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Foreign body impaction of the vertebral canal
AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y –H EA D A N D N E CK ME D I CI NE AN D SUR G E RY 3 4 ( 2 0 13 ) 72 4–7 2 6
Available online at www.sciencedirect.com
ScienceDirect www.elsevier.com/locate/amjoto
Foreign body impaction of the vertebral canal☆ Yunwei Chen, BA a , Nipun Chhabra, MD b , Yi-Chun Carol Liu, MD c,⁎, James E. Arnold, MD c , Rod P. Rezaee, MD c a b c
Case Western Reserve University School of Medicine, Cleveland, OH, USA Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA Ear, Nose, and Throat Institute, Case Western Reserve University, University Hospitals Case Medical Center, Cleveland, OH, USA
ARTI CLE I NFO
A BS TRACT
Article history:
Foreign body impactions in the aerodigestive tract are common, but have the potential for
Received 2 May 2013
serious complications. A foreign body may disrupt the mucosal lining and migrate regionally thereby risking impingement or injury to critical neurovascular structures in the cervical region. It is important to recognize potential complications that may arise from luminal compromise. In such cases, expeditious surgical treatment is warranted. © 2013 Elsevier Inc. All rights reserved.
1.
Introduction
Aerodigestive tract foreign body ingestion in the pediatric population is commonly seen in otolaryngology. Given the close proximity of important anatomic structures, there is potential for serious morbidity or even mortality. Complications stemming from luminal perforation include infection, vascular, or neurologic injury. We present a case of hypopharyngeal foreign body impaction extending to the vertebral canal that highlights the hazardous nature of these cases and the necessity for urgent surgical intervention.
2.
Case report
An otherwise healthy 13-year-old male presented to the emergency department with a one-day history of cervical pain, dysphagia, and blood tinged sputum. The patient admitted to having swallowed a large sewing needle while playing approximately five days prior to presentation. Plain cervical radiographs revealed a linear metallic foreign body in the proximal pharynx. A cervical stabilizing collar was placed and the patient was subsequently transferred to our tertiary institution for further management.
The patient was stable upon arrival without respiratory symptoms or neurologic sequelae. Empiric intravenous broadspectrum antibiotics were commenced and a contrasted computed tomography angiogram (CTA) demonstrated a radiopaque foreign body lodged in the proximity of the right piriform sinus and positioned over the C4 vertebrae [Fig. 1]. The object extended beyond the retropharyngeal space into the transverse foramina immediately adjacent to the left vertebral artery [Figs. 2A, B]. No evidence of vascular injury was found. The decision was made to urgently proceed with surgical exploration. Following general mask anesthesia, direct laryngoscopy revealed the round head of a pin obliquely entering the right posterior pharyngeal wall. An endotracheal tube was placed and secured under direct visualization. Suspension laryngoscopy was performed and the shaft of the pin was engaged and meticulously extracted using cup forceps [Fig. 3]. Following removal, examination revealed the punctate entry point, but no evidence of significant mucosal disruption, infection, or hematoma. Normal carotid artery pulsations were also appreciated. The patient was monitored in the intensive care unit and post-operative cervical magnetic resonance angiography (MRA) was performed with no evidence of subintimal abnormalities or stenosis of the vertebral arteries. His
☆
The authors have no funding, financial relationships, or conflicts of interest to disclose. ⁎ Corresponding author. Ear, Nose, and Throat Institute, Department of Otolaryngology-Head and Neck Surgery, 11100 Euclid Avenue, Cleveland, OH 44106, USA. E-mail address: [email protected] (Y.-C.C. Liu). 0196-0709/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjoto.2013.05.003
AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y –H EA D A N D N E CK ME D I CI N E AN D SUR G E RY 3 4 ( 2 0 13 ) 72 4–7 2 6
725
Fig. 3 – Surgical extraction yielded a large sewing pin.
Fig. 1 – CTA demonstrating radiopaque foreign body positioned over the C4 vertebrae.
symptoms rapidly improved over the following 24 hours and his diet was slowly advanced. Flexible fiberoptic laryngoscopy showed no evidence of bleeding, edema, or significant mucosal trauma of the hypopharynx. He was subsequently discharged with continued oral antibiotics and maintained an uneventful follow-up and recovery.
3.
Discussion
Over 100,000 cases of foreign body ingestion are reported annually by the American Association of Poison Control, accounting for approximately 4% of exposures [1]. Aerodigestive foreign body impaction most commonly involves the esophagus, and specifically the cricopharyngeal or cervical portions are the primary sites in the pediatric population [2].
Fig. 2 – (A) Sagittal three-dimensional reconstruction of CTA with foreign body positioned medial to the carotid artery. (B) The foreign body is impacted within the vertebral canal, directly adjacent to the vertebral artery.
Frequent objects include fish and chicken bones, dentures, coins, and needles [3]. Of these, coins are most the common pediatric esophageal foreign body, representing 76% of cases in patients under and 53% over the age of five, respectively [4]. Fortunately, the majority of small, blunt objects pass through the gastrointestinal tract spontaneously. Complications are related to the foreign body’s shape, size, and location, with larger and more serrated objects causing the most severe damage. Sustained hypopharyngeal and esophageal impactions may result in viscous perforation with subsequent migration, vascular compromise, or infection. The migration of a foreign object is dependent on its shape and orientation. In a case series of 24 patients, objects oriented in the horizontal plane had the greatest likelihood of extraluminal migration [5]. Additionally, passage through adjacent tissue planes is facilitated by coughing, swallowing, and esophageal peristalsis [6]. Vascular complications include penetration or injury to the vertebral, facial, or carotid arteries. Infection may present as mild localized inflammation or cellulitis or in severe cases, thyroid, epidural, and mediastinal abscesses may occur. Acute mediastinitis was seen in 3% of nearly 3,000 patients with aerodigestive tract foreign body impaction over a 40-year time period, with a mortality rate of 30% [7]. Prolonged impaction coupled with a delay in diagnosis and time to extraction is associated with a significantly higher complication rate. Prophylactic antibiotics are supported in the literature to reduce postoperative infections, especially in cases of luminal compromise or mucosal disruption [7]. Odynophagia is by far the most common presenting symptom of foreign body impaction, though patients may also present with dysphagia, dsyphonia, dyspnea, and excessive salivation [8]. The pediatric population demands a higher level of clinical suspicion as findings may be more subtle, including refusal of oral intake, or symptoms consistent with a mild upper respiratory infection. Fever, chills, cervical tenderness, swelling, or crepitus are indications for urgent management. In the majority of cases, aerodigestive foreign body ingestion and impaction is a clinical diagnosis. Indirect
726
AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y –H EA D A N D N E CK ME D I CI NE AN D SUR G E RY 3 4 ( 2 0 13 ) 72 4–7 2 6
laryngeal mirror exam or fiberoptic laryngoscopy is commonly employed. In more complicated cases where luminal integrity is uncertain or direct visualization is limited, radiographic imaging is useful. Plain radiographs are the first line modality, though CT imaging is more definitive with a sensitivity approaching 95% for foreign body detection [9]. CTA or MRA should be considered based on history and whether vascular compromise is suspected. Radiographic imaging for the workup of aerodigestive foreign bodies is controversial in the literature. Clinical judgment should take precedence as a delay in diagnosis and treatment may impact outcomes. Radiographic imaging should therefore be decided on a case-by-case basis. In our patient, the plain film findings, type of object, and proximity to the vertebral canal necessitated angiography prior to surgical intervention. Rigid laryngoscopy and endoscopy offer optimal visualization for surgical treatment, but care must be taken as manipulation of the neck and airway may shift objects extraluminally and preclude endoscopic removal. In a study of 105 patients, 98% of esophageal foreign bodies were removed endoscopically, though lacerations and perforations occurred in nearly 7% and 1% of cases, respectively [10]. Anesthetic induction should be carefully monitored as impacted objects may migrate during endotracheal tube placement [11]. Open surgical retrieval may be warranted in cases of endoscopic failure, infectious complications such as abscess or mediastinitis, or vascular compromise.
4.
Conclusion
Aerodigestive foreign body impactions are a common occurrence. Although the majority of objects are benign and easily removed, the potential for mortality or severe morbidity exists. In complex cases, the close proximity to critical
anatomic structures mandates a judicious workup with skilled and expeditious surgical treatment.
REFERENCES
[1] Bronstein AC, Spyker DA, Cantilena Jr LR, et al. 2010 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 28th Annual Report. Clin Toxicol (Phila) 2011;49:910–41. [2] Louie JP, Alpern ER, Windreich RM. Witnessed and unwitnessed esophageal foreign bodies in children. Pediatr Emerg Care 2005;21:582–5. [3] Nandi P, Ong GB. Foreign body in the oesophagus: review of 2394 cases. Br J Surg 1978;65:5–9. [4] Lemberg PS, Darrow DH, Holinger LD. Aerodigestive tract foreign bodies in the older child and adolescent. Ann Otol Rhinol Laryngol 1996;105:267–71. [5] Chee LW, Sethi DS. Diagnostic and therapeutic approach to migrating foreign bodies. Ann Otol Rhinol Laryngol 1999;108: 177–80. [6] Cheng YC, Lee WC, Kuo LC, et al. Protrusion of a migrated fish bone in the neck. Am J Otolaryngol 2009;30:203–5. [7] Liu J, Zhang X, Xie D, et al. Acute mediastinitis associated with foreign body erosion from the hypopharynx and esophagus. Otolaryngol Head Neck Surg 2012;146:58–62. [8] Hajiioannou J, Kousoulis P, Florou V, et al. Iatrogenic migration of an impacted pharyngeal foreign body of the hypopharynx to the prevertebral space. Int J Otolaryngol 2011;2011:274102. [9] Eliashar R, Dano I, Dangoor E, et al. Computed tomography diagnosis of esophageal bone impaction: a prospective study. Ann Otol Rhinol Laryngol 1999;108:708–10. [10] Chaves DM, Ishioka S, Felix VN, et al. Removal of a foreign body from the upper gastrointestinal tract with a flexible endoscope: a prospective study. Endoscopy 2004;36:887–92. [11] Wax MK. Endobronchial placement of a safety pin during intubation. Otolaryngol Head Neck Surg 2000;123:742–3.
Available online at www.sciencedirect.com
ScienceDirect www.elsevier.com/locate/amjoto
Foreign body impaction of the vertebral canal☆ Yunwei Chen, BA a , Nipun Chhabra, MD b , Yi-Chun Carol Liu, MD c,⁎, James E. Arnold, MD c , Rod P. Rezaee, MD c a b c
Case Western Reserve University School of Medicine, Cleveland, OH, USA Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA Ear, Nose, and Throat Institute, Case Western Reserve University, University Hospitals Case Medical Center, Cleveland, OH, USA
ARTI CLE I NFO
A BS TRACT
Article history:
Foreign body impactions in the aerodigestive tract are common, but have the potential for
Received 2 May 2013
serious complications. A foreign body may disrupt the mucosal lining and migrate regionally thereby risking impingement or injury to critical neurovascular structures in the cervical region. It is important to recognize potential complications that may arise from luminal compromise. In such cases, expeditious surgical treatment is warranted. © 2013 Elsevier Inc. All rights reserved.
1.
Introduction
Aerodigestive tract foreign body ingestion in the pediatric population is commonly seen in otolaryngology. Given the close proximity of important anatomic structures, there is potential for serious morbidity or even mortality. Complications stemming from luminal perforation include infection, vascular, or neurologic injury. We present a case of hypopharyngeal foreign body impaction extending to the vertebral canal that highlights the hazardous nature of these cases and the necessity for urgent surgical intervention.
2.
Case report
An otherwise healthy 13-year-old male presented to the emergency department with a one-day history of cervical pain, dysphagia, and blood tinged sputum. The patient admitted to having swallowed a large sewing needle while playing approximately five days prior to presentation. Plain cervical radiographs revealed a linear metallic foreign body in the proximal pharynx. A cervical stabilizing collar was placed and the patient was subsequently transferred to our tertiary institution for further management.
The patient was stable upon arrival without respiratory symptoms or neurologic sequelae. Empiric intravenous broadspectrum antibiotics were commenced and a contrasted computed tomography angiogram (CTA) demonstrated a radiopaque foreign body lodged in the proximity of the right piriform sinus and positioned over the C4 vertebrae [Fig. 1]. The object extended beyond the retropharyngeal space into the transverse foramina immediately adjacent to the left vertebral artery [Figs. 2A, B]. No evidence of vascular injury was found. The decision was made to urgently proceed with surgical exploration. Following general mask anesthesia, direct laryngoscopy revealed the round head of a pin obliquely entering the right posterior pharyngeal wall. An endotracheal tube was placed and secured under direct visualization. Suspension laryngoscopy was performed and the shaft of the pin was engaged and meticulously extracted using cup forceps [Fig. 3]. Following removal, examination revealed the punctate entry point, but no evidence of significant mucosal disruption, infection, or hematoma. Normal carotid artery pulsations were also appreciated. The patient was monitored in the intensive care unit and post-operative cervical magnetic resonance angiography (MRA) was performed with no evidence of subintimal abnormalities or stenosis of the vertebral arteries. His
☆
The authors have no funding, financial relationships, or conflicts of interest to disclose. ⁎ Corresponding author. Ear, Nose, and Throat Institute, Department of Otolaryngology-Head and Neck Surgery, 11100 Euclid Avenue, Cleveland, OH 44106, USA. E-mail address: [email protected] (Y.-C.C. Liu). 0196-0709/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjoto.2013.05.003
AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y –H EA D A N D N E CK ME D I CI N E AN D SUR G E RY 3 4 ( 2 0 13 ) 72 4–7 2 6
725
Fig. 3 – Surgical extraction yielded a large sewing pin.
Fig. 1 – CTA demonstrating radiopaque foreign body positioned over the C4 vertebrae.
symptoms rapidly improved over the following 24 hours and his diet was slowly advanced. Flexible fiberoptic laryngoscopy showed no evidence of bleeding, edema, or significant mucosal trauma of the hypopharynx. He was subsequently discharged with continued oral antibiotics and maintained an uneventful follow-up and recovery.
3.
Discussion
Over 100,000 cases of foreign body ingestion are reported annually by the American Association of Poison Control, accounting for approximately 4% of exposures [1]. Aerodigestive foreign body impaction most commonly involves the esophagus, and specifically the cricopharyngeal or cervical portions are the primary sites in the pediatric population [2].
Fig. 2 – (A) Sagittal three-dimensional reconstruction of CTA with foreign body positioned medial to the carotid artery. (B) The foreign body is impacted within the vertebral canal, directly adjacent to the vertebral artery.
Frequent objects include fish and chicken bones, dentures, coins, and needles [3]. Of these, coins are most the common pediatric esophageal foreign body, representing 76% of cases in patients under and 53% over the age of five, respectively [4]. Fortunately, the majority of small, blunt objects pass through the gastrointestinal tract spontaneously. Complications are related to the foreign body’s shape, size, and location, with larger and more serrated objects causing the most severe damage. Sustained hypopharyngeal and esophageal impactions may result in viscous perforation with subsequent migration, vascular compromise, or infection. The migration of a foreign object is dependent on its shape and orientation. In a case series of 24 patients, objects oriented in the horizontal plane had the greatest likelihood of extraluminal migration [5]. Additionally, passage through adjacent tissue planes is facilitated by coughing, swallowing, and esophageal peristalsis [6]. Vascular complications include penetration or injury to the vertebral, facial, or carotid arteries. Infection may present as mild localized inflammation or cellulitis or in severe cases, thyroid, epidural, and mediastinal abscesses may occur. Acute mediastinitis was seen in 3% of nearly 3,000 patients with aerodigestive tract foreign body impaction over a 40-year time period, with a mortality rate of 30% [7]. Prolonged impaction coupled with a delay in diagnosis and time to extraction is associated with a significantly higher complication rate. Prophylactic antibiotics are supported in the literature to reduce postoperative infections, especially in cases of luminal compromise or mucosal disruption [7]. Odynophagia is by far the most common presenting symptom of foreign body impaction, though patients may also present with dysphagia, dsyphonia, dyspnea, and excessive salivation [8]. The pediatric population demands a higher level of clinical suspicion as findings may be more subtle, including refusal of oral intake, or symptoms consistent with a mild upper respiratory infection. Fever, chills, cervical tenderness, swelling, or crepitus are indications for urgent management. In the majority of cases, aerodigestive foreign body ingestion and impaction is a clinical diagnosis. Indirect
726
AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y –H EA D A N D N E CK ME D I CI NE AN D SUR G E RY 3 4 ( 2 0 13 ) 72 4–7 2 6
laryngeal mirror exam or fiberoptic laryngoscopy is commonly employed. In more complicated cases where luminal integrity is uncertain or direct visualization is limited, radiographic imaging is useful. Plain radiographs are the first line modality, though CT imaging is more definitive with a sensitivity approaching 95% for foreign body detection [9]. CTA or MRA should be considered based on history and whether vascular compromise is suspected. Radiographic imaging for the workup of aerodigestive foreign bodies is controversial in the literature. Clinical judgment should take precedence as a delay in diagnosis and treatment may impact outcomes. Radiographic imaging should therefore be decided on a case-by-case basis. In our patient, the plain film findings, type of object, and proximity to the vertebral canal necessitated angiography prior to surgical intervention. Rigid laryngoscopy and endoscopy offer optimal visualization for surgical treatment, but care must be taken as manipulation of the neck and airway may shift objects extraluminally and preclude endoscopic removal. In a study of 105 patients, 98% of esophageal foreign bodies were removed endoscopically, though lacerations and perforations occurred in nearly 7% and 1% of cases, respectively [10]. Anesthetic induction should be carefully monitored as impacted objects may migrate during endotracheal tube placement [11]. Open surgical retrieval may be warranted in cases of endoscopic failure, infectious complications such as abscess or mediastinitis, or vascular compromise.
4.
Conclusion
Aerodigestive foreign body impactions are a common occurrence. Although the majority of objects are benign and easily removed, the potential for mortality or severe morbidity exists. In complex cases, the close proximity to critical
anatomic structures mandates a judicious workup with skilled and expeditious surgical treatment.
REFERENCES
[1] Bronstein AC, Spyker DA, Cantilena Jr LR, et al. 2010 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 28th Annual Report. Clin Toxicol (Phila) 2011;49:910–41. [2] Louie JP, Alpern ER, Windreich RM. Witnessed and unwitnessed esophageal foreign bodies in children. Pediatr Emerg Care 2005;21:582–5. [3] Nandi P, Ong GB. Foreign body in the oesophagus: review of 2394 cases. Br J Surg 1978;65:5–9. [4] Lemberg PS, Darrow DH, Holinger LD. Aerodigestive tract foreign bodies in the older child and adolescent. Ann Otol Rhinol Laryngol 1996;105:267–71. [5] Chee LW, Sethi DS. Diagnostic and therapeutic approach to migrating foreign bodies. Ann Otol Rhinol Laryngol 1999;108: 177–80. [6] Cheng YC, Lee WC, Kuo LC, et al. Protrusion of a migrated fish bone in the neck. Am J Otolaryngol 2009;30:203–5. [7] Liu J, Zhang X, Xie D, et al. Acute mediastinitis associated with foreign body erosion from the hypopharynx and esophagus. Otolaryngol Head Neck Surg 2012;146:58–62. [8] Hajiioannou J, Kousoulis P, Florou V, et al. Iatrogenic migration of an impacted pharyngeal foreign body of the hypopharynx to the prevertebral space. Int J Otolaryngol 2011;2011:274102. [9] Eliashar R, Dano I, Dangoor E, et al. Computed tomography diagnosis of esophageal bone impaction: a prospective study. Ann Otol Rhinol Laryngol 1999;108:708–10. [10] Chaves DM, Ishioka S, Felix VN, et al. Removal of a foreign body from the upper gastrointestinal tract with a flexible endoscope: a prospective study. Endoscopy 2004;36:887–92. [11] Wax MK. Endobronchial placement of a safety pin during intubation. Otolaryngol Head Neck Surg 2000;123:742–3.