Retained hypodermic needles in the neck.

A 42-year-old man with hepatitis C presented to the emergency department with fever and a tender, fluctuant neck mass on the right. He had a well-documented history of intravenous heroin use, which caused him to undergo multiple incisions and drainages of peripheral abscesses.

Contrast-enhanced computed tomography (CT) of the neck detected an abscess and evidence of several metallic foreign bodies that appeared to be broken fragments of hypodermic needles (figure). The patient was emergently taken to the operating room for incision and drainage of the abscess and admitted for treatment with intravenous antibiotics. Cultures were consistent with oxacillin-resistant Staphylococcus aureus, requiring 2 weeks of vancomycin. However, the patient left the hospital against medical advice prior to the completion of his antibiotic regimen.

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When peripheral veins become sclerosed as a result of a long history of injections, end-stage intravenous drug abusers often resort to injecting substances into deep cervical neck veins. Abusers call such an injection a "pocket shot," referring to the pocket between the sternal and clavicular heads of the sternocleidomastoid muscle. The complications of this maneuver can be severe and life-threatening. Infectious complications include abscess formation, cellulitis, mycotic aneurysms, and clavicular osteomyelitis. (1) Other reported adverse effects include vocal fold paralysis, pneumothorax, internal jugular vein thrombosis, and foreign-body embolus formation resulting in cardiac and pulmonary complications. (2-5)

Many intravenous drug abusers reuse needles dozens of times. As a result of repeatedly bending the needle into the desired configuration and given the difficulty of self-injecting deep cervical neck veins, it should be no surprise that retained broken needles are common in this population. Any such patient with a complication of deep cervical injection should undergo proper imaging studies to assist in surgical planning and to reduce the risk of accidental needle stick to the surgical team.

References

(1.) Williams MF, Eisele DW, Wyatt SH. Neck needle foreign bodies in intravenous drug abusers. Laryngoscope 1993;103:59-63.

(2.) LeMaire SA, Wall MJ Jr., Mattox KL. Needle embolus causing cardiac puncture and chronic constrictive pericarditis. Ann Thorac Surg 1998;65:1786-7.

(3.) Brunette DD, Plummer DW. Pulmonary embolization of needle fragments resulting from intravenous drug abuse. Am J Emerg Med 1988;6:124-7.

(4.) Hillstrom RP, Cohn AM, McCarroll KA. Vocal cord paralysis resulting from neck injections in the intravenous drug use population. Laryngoscope 1990;100:503-6.

(5.) Lin D, Reeck JB, Murr AH. Internal jugular vein thrombosis and deep neck infection from intravenous drug use: Management strategy. Laryngoscope 2004;114:56-60.

Michael J. Rodriguez, MD; Simon Angeli, MD

From the Department of Otolaryngology, University of Miami School of Medicine.