Abstract
A 68 year-old female was referred to our department with a history of swallowing a fish bone, she reported continuous pain when swallowing. The bone was not evident on endoscopic examination; however, on CT scans a foreign body was identified in the upper esophagus. The bone was buried in the mucosa of the upper esophagus and an emergent rigid esophagoscopy was performed under general anesthesia in order to remove it. The fish bone was successfully removed with the use of intraoperative cervical ultrasonography.
1
Introduction
Fish bones are the most common foreign bodies found in the upper aerodigestive tract in adults, composing up to 71% of foreign-body presentations . The most common sites of impaction are the lower pole of the tonsil, base of the tongue, vallecula, and cervical esophagus . In most patients, these foreign bodies are identified on inspection or endoscopic observation; few patients present with submucosal pharyngeal foreign bodies. Computerized tomography is considered the gold standard for detection of submucosal foreign bodies because of the ability to localize an object in multiple planes and the creation of a 3-dimensional image. Difficulty arises when looking for a small object in the submucosal pharynx or esophagus. Intraoperative feedback or guidance, especially when navigating through troublesome locations, can be extremely useful. Although exploration for buried submucosal foreign bodies is a difficult procedure, there are few studies reporting the use of intraoperative ultrasonography in the head and neck region to assist in this procedure . We report a case in which intraoperative ultrasound imaging was used and present this paper as a guide for the surgical retrieval of foreign bodies.
This study was approved by the Institutional Review Board of Japanese Red Cross Medical Center.
2
Case report
A 68-year-old female was referred to our department with a history of swallowing a fish bone. She had swallowed a bolus of rice many times after swallowing the fish bone and experienced continuous swallowing pain. No foreign bodies were observed on an endoscopic examination; however, a foreign body was identified on CT scans at the hypopharynx to upper esophagus ( Fig. 1 ).
An emergent rigid esophagoscopy was performed under general anesthesia. Despite a thorough search, the fish bone could not be found. As such, we proceeded to perform an intraoperative cervical ultrasound-guided fish bone retrieval. A high-frequency linear transducer was used from a cervical approach to localize the fish bone and give real-time guidance during the operation. It provided an accurate distance in centimeters of the foreign body from the forceps in the esophagus ( Fig. 2 ). The fish bone was successfully located in the submucosa of the upper esophagus and then removed with a mucosal incision without any complications ( Fig. 3 ). The bone was 24 mm long ( Fig. 4 ).
