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Highlights • The literature scarcely describes high anterior neck approaches to deep intra-glossal foreign bodies, tending to focus on transoral removal. • This case describes an approach that is utilised in insertion of bilateral hypoglossal nerve stimulators. • The approach includes midline transcervical incision, and exposure and midline separation of mylohyoid and geniohyoid muscles to expose genioglossi muscles. • This approach carries low morbidity compared to transoral approaches despite traditional dogma mandating avoidance of open neck approaches., Introduction and importance In the era of both new bilateral hypoglossal nerve stimulator and long-standing experience with Sistrunk’s procedures, it is notable that the literature scarcely describes high anterior neck approaches, tending to focus on transoral removal of intra-glossal foreign bodies. Herein we describe a case of a low morbidity anterior approach for access to an intra-glossal foreign body and discuss the implications. Case presentation A morbidly obese 73 year old lady presented acutely after inadvertent ingestion of a sewing needle. Initial assessment demonstrated an intraglossal foreign body which subsequently migrated into the deep substance of the tongue. Endoscopic retrieval was attempted but was unsuccessful. A midline transcervical anterior neck incision was made, exposure and midline separation of mylohyoid, and midline dissection of geniohyoid muscles was performed to expose genioglossi muscles and the foreign body removed. The patient recovered well without complication. Clinical discussion This approach carries low morbidity compared to transoral approaches despite traditional dogma mandating avoidance of open neck approaches. Such approaches have recently been developed for implantation of bilateral hypoglossal nerve stimulators. Conclusion Otolaryngologists should consider midline transcervical approach to retrieve deep intra-glossal foreign bodies, particularly in scenarios where other options may not provide adequate access or may enhance intra-oral morbidity.