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An unusual presentation of fish bone ingestion in an adolescent girl – A case report
Egyptian Journal of Ear, Nose, Throat and Allied Sciences (2016) 17, 95–97
H O S T E D BY
Egyptian Society of Ear, Nose, Throat and Allied Sciences
Egyptian Journal of Ear, Nose, Throat and Allied Sciences www.ejentas.com
CASE REPORT
An unusual presentation of fish bone ingestion in an adolescent girl – A case report Santosh Kumar Swain a,*, Neha Singh b, Mahesh Chandra Sahu c a Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha ‘‘O” Anusandhan University, K8, Kalinganagar, Bhubaneswar 751003, Odisha, India b Department of Anaesthesiology, IMS and SUM Hospital, Siksha ‘‘O” Anusandhan University, K8, Kalinganagar, Bhubaneswar 751003, Odisha, India c Directorate of Medical Research, IMS and SUM Hospital, Siksha ‘‘O” Anusandhan University, K8, Kalinganagar, Bhubaneswar 751003, Odisha, India
Received 22 February 2016; accepted 25 April 2016 Available online 17 June 2016
KEYWORDS Fish bone; Retropharyngeal abscess; Foreign body
Abstract Fish bones are common foreign bodies encountered in the throat. Fish bones may migrate downward if they are not removed early. Rarely, they are embedded in the soft tissue causing retropharyngeal abscess (RPA) formation. RPA needs prompt diagnosis and early management which often requires surgical drainage to achieve optimum result. The diagnosis is based on clinical and radiological pictures. The management needs securing of the airway, surgical drainage and antibiotics. We report a case of ingested foreign body of fish bone presented with RPA after one month of ingestion in a 15 year old girl. Imaging confirmed the fish bone in the retropharyngeal space, which was removed by transoral approach. Ó 2016 Egyptian Society of Ear, Nose, Throat and Allied Sciences. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-ncnd/4.0/).
1. Introduction A deep neck space infection like retropharyngeal abscess (RPA) is a serious and occasionally creates a life-threatening situation as a result of the anatomical location and potential compromise to the upper airway.1 In children RPA is usually due to non-traumatic causes like suppuration of the retropharyngeal lymph nodes, which are draining from the nose, nasopharynx, paranasal sinuses and oropharynx. Traumatic * Corresponding author. Cell: +91 9556524887. E-mail address: [email protected] (S.K. Swain). Peer review under responsibility of Egyptian Society of Ear, Nose, Throat and Allied Sciences.
causes are due to fish bone injury and it’s lodgment in retropharyngeal space is an extremely rare incidence. Fish bones are often encountered as foreign body (FB) in the throat. Fish bones are commonly lodged at tonsils. However, occasionally they migrate downward and get lodged more distally. If it embedded in the soft tissue, sometimes leads to abscess formation. A fully embedded fish bone in the soft tissue of the aero-digestive tract is often difficult to detect and may be misdiagnosed. Rarely fish bone is seen in the retropharyngeal space. Sometimes this FB can cause life threatening manifestations but interestingly can remain embedded in the tissue without any clinical manifestations for months or years.2 Early diagnosis helps to start immediate therapeutic management which helps for optimal patient survival. We report a
http://dx.doi.org/10.1016/j.ejenta.2016.04.003 2090-0740 Ó 2016 Egyptian Society of Ear, Nose, Throat and Allied Sciences. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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case of RPA following ingestion of the fish bone which was detected after a symptom free period of one month. 2. Case report A 15 year old girl attended the Out Patient Department of Otorhinolaryngology with complaints of fever, throat pain and odynophagia since 5 days. She had a history of fish bone ingestion one month back followed by mild pain for which she had taken medication and mouth gargle from local doctor without detecting any FB from the pharynx. On examination, foul smelling, thick, straw colored secretion is seen in the oral cavity and oropharynx; with bulging of the posterior pharyngeal wall. Ear and nasal examinations were within normal limit. Vital signs were a blood pressure of 110/70 mmHg, a pulse rate of 92/minute, a respiratory rate of 24/minute and the temperature was 37.4 °C. X-ray of the soft tissue of the neck revealed widening of the pre-vertebral space with a radio-opaque FB (Fig. 1).The patient was resuscitated with intravenous fluid and broad spectrum antibiotics. She was planned for abscess drainage under general anesthesia. Intubation was little difficult but was achieved at the end with a 7 mm size endotracheal tube and a gauze pack placed around the endotracheal tube. A vertical incision was made over the bulging area on posterior pharyngeal wall with the help of 11 size surgical blade. Just below the mucosa of posterior pharyngeal wall, the FB was elicited, a fish bone was taken out with the help of microlaryngeal cup forceps (Fig. 2). Around 15 ml of pus was drained which was sent for culture and sensitivity. The patient was started with intravenous antibiotics, analgesics and anti-inflammatory agents. The culture report revealed a growth of mixed group of bacteria: Staphylococcus aureus, Klebsiella pneumonia and anaerobic streptococci. The patient was discharged on second post-operative day with a course of antibiotics as per culture and sensitivity reports.
Figure 1 X-ray of the soft tissue of the neck with a lateral view showing the presence of fish bone in the retropharyngeal space and also widening of prevertebral soft tissue.
Figure 2 Picture of fish bone after it’s removal from the retropharyngeal space.
3. Discussion Foreign body (FB) ingestion is a commonly encountered clinical problem among both children and adults. Common foreign bodies in children are coins but others like buttons, batteries, safety pins, marbles and bottle tops are also reported whereas among adults common foreign bodies are dentures, metallic wires or bones.3 Most commonly the ingested FB is lodged at palatine tonsils, base of tongue and upper third of the esophagus.4 FB ingestion may result in serious life threatening complications like pharyngoesophageal perforation, aortoesophageal fistula, carotid artery rupture and deep neck space infection.5 These complications may lead to a fatal end in the absence of a quick and proper intervention. Fish bone ingestion which leading to RPA is a rare incidence in clinical practice. The retropharyngeal space is present between the middle and deep layers of deep cervical fascia. It is located anteriorly to danger space and pre-vertebral space, laterally adjacent to carotid space, anteriorly adjacent to pharynx and esophagus, above to skull base and below to the upper mediastinum to T3 level.6 The infection in the retropharyngeal space can occur by different ways. Infections from the contagious area spread to the retropharyngeal space secondary to penetrating foreign bodies. It may occur through oropharyngeal infections via accidental lacerations which may occur following falling down over objects like toys, sticks, pencil or tooth brush into the mouth.7 The iatrogenic spread of infections may occur during instrumentation with a laryngoscope, endotracheal intubation, surgery, endoscopy, Ryle’s tube placement and dental injection procedures, which can cause inoculation of micro-organisms directly into the retropharyngeal space. In pediatric population, RPA almost always begins with a suppurative lymph node in the retropharyngeal space. When pus is confined to the necrotic lymph node, the illness may be dormant or indolent. If the patient is not treated, the pus will escape the lymph node capsule and enter freely into the retropharyngeal space which has no barrier from the skull base to mediastinum and the child becomes critically septic.8
Case of fish bone ingestion in adolescent girl The onset of clinical presentation of fish bone ingestion varies from days to months or years. Acute manifestations like neck swelling with toxic symptoms may occur, even after one day duration of ingestion. Sometimes FB may remain quiescent for years before ending with a complication and there is no correlation between mortality and duration of FB ingestion.2 Radiological localization is a must for decision regarding removal of foreign bodies. In X-ray, the grossly widened prevertebral soft tissue shadow is an indicator for the provisional diagnosis of RPA. CT and MRI imaging can define the potential neck spaces and extent of the retropharyngeal infection and monitoring the evolution of abscess formation. Submucosal and deep seated FB leading to cellulitis and abscess formation in the retropharyngeal area can be managed by an intraoral or external approach. The RPA with fish bone needs prompt diagnosis and early management which needs immediate surgical drainage along with fish bone removal to achieve the best outcome. Treatment of RPA needs rehydration, intravenous antibiotics and surgical drainage under general anesthesia with the help of an expert anesthetist.9 Securing adequate airways is a priority in patients with RPA with a compromised upper respiratory tract. The surgical approaches for RPA are transoral, transcervical, endoscopic transnasal or combined.10 The transoral route is usually advised for acute RPA those seen medially. The transoral approach provides a good result and avoids a neck incision with scar. However it is done under general anesthesia. Transcervical approach is carried out if RPA spreads to the parapharyngeal space or recurrence of abscess after transoral approach. Patients with only cellulitis at the retropharyngeal space are managed with parenteral antibiotics alone. However this type of patient should be closely observed for future development of an abscess. In rare cases, both transoral and external approaches are done. Cold RPA due to tubercular origin is drained by external trans-cervical approach for preventing dissemination of the infection into the gastrointestinal tract. The dreaded complications of RPA can be avoided by vigilance, careful evaluation and aggressive treatment. 4. Conclusion Fish bone is often encountered as a FB in upper digestive tract. This clinical situation is favorable when the diagnosis and its
97 removal are made in time. The occurrence of complications, particularly retropharyngeal abscess is an extremely rare one and burdened with a high morbidity and mortality. Early diagnosis and prompt treatment are essential for preventing catastrophic complications. Treating physicians should maintain a high index of suspicion when encountering the patient with odynophagia, unexplained neck pain or swelling and should perform detailed history taking of fish bone ingestion and performing the necessary investigations for avoiding the delay in treatment. References 1. Craig FW, Schunk JE. Retropharyngeal abscess in children: clinical presentation, utility of imaging and current management. Pediatrics. 2003;111:1394–1398. 2. Mohamad I, Tuan Habib SN. Fish bone migration presenting as a neck lump. Brunei Int Med J. 2007;7(1):41–44. 3. Shivakumar AM, Naik AS, Prashanth KB, Girish F, Hongal GF, Chaturvedy G. Foreign bodies in upper digestive tract. Indian J Otolaryngol Head Neck Surg. 2006;58(1):63–68. 4. Chung S, Forte V, Campisi P. A review of pediatric foreign body ingestion and management. Clin Pediatr Emerg Med. 2010;11:225–230. 5. Wang S, Liu J, Chen Y, Yang X, Xie D, Li S. Diagnosis and treatment of nine cases with carotid artery rupture due to hypopharyngeal and cervical esophageal foreign body ingestion. Eur Arch Otorhino Laryngol. 2013;270:1125–1130. 6. Gonzalez-Beicos A, Nunez D. Imaging of acute head and neck infections. Radiol Clin North Am. 2012;50:73–83. 7. Wahbeh G, Wyllie R, Kay M. Foreign body ingestion in infants and children: location, location, location. Clin Pediatr (Phila). 2002;41:633–640. 8. Kirse DJ, Roberson DW. Surgical management of retropharyngeal space infections in children. Laryngoscope. 2001;111:1413–1422. 9. Wong DKC, Brown C, Mills N, Spielmann P, Neeff M. To drain or not to drain-management of pediatric deep neck abscesses: a case control study. Int J Pediatr Otorhinolaryngol. 2012;76 (12):1810–1813. 10. Schuller PJ, Cohen M, Greve J, et al. Surgical management of retropharyngeal abscess. Acta Otolaryngol. 2009;129 (11):1274–1279.
H O S T E D BY
Egyptian Society of Ear, Nose, Throat and Allied Sciences
Egyptian Journal of Ear, Nose, Throat and Allied Sciences www.ejentas.com
CASE REPORT
An unusual presentation of fish bone ingestion in an adolescent girl – A case report Santosh Kumar Swain a,*, Neha Singh b, Mahesh Chandra Sahu c a Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha ‘‘O” Anusandhan University, K8, Kalinganagar, Bhubaneswar 751003, Odisha, India b Department of Anaesthesiology, IMS and SUM Hospital, Siksha ‘‘O” Anusandhan University, K8, Kalinganagar, Bhubaneswar 751003, Odisha, India c Directorate of Medical Research, IMS and SUM Hospital, Siksha ‘‘O” Anusandhan University, K8, Kalinganagar, Bhubaneswar 751003, Odisha, India
Received 22 February 2016; accepted 25 April 2016 Available online 17 June 2016
KEYWORDS Fish bone; Retropharyngeal abscess; Foreign body
Abstract Fish bones are common foreign bodies encountered in the throat. Fish bones may migrate downward if they are not removed early. Rarely, they are embedded in the soft tissue causing retropharyngeal abscess (RPA) formation. RPA needs prompt diagnosis and early management which often requires surgical drainage to achieve optimum result. The diagnosis is based on clinical and radiological pictures. The management needs securing of the airway, surgical drainage and antibiotics. We report a case of ingested foreign body of fish bone presented with RPA after one month of ingestion in a 15 year old girl. Imaging confirmed the fish bone in the retropharyngeal space, which was removed by transoral approach. Ó 2016 Egyptian Society of Ear, Nose, Throat and Allied Sciences. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-ncnd/4.0/).
1. Introduction A deep neck space infection like retropharyngeal abscess (RPA) is a serious and occasionally creates a life-threatening situation as a result of the anatomical location and potential compromise to the upper airway.1 In children RPA is usually due to non-traumatic causes like suppuration of the retropharyngeal lymph nodes, which are draining from the nose, nasopharynx, paranasal sinuses and oropharynx. Traumatic * Corresponding author. Cell: +91 9556524887. E-mail address: [email protected] (S.K. Swain). Peer review under responsibility of Egyptian Society of Ear, Nose, Throat and Allied Sciences.
causes are due to fish bone injury and it’s lodgment in retropharyngeal space is an extremely rare incidence. Fish bones are often encountered as foreign body (FB) in the throat. Fish bones are commonly lodged at tonsils. However, occasionally they migrate downward and get lodged more distally. If it embedded in the soft tissue, sometimes leads to abscess formation. A fully embedded fish bone in the soft tissue of the aero-digestive tract is often difficult to detect and may be misdiagnosed. Rarely fish bone is seen in the retropharyngeal space. Sometimes this FB can cause life threatening manifestations but interestingly can remain embedded in the tissue without any clinical manifestations for months or years.2 Early diagnosis helps to start immediate therapeutic management which helps for optimal patient survival. We report a
http://dx.doi.org/10.1016/j.ejenta.2016.04.003 2090-0740 Ó 2016 Egyptian Society of Ear, Nose, Throat and Allied Sciences. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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case of RPA following ingestion of the fish bone which was detected after a symptom free period of one month. 2. Case report A 15 year old girl attended the Out Patient Department of Otorhinolaryngology with complaints of fever, throat pain and odynophagia since 5 days. She had a history of fish bone ingestion one month back followed by mild pain for which she had taken medication and mouth gargle from local doctor without detecting any FB from the pharynx. On examination, foul smelling, thick, straw colored secretion is seen in the oral cavity and oropharynx; with bulging of the posterior pharyngeal wall. Ear and nasal examinations were within normal limit. Vital signs were a blood pressure of 110/70 mmHg, a pulse rate of 92/minute, a respiratory rate of 24/minute and the temperature was 37.4 °C. X-ray of the soft tissue of the neck revealed widening of the pre-vertebral space with a radio-opaque FB (Fig. 1).The patient was resuscitated with intravenous fluid and broad spectrum antibiotics. She was planned for abscess drainage under general anesthesia. Intubation was little difficult but was achieved at the end with a 7 mm size endotracheal tube and a gauze pack placed around the endotracheal tube. A vertical incision was made over the bulging area on posterior pharyngeal wall with the help of 11 size surgical blade. Just below the mucosa of posterior pharyngeal wall, the FB was elicited, a fish bone was taken out with the help of microlaryngeal cup forceps (Fig. 2). Around 15 ml of pus was drained which was sent for culture and sensitivity. The patient was started with intravenous antibiotics, analgesics and anti-inflammatory agents. The culture report revealed a growth of mixed group of bacteria: Staphylococcus aureus, Klebsiella pneumonia and anaerobic streptococci. The patient was discharged on second post-operative day with a course of antibiotics as per culture and sensitivity reports.
Figure 1 X-ray of the soft tissue of the neck with a lateral view showing the presence of fish bone in the retropharyngeal space and also widening of prevertebral soft tissue.
Figure 2 Picture of fish bone after it’s removal from the retropharyngeal space.
3. Discussion Foreign body (FB) ingestion is a commonly encountered clinical problem among both children and adults. Common foreign bodies in children are coins but others like buttons, batteries, safety pins, marbles and bottle tops are also reported whereas among adults common foreign bodies are dentures, metallic wires or bones.3 Most commonly the ingested FB is lodged at palatine tonsils, base of tongue and upper third of the esophagus.4 FB ingestion may result in serious life threatening complications like pharyngoesophageal perforation, aortoesophageal fistula, carotid artery rupture and deep neck space infection.5 These complications may lead to a fatal end in the absence of a quick and proper intervention. Fish bone ingestion which leading to RPA is a rare incidence in clinical practice. The retropharyngeal space is present between the middle and deep layers of deep cervical fascia. It is located anteriorly to danger space and pre-vertebral space, laterally adjacent to carotid space, anteriorly adjacent to pharynx and esophagus, above to skull base and below to the upper mediastinum to T3 level.6 The infection in the retropharyngeal space can occur by different ways. Infections from the contagious area spread to the retropharyngeal space secondary to penetrating foreign bodies. It may occur through oropharyngeal infections via accidental lacerations which may occur following falling down over objects like toys, sticks, pencil or tooth brush into the mouth.7 The iatrogenic spread of infections may occur during instrumentation with a laryngoscope, endotracheal intubation, surgery, endoscopy, Ryle’s tube placement and dental injection procedures, which can cause inoculation of micro-organisms directly into the retropharyngeal space. In pediatric population, RPA almost always begins with a suppurative lymph node in the retropharyngeal space. When pus is confined to the necrotic lymph node, the illness may be dormant or indolent. If the patient is not treated, the pus will escape the lymph node capsule and enter freely into the retropharyngeal space which has no barrier from the skull base to mediastinum and the child becomes critically septic.8
Case of fish bone ingestion in adolescent girl The onset of clinical presentation of fish bone ingestion varies from days to months or years. Acute manifestations like neck swelling with toxic symptoms may occur, even after one day duration of ingestion. Sometimes FB may remain quiescent for years before ending with a complication and there is no correlation between mortality and duration of FB ingestion.2 Radiological localization is a must for decision regarding removal of foreign bodies. In X-ray, the grossly widened prevertebral soft tissue shadow is an indicator for the provisional diagnosis of RPA. CT and MRI imaging can define the potential neck spaces and extent of the retropharyngeal infection and monitoring the evolution of abscess formation. Submucosal and deep seated FB leading to cellulitis and abscess formation in the retropharyngeal area can be managed by an intraoral or external approach. The RPA with fish bone needs prompt diagnosis and early management which needs immediate surgical drainage along with fish bone removal to achieve the best outcome. Treatment of RPA needs rehydration, intravenous antibiotics and surgical drainage under general anesthesia with the help of an expert anesthetist.9 Securing adequate airways is a priority in patients with RPA with a compromised upper respiratory tract. The surgical approaches for RPA are transoral, transcervical, endoscopic transnasal or combined.10 The transoral route is usually advised for acute RPA those seen medially. The transoral approach provides a good result and avoids a neck incision with scar. However it is done under general anesthesia. Transcervical approach is carried out if RPA spreads to the parapharyngeal space or recurrence of abscess after transoral approach. Patients with only cellulitis at the retropharyngeal space are managed with parenteral antibiotics alone. However this type of patient should be closely observed for future development of an abscess. In rare cases, both transoral and external approaches are done. Cold RPA due to tubercular origin is drained by external trans-cervical approach for preventing dissemination of the infection into the gastrointestinal tract. The dreaded complications of RPA can be avoided by vigilance, careful evaluation and aggressive treatment. 4. Conclusion Fish bone is often encountered as a FB in upper digestive tract. This clinical situation is favorable when the diagnosis and its
97 removal are made in time. The occurrence of complications, particularly retropharyngeal abscess is an extremely rare one and burdened with a high morbidity and mortality. Early diagnosis and prompt treatment are essential for preventing catastrophic complications. Treating physicians should maintain a high index of suspicion when encountering the patient with odynophagia, unexplained neck pain or swelling and should perform detailed history taking of fish bone ingestion and performing the necessary investigations for avoiding the delay in treatment. References 1. Craig FW, Schunk JE. Retropharyngeal abscess in children: clinical presentation, utility of imaging and current management. Pediatrics. 2003;111:1394–1398. 2. Mohamad I, Tuan Habib SN. Fish bone migration presenting as a neck lump. Brunei Int Med J. 2007;7(1):41–44. 3. Shivakumar AM, Naik AS, Prashanth KB, Girish F, Hongal GF, Chaturvedy G. Foreign bodies in upper digestive tract. Indian J Otolaryngol Head Neck Surg. 2006;58(1):63–68. 4. Chung S, Forte V, Campisi P. A review of pediatric foreign body ingestion and management. Clin Pediatr Emerg Med. 2010;11:225–230. 5. Wang S, Liu J, Chen Y, Yang X, Xie D, Li S. Diagnosis and treatment of nine cases with carotid artery rupture due to hypopharyngeal and cervical esophageal foreign body ingestion. Eur Arch Otorhino Laryngol. 2013;270:1125–1130. 6. Gonzalez-Beicos A, Nunez D. Imaging of acute head and neck infections. Radiol Clin North Am. 2012;50:73–83. 7. Wahbeh G, Wyllie R, Kay M. Foreign body ingestion in infants and children: location, location, location. Clin Pediatr (Phila). 2002;41:633–640. 8. Kirse DJ, Roberson DW. Surgical management of retropharyngeal space infections in children. Laryngoscope. 2001;111:1413–1422. 9. Wong DKC, Brown C, Mills N, Spielmann P, Neeff M. To drain or not to drain-management of pediatric deep neck abscesses: a case control study. Int J Pediatr Otorhinolaryngol. 2012;76 (12):1810–1813. 10. Schuller PJ, Cohen M, Greve J, et al. Surgical management of retropharyngeal abscess. Acta Otolaryngol. 2009;129 (11):1274–1279.