Abstract
This is a 58 year old male who presented to our institution with foreign body sensation after eating fish the night before. Although lateral soft tissue films of the neck demonstrated a linear foreign body, this was missed and the patient was discharged home. One week later, he re-presented with persistent throat pain. A computed tomography scan of the neck demonstrated erosion of the foreign body through the esophageal wall and a rim enhancing collection in the right thyroid lobe. The patient was admitted and broad spectrum antibiotics were started. Using a transoral endoscopic approach the abscess was drained and a 2.0 cm sharp fishbone was successfully removed from a perforation at the esophageal inlet. A nasogastric tube was placed and the patient was kept NPO for 14 days postoperatively while his perforation healed. He had improvement in his symptoms and was stable in follow up.
1
Introduction
Foreign bodies of the upper aerodigestive tract can have significant consequences and migrate to atypical locations if missed on initial presentation. We present a case of transoralendoscopic removal of a retained foreign body to demonstrate this method as a viable option for such cases.
2
Case report
A 58-year-old man with a history of type II diabetes presented to the emergency department with a foreign body sensation in his throat after eating fish the night before. A soft tissue film of the neck demonstrated the foreign body, however this was initially missed. The patient was discharged home with instructions to return is his symptoms did not resolve.
One week later, the patient returned to the emergency department due to persistent throat pain. He noted an episode of choking that awoke him from sleep the night before. He was afebrile and denied fevers. The emergency department obtained repeat soft tissue films, which showed the object ( Fig. 1 ). Otolaryngology was consulted for evaluation. On exam, he was tender to palpation over the right thyroid lobe. Fiberoptic laryngoscopy showed mild pooling of saliva at the esophageal inlet, but no foreign body was visualized. A computed tomography (CT) scan of the neck was obtained, which demonstrated a linear foreign body in the esophagus with erosion through the esophageal wall anteriorly. The tip of the object lied within the stroma of the right thyroid lobe with a surrounding 1.5-cm rim-enhancing collection ( Fig. 2 ).
The patient was admitted to the otolaryngology service and broad-spectrum antibiotics were started. Cardiothoracic surgery was consulted for evaluation of the esophageal perforation. Due to the location of the foreign body and the abscess in the neck, both endoscopic and external approaches were considered. However, due to the location of the abscess an external approach would involve a hemi-thyroidectomy and potential injury of the recurrent laryngeal nerve. Due to this risk, the patient was taken to the operating room for endoscopic removal.
Using the direct laryngoscope and multiple endoscopic instruments, the perforation was discovered anteriorly at the level of the cricopharyngeus muscle. When probed with an optical forceps, purulent fluid returned ( Fig. 3 ). The perforation was further explored and a free edge of the foreign body coming out of the thyroid was visualized ( Fig. 4 ). An optical forceps and suction were used to stent the perforation open while another pair of optical forceps was used to extract a 2.0-cm fishbone ( Fig. 5 ). A nasogastric tube was placed and the patient was extubated.
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