating with splenic flexure of the colon [].\nThe patient was posted for elective exploratory laparotomy. On laparotomy, an intact ball point pen of size about 11 cm in length was found to be the foreign body with its tip inside the lumen of splenic flexure and its rear end facing the external ulcer []. The pen was carefully delivered through the external wound and the sealed perforation of size 1 × 1 cm was closed primarily []. Postoperative period was uneventful and the patient was discharged on the 11th postoperative day.\nThe patient recollected that he had swallowed the very same pen in 2004 when he had been very psychotic []. He reported that he had vague abdomen pain on and off, which he did not feel serious enough to report. There was no record of abdomen pain in the patient's case notes over the previous 13 years.\nHe is doing physically well and is on regular follow-up. He is not regularly employed but helps his family in household chores. He is currently on clozapine 450 mg/day, on which he has a serum level was 933 ng/mL.