Abstract
Most migrated foreign bodies in the neck were removed immediately in patients with persistent symptoms. It is a rare condition that a fish bone was buried for a prolonged time in the tongue with little discomfort. We report a unique case of an ingested fish bone lodged in the tongue for 16 months until infection ensued. Ludwig angina was considered first because the patient had fever, odynophagia, swelling of the tongue, and mouth floor. The fish bone buried in the tongue was incidentally found on the computed tomography scan and successfully removed by surgical exploration. Although dental infection is the most common underlying cause in Ludwig angina, embedded foreign body should be considered as one of the pathogenesis. On the other hand, computed tomography scan can be useful in identifying extraluminal migration of fish bones in the neck.
1
Case report
A 66-year-old woman visited our otolaryngologic department because of progressive swelling of the tongue, odynophagia, and fever for about 1 week. The physical examination showed swelling of the tongue and mouth floor, and her medical history was unremarkable. The blood examination showed increased white blood cell count level. Ludwig angina was considered first, and intravenous antibiotics were administrated. We considered surgical intervention first, but the preoperatively computed tomography (CT) scan of the neck showed one 18-mm-long foreign body in the sublingual space with abscess formation ( Fig. 1 ). The foreign body was suspected to be a fish bone because of its linear shape. The patient then recalled that she had the sensation of a foreign body being stuck in her throat after accidentally swallowing a fish bone from a mullet 16 months previously. She had visited an otolarygologist, but no fish bone was found after thorough examination, including flexible fiberoptic pharyngolaryngoscopy. Meanwhile, the sensation of the foreign body and the pain gradually disappeared and the patient had not had any symptoms until this event occurred.
Under the impression of a buried fish bone complicating as Ludwig angina, an emergent operation was performed under general anesthesia. We made a horizontal incision in the floor of the mouth because of the shorter distance to the fish bone. However, the thin buried fish bone was very difficult to identify from the surrounding inflamed muscle. We even used portable plain radiography to locate the fish bone but failed. Finally, we dislodged it ( Fig. 2 ) from the deep of tongue according its location showed on the CT scan. The pathologic report of the tissue around the fish bone showed acute and chronic inflammatory cell infiltration and focal granulation tissue formation. The postoperative course was uneventful. The patient was prescribed empiric antibiotics and the odynophagia disappeared. She was discharged 3 days after the operation.
2
Discussion
Foreign bodies in the upper aerodigestive tract are common problems in otolaryngologic emergencies, and fish bones are the most frequent found objects. Extraluminal migration of fish bone to adjacent structures such as the thyroid, carotid artery, subcutaneous neck, and cervical spine have been reported . The symptoms and signs may remain persistent or silent for a long time depending on the migration route. In Taiwan, there are many different ways to cook fish, but the most popular ways are to fry or steam a whole fish without removing the bones. The fish bones are picked out with chopsticks before eating or spat out thereafter. Consequently, lodged fish bones in the upper aerodigestive tract are commonly encountered in emergency rooms or otolaryngologic outpatient clinics in Taiwan.
Fish bones commonly lodge in the oral cavity, oropharynx, or hypopharynx and can be removed using forceps with or without local anesthesia. However, unusual conditions such as extraluminal migration of the fish bone to adjacent structures may occur. Chee and Sethi reported 24 migrated foreign bodies in the neck. All of the foreign bodies were sharp and linear, and 18 (75%) of these objects were removed within 24 hours. However, it is difficult to find the fish bone impacted in the surrounding tissue of the aerodigestive tract by physical examination and endoscopy alone. Plain radiography poorly visualizes fish bones in soft tissue, and visibility varies with fish species, location, and orientation . However, CT scans are useful when impacted fish bone is highly suspected by the physician and in identifying and locating the fish bone in selected patients with persistent symptoms. The surgical method to remove the migrated fish bone often depends on its location and relationship to the surrounding structures .
On the other hand, Ludwig angina is a diffuse inflammation of the submandibular and sublingual space. The possible pathogenesis includes dental infection, peritonsillar or parapharyngeal abscesses, oral lacerations, mandibular fractures, and submandibular sialoadenitis , whereas dental infection is the most common underlying cause . The main treatment of Ludwig angina consists of use of intravenous antibiotics and surgical drainage; the source of infection should be determined and eliminated . This case can demonstrate that an embedded foreign body should be included in the pathogenesis of Ludwig angina. If we just perform surgical drainage of the abscess but overlook the fish bone revealed on the CT scan or neglect the history of fish bone impaction, potential consequence includes that repeated deep neck infection or abscess formation may occur.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
