In Through the Mouth, Out Through the Ear: Utilizing an Atypical Postauricular Transtympanic Approach for Removal of a Parapharyngeal Space Foreign Body in a Toddler

This case report presents a postauricular, transtympanic approach to accessing the parapharyngeal space in a 10-month-old child who sustained a traumatic transoral lead pencil injury. This injury resulted in the presence of a lead foreign body in the parapharyngeal space, extending into the middle ear. The child was found with a lead pencil in their mouth when an accidental contact caused the pencil tip to enter the pharynx near the carotid artery. Blood was observed in the mouth but fortunately suffered no other apparent injuries. Fortunately, emergency vascular studies of the head and neck revealed normal findings. The carotid artery and internal jugular vein were not affected by the pencil’s passage. A computed tomography (CT) scan revealed a 9mm long dense foreign body in the parapharyngeal space adjacent to the tympanic bone. Initially, the radiological impression suggested a traumatically displaced styloid process. Head and neck surgery was consulted to explore transcervical, transoral, or transparotid infratemporal approaches to the parapharyngeal space for foreign body removal. However, these approaches were deemed suboptimal for a 10-month-old child. Neurotology was consulted and offered a postauricular approach with partial tympanic bone removal to access the parapharyngeal space. This approach was successfully executed, and the foreign body was removed completely and safely. Meticulous and gentle technique was employed to extract the lead foreign body in one piece. The tympanic defect was reconstructed using autologous grafting. This case underscores the benefits of a multidisciplinary team in managing skull base pathologies, the unpredictable nature of traumatically introduced foreign bodies in the skull base, and an atypical method of accessing the parapharyngeal space. While transoral or transcervical approaches are technically feasible, a postauricular transtympanic approach provided safe access with significantly reduced morbidity in a 10-month-old child. Skull base teams should consider all potential access routes when managing unusual pathologies. Publication History Article published online: 27 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany