Fractured aluminum nasopharyngeal swab during drive-through testing for COVID-19: radiographic detection of a retained foreign body

Abstract

The ongoing coronavirus disease 2019 (COVID-19) pandemic has increased the need for safe and efficient testing as a key containment strategy. Drive-through testing with nasopharyngeal swab has been implemented in many places in the USA as it allows for expeditious testing of large numbers of patients, limits healthcare workers' risk of exposure, and minimizes the use of personal protective equipment. We present a case where the aluminum shaft of the nasopharyngeal swab fractured during specimen collection at a drive-through testing facility and was suspected to have remained in the asymptomatic patient. Initial evaluation with a series of radiographs covering the skull base, neck, chest, and abdomen did not reveal the swab. On further clinical evaluation, the swab was found endoscopically, lodged between the left inferior turbinate and nasal floor, and was removed by an otorhinolaryngologist. Using a phantom model, we aimed to delineate an imaging technique to better visualize the aluminum shaft of the nasopharyngeal swab on radiographs to help in identification. A technique using lower tube voltage (kVp) with tight collimation centered at the nasal bones area produced the best visualization of the aluminum shaft of the swab. Recognition that aluminum foreign bodies may be difficult to visualize radiographically and optimization of radiograph acquisition technique may help guide clinical management in unusual cases. Further evaluation with computed tomography or endoscopy should be considered in suspected cases where radiographs are negative.

Role of the otolaryngologist in nasopharyngeal swab training: A case report and review of the literature

“…In the aforementioned Treviso Hospital study, there were 3 instances of epistaxis requiring nasal packing, 2 broken swabs that lodged into the nasal cavity, prompting intervention by otolaryngologists, and 1 case of a septal abscess following nasopharyngeal swabbing [ 19 ]. In a review of the literature regarding other major complications of nasopharyngeal swabs, there were at least 7 other instances in which the nasopharyngeal swab shaft broke within the nasal cavity of the patient, all of which required endoscopy for retrieval [ [21] , [22] , [23] , [24] , [25] ]. Three of these instances involved the shaft fragment inserting inferior to the inferior nasal turbinate, while two instances involved a fragment eventually being found in the gastric cavity [ [21] , [22] , [23] , 26 ].…”

“…In a review of the literature regarding other major complications of nasopharyngeal swabs, there were at least 7 other instances in which the nasopharyngeal swab shaft broke within the nasal cavity of the patient, all of which required endoscopy for retrieval [ [21] , [22] , [23] , [24] , [25] ]. Three of these instances involved the shaft fragment inserting inferior to the inferior nasal turbinate, while two instances involved a fragment eventually being found in the gastric cavity [ [21] , [22] , [23] , 26 ]. In a study on 96 volunteers with both commercial swabs and 3D-printed swabs, the most common complications of commercial swab sampling included headache (5.2%), rhinorrhea (5.2%), and epistaxis (8.3%); however, one participant eventually had to be hospitalized for recurrent episodic bleeding after a commercial swab test [ 27 ].…”

An Unusual and Unexpected Result of Diagnostic Sampling for COVID-19

“…Other methods of sampling include sputum samples, bronchoalveolar lavage, or a bronchoscopic brush biopsy with a variable degree of accuracy [ 7 ]. One of the serious reported complications of taking a swab is that of the swab stick breaking, resulting in the broken part getting stuck as a foreign body in the nasopharynx or the lower respiratory tracts [ 8 , 9 ].…”

New Clinical Anatomical Interpretation of COVID-19 Pandemic Infection

“…Therefore, the nasopharyngeal swab may be the most proper method for taken the sample. The complication of nasopharyngeal procedure is swab fracture which considered as a foreign body that result in obstruction or infection of lower respiratory airway (Azar et al, 2020) or the nasal roof penetration (Miller et al, 2020) leading to meningitis or either temporally or permanent Anosmia (loss of smell) due to olfactory nerve injury.…”