Abstract
Esophageal impaction of fish bone caused by accidental swallowing in adults is a challenging emergency by itself. When the fish bone is impacted horizontally at the level of thoracic esophagus it becomes not only more challenging but also a rare clinical entity. We experienced such a case in an adult male patient who had impaction of fish bone at the level of thoracic esophagus after unintentional ingestion of fish bone. The patient came to our emergency department with difficulty in swallowing and breathing especially while sitting upright associated with severe chest discomfort. A review of history revealed that he consumed a sardine 2 hours ago and since then he has been experiencing these symptoms. A plain x-ray of soft tissue neck revealed suspicion of fish bone and Computed tomography (CT) of neck confirmed an impacted linear structure with high bone density extending from the left lateral wall to right lateral wall of thoracic esophagus in close proximity to thyroid gland. Patient underwent emergency surgery with rigid esophagoscopy for extraction of fish bone under general anesthesia. This patient, had a narrow escape from lethal complications like injury of thyroid gland, pericardium and carotid artery, which are likely to happen when a fish bone is tightly stuck with both ends on esophageal mucosa which is very close to vital structures in the mediastinum. The patient was admitted for observation after the surgery, and was on antibiotics along with other symptomatic measures as a precautionary method. The patient recovered without any complications and was subsequently discharged.
Case report
A 49 – year old male presented to the emergency department with complaints of difficulty in swallowing and chest discomfort which persisted for 2 hours. He mentioned that while eating a sardine, he accidentally ingested the fish bone, after which he started experiencing some discomfort similar to that of a fish bone being stuck in his throat. Clinical examination,revealed body temperature of 36.8c, heart rate of 98 bpm, respiratory rate of 24 bpm, and blood pressure of 116/75 mm Hg. Laboratory results were unremarkable. Indirect laryngeal examination showed pooling of saliva. Laryngeal fiberoptic examination was unable to detect a fish bone in the larynx or pharynx. A plain x-ray soft tissue neck revealed suspicion of fish bone ( Fig. 1 ) and Computed tomography (CT) of neck ( Fig. 2 a & b) confirmed an impacted linear structure with high bone density extending from the left lateral wall to right lateral wall of thoracic esophagus very close to thyroid gland. As the chest discomfort and dysphagia deteriorated and the patient was in severe distress, it was decided to extract the fishbone under general anesthesia through the endotracheal intubation. At first, a Karl-Storz Rigid esophagoscope(Total length 30 cm, Inner diameter size 11 × 12 mm and outer diameter size 12 × 16 mm) was introduced to extract the fish bone. In the first attempt, a rigid alligator forceps (25 cm working length and 1.5 mm sheath diameter) was used to grasp the fishbone but it couldn’t be extracted because both ends of the fishbone was tightly stuck in the esophageal mucosa. The modus operandi had to be altered from the norm so as not to damage the mucosa. In the second attempt, a countertraction was first applied to the mucosa with another pair of rigid alligator forceps, and then the operating surgeon pulled at one end of the fish bone and moved it slowly away from the mucosa with utmost caution so as not to cause any damage to the mucosa during the extraction procedure . This technique was possible only because of the expanded lumen of rigid esophagoscope as it could prevent direct contact between a sharp object and the mucosa, allowing objects to be removed with ease thereby preventing any damage to the mucosa. This type of procedure is analogous with the concept of the “four hands technique” employed in various endoscopic surgeries. In the present case, we decided not to close the esophagus as the perforation was small. The fish bone extracted was T-shaped and around 2 cm in length ( Fig. 3 ). A fishbone this big and horizontally stuck in the thoracic esophagus was a rare clinical entity and thus the removal was even more challenging for the otolaryngologist. This case however, cautions us that it is always necessary to take precautionary measures in advance for potential complications, such as bleeding due to lacerations and further perforations.
