Sir, an 18-year-old man presented to the hospital at night team in our unit complaining of an alleged assault. He claimed that he was struck on the left side of his face. He was unaware of being struck with an object. There had been no loss of consciousness or other injuries. He had been drinking alcohol. There was no medical history of note.

Clinical examination revealed a 1 cm laceration on his left cheek. No other injuries were noted. The hospital at night team did not suspect a penetrating injury and therefore did not perform radiographic investigations. The provisional diagnosis of a simple facial laceration had been established. The oral and maxillofacial surgery (OMFS) team was asked to treat the facial laceration.

However, on examining the patient, the OMFS team noted left sided preauricular tenderness. For that reason, radiographs were ordered. These revealed evidence of a penetrating foreign body embedded in his left cheek (Fig. 1). The patient was brought to theatre to have the foreign body removed. Preauricular incision revealed a metal foreign body below the left zygomatic arch (Fig. 2). The foreign body was carefully removed and an 8 cm section of the tip of a snooker cue was removed, complete with the rubber tip (Fig. 3). The snooker cue had been lying in a tract from the laceration at the left cheek, passing superiolaterally up along the external oblique ridge of the mandible, and embedded beneath the arch of the zygoma. Meticulous irrigation and debridement was performed and the wounds were closed primarily (Fig. 4).

Figure 1
figure 1

Radiograph showing penetrating foreign body embedded in the left cheek

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Figure 2
figure 2

The metal foreign body below the left zygomatic arch

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Figure 3
figure 3

The 8 cm section of the tip of a snooker cue complete with the rubber tip

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Figure 4
figure 4

Meticulous irrigation and debridement was performed and the wounds were closed primarily

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Penetrating facial foreign bodies are relatively uncommon.1 However, their identification and removal from wounds is often necessary. In adults, most cases of soft tissue foreign bodies after trauma or accidents are asymptomatic. Symptoms, if present, could be pain or discomfort, local swelling and facial cellulitis.2 The discovery of an occult penetrating facial foreign body on routine dental radiograph has been previously described.3 However, their presence may not be considered if they do not show up on radiographs.4

The localisation of facial foreign bodies is important so that adjacent structure injury can be avoided and the time of removal can be reduced. Various imaging modalities, including plain radiography, xerography, computed tomography, and ultrasonography, have been advocated for detecting facial foreign bodies.5 If plain radiographs, history and clinical examination fail to reveal the presence of superficial FBs, ultrasound or computed tomography can be used as an alternative method.6

Prompt diagnosis and appropriate treatment of penetrating facial injuries may lead to only minor sequelae. However, these patients may be in need of prompt resuscitation, due to bleeding both externally as well as intracranially. If an intracranial foreign body is suspected, urgent neuroimaging is mandatory to determine exact location and depth of the pen.7

This was an unusual case; firstly, there was absolutely no recollection of a snooker cue being used during the alleged assault and secondly, there was no exit wound suggesting a penetrating injury. Despite a history of assault, foreign bodies may not be suspected clinically leading to a delay in diagnosis. Clinical surgery is reliant on thorough history taking and careful examination. However, surprises can still occur and a surgeon has to be prepared for the unexpected. We recommend that hospital at night contact the maxillofacial team on call when suspected penetrating facial injuries present to the emergency department.