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Migration of a thermometer to the mediastinum
European Journal of Radiology Extra 62 (2007) 15–17
Migration of a thermometer to the mediastinum Evagelos Vryonis a , Eleni Mylona a,∗ , Panagiotis Fanourgiakis a , Styliani Golfinopoulou a , Ioannis Kalogeropoulos b , Athanasios Skoutelis a a
5th Department of Internal Medicine, Evagelismos Hospital, 45-47 Hipsilantou Street, Kolonaki, GR-106 76 Athens, Greece b Department of Radiology, Evagelismos Hospital, Athens, Greece Received 18 September 2006; received in revised form 15 January 2007; accepted 18 January 2007
Abstract We report the radiological findings of a thermometer having migrated to the posterior mediastinum after ingestion and perforation of the esophagus, in an asymptomatic patient. Asymptomatic migration of a foreign body in the mediastinum after ingestion is an extremely rare phenomenon. Management can be conservative or surgical. © 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Esophageal perforation; Mediastinum; Thermometer; Foreign body
1. Introduction Ingestion of foreign bodies is common, especially among the pediatric age group, whereas in adults occurs more commonly among those with psychiatric disorders or mental retardation, prisoners and alcoholics [1]. Impacted foreign bodies in the esophagus can easily cause mucosal ulceration, inflammation or can result in complications such as para- or retroesophageal abscess, mediastinitis, empyema, perforation or even aortoesophageal fistula [2]. 2. Case report A 37-year-old woman, drug-addict, appeared in hospital with cellulitis of the right hand. Among all the ordinary admission exams, the patient was subjected to chest Xray. Chest radiography identified a radiopaque foreign body, consistent with that of a thermometer, appearing to be in the thoracic esophagus. Neither pneumothorax, nor subcutaneous emphysema was evident (Figs. 1 and 2). Subsequent history revealed the ingestion of a thermometer several months before. The patient had no difficulty eating. ∗
Corresponding author. Tel.: +30 210 7201430; fax: +30 210 7216408. E-mail addresses: [email protected], [email protected] (E. Mylona). 1571-4675/$ – see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrex.2007.01.007
Flexible esophagoscopy showed that the foreign body was outside the esophageal lumen. There was no identification of the perforation site, stricture or diverticulum. A contrast shallow esophagogram revealed no evidence of fluid leakage and showed the thermometer to have perforated the esophagus. However, the thermometer had not just been walled off in either the mucosal or muscular layer of the organ, but it had in fact, perforated the esophagus [2]. Evidently, the thermometer had come into contact with the posterior wall of the esophagus (Fig. 3). Moreover, a subsequent computed tomography scan with contrast confirmed the existence of the foreign body in the posterior mediastinum, without mediastinal air or fluid (Fig. 4). Due to the potential rupture and the mediastinitis it could be caused by mercury, we suggested the surgical removal of the thermometer. However, the patient refused any surgical procedure and left the hospital on her own responsibility. 3. Discussion The ingestion of foreign bodies is a common occurrence that usually follows a benign course, while impacted foreign bodies may cause severe complications [3]. Our case is the first to report perforation of the esophagus by a thermometer in an asymptomatic patient. Sporadic literature reports confirm that a small number of ingested foreign bodies perforate
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E. Vryonis et al. / European Journal of Radiology Extra 62 (2007) 15–17
Fig. 1. Chest radiography identified a thermometer-like opacity in the mediastinum.
the esophagus and migrate extraluminally with no symptoms [4,5]. Treatment of esophageal perforation depends on the etiology, site and size of perforation, the time elapsed between perforation and diagnosis, underlying esophageal disease and the overall health status of the patient [6]. Evidence from the literature supports primary repair regardless of the time of presentation and suggest esophagectomy for patients with an underlying cancer or extensive transmural necrosis. However, it is also suggested that a small, carefully selected group of patients with perforations contained within the mediastinum that drained spontaneously into the native esophagus may be treated successfully without operation [7]. In our case, the foreign body was an incidental finding, detected several months after ingestion to have migrated extraluminally without any
Fig. 3. The contrast shallow esophagogram revealed the thermometer in the mediastinum, outside the esophagus and in contact with the posterior wall of it.
Fig. 4. CT scan shows that the thermometer has migrated to the posterior mediastinum.
identification of the perforation site. Nevertheless and due to the potential rapture and mercury caused mediastinitis we suggested the surgical removal of the thermometer but the patient refused her consent.
References
Fig. 2. This is the latter view.
[1] Webb WA. Management of foreign bodies of the upper gastrointestinal tract: update. Gastrointest Endosc 1995;41:39–50. [2] Athanassiadi K, Gerazounis M, Metaxas E, Kalantzi N. Management of esophageal foreign bodies: a retrospective review of 400 cases. Eur J Cardio-thoracic Surg 2002;21:653–6.
E. Vryonis et al. / European Journal of Radiology Extra 62 (2007) 15–17 [3] Miller RS, Willging JP, Rutter MJ, Rookkapan K. Chronic esophageal foreign bodies in pediatric patients: a retrospective review. Int J Ped Otorhinolaryngol 2004;68:265–72. [4] Janik JS, Bailey WC, Burrington JD. Occult coin perforation of the esophagus. J Ped Surg 1986;21(9):794–7. [5] Nahman BJ, Mueller CF. Asymptomatic esophageal perforation by a coin in a child. Ann Emerg Med 1984;13:627–9.
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[6] Mendelson MH. Esophageal emergencies. In: Tintinally JE, Kelen DG, Stapczynski JS, editors. Emergency medicine: a comprehensive study guide. 5th ed. New York: McGraw-Hill; 2000. p. 523–9. [7] Port JL, Kent MS, Korst RJ, Bacchetta M, Altorki N. Thoracic esophageal perforations: a decade of experience. Ann Thorac Surg 2003;75:1071–4.
Migration of a thermometer to the mediastinum Evagelos Vryonis a , Eleni Mylona a,∗ , Panagiotis Fanourgiakis a , Styliani Golfinopoulou a , Ioannis Kalogeropoulos b , Athanasios Skoutelis a a
5th Department of Internal Medicine, Evagelismos Hospital, 45-47 Hipsilantou Street, Kolonaki, GR-106 76 Athens, Greece b Department of Radiology, Evagelismos Hospital, Athens, Greece Received 18 September 2006; received in revised form 15 January 2007; accepted 18 January 2007
Abstract We report the radiological findings of a thermometer having migrated to the posterior mediastinum after ingestion and perforation of the esophagus, in an asymptomatic patient. Asymptomatic migration of a foreign body in the mediastinum after ingestion is an extremely rare phenomenon. Management can be conservative or surgical. © 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Esophageal perforation; Mediastinum; Thermometer; Foreign body
1. Introduction Ingestion of foreign bodies is common, especially among the pediatric age group, whereas in adults occurs more commonly among those with psychiatric disorders or mental retardation, prisoners and alcoholics [1]. Impacted foreign bodies in the esophagus can easily cause mucosal ulceration, inflammation or can result in complications such as para- or retroesophageal abscess, mediastinitis, empyema, perforation or even aortoesophageal fistula [2]. 2. Case report A 37-year-old woman, drug-addict, appeared in hospital with cellulitis of the right hand. Among all the ordinary admission exams, the patient was subjected to chest Xray. Chest radiography identified a radiopaque foreign body, consistent with that of a thermometer, appearing to be in the thoracic esophagus. Neither pneumothorax, nor subcutaneous emphysema was evident (Figs. 1 and 2). Subsequent history revealed the ingestion of a thermometer several months before. The patient had no difficulty eating. ∗
Corresponding author. Tel.: +30 210 7201430; fax: +30 210 7216408. E-mail addresses: [email protected], [email protected] (E. Mylona). 1571-4675/$ – see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrex.2007.01.007
Flexible esophagoscopy showed that the foreign body was outside the esophageal lumen. There was no identification of the perforation site, stricture or diverticulum. A contrast shallow esophagogram revealed no evidence of fluid leakage and showed the thermometer to have perforated the esophagus. However, the thermometer had not just been walled off in either the mucosal or muscular layer of the organ, but it had in fact, perforated the esophagus [2]. Evidently, the thermometer had come into contact with the posterior wall of the esophagus (Fig. 3). Moreover, a subsequent computed tomography scan with contrast confirmed the existence of the foreign body in the posterior mediastinum, without mediastinal air or fluid (Fig. 4). Due to the potential rupture and the mediastinitis it could be caused by mercury, we suggested the surgical removal of the thermometer. However, the patient refused any surgical procedure and left the hospital on her own responsibility. 3. Discussion The ingestion of foreign bodies is a common occurrence that usually follows a benign course, while impacted foreign bodies may cause severe complications [3]. Our case is the first to report perforation of the esophagus by a thermometer in an asymptomatic patient. Sporadic literature reports confirm that a small number of ingested foreign bodies perforate
16
E. Vryonis et al. / European Journal of Radiology Extra 62 (2007) 15–17
Fig. 1. Chest radiography identified a thermometer-like opacity in the mediastinum.
the esophagus and migrate extraluminally with no symptoms [4,5]. Treatment of esophageal perforation depends on the etiology, site and size of perforation, the time elapsed between perforation and diagnosis, underlying esophageal disease and the overall health status of the patient [6]. Evidence from the literature supports primary repair regardless of the time of presentation and suggest esophagectomy for patients with an underlying cancer or extensive transmural necrosis. However, it is also suggested that a small, carefully selected group of patients with perforations contained within the mediastinum that drained spontaneously into the native esophagus may be treated successfully without operation [7]. In our case, the foreign body was an incidental finding, detected several months after ingestion to have migrated extraluminally without any
Fig. 3. The contrast shallow esophagogram revealed the thermometer in the mediastinum, outside the esophagus and in contact with the posterior wall of it.
Fig. 4. CT scan shows that the thermometer has migrated to the posterior mediastinum.
identification of the perforation site. Nevertheless and due to the potential rapture and mercury caused mediastinitis we suggested the surgical removal of the thermometer but the patient refused her consent.
References
Fig. 2. This is the latter view.
[1] Webb WA. Management of foreign bodies of the upper gastrointestinal tract: update. Gastrointest Endosc 1995;41:39–50. [2] Athanassiadi K, Gerazounis M, Metaxas E, Kalantzi N. Management of esophageal foreign bodies: a retrospective review of 400 cases. Eur J Cardio-thoracic Surg 2002;21:653–6.
E. Vryonis et al. / European Journal of Radiology Extra 62 (2007) 15–17 [3] Miller RS, Willging JP, Rutter MJ, Rookkapan K. Chronic esophageal foreign bodies in pediatric patients: a retrospective review. Int J Ped Otorhinolaryngol 2004;68:265–72. [4] Janik JS, Bailey WC, Burrington JD. Occult coin perforation of the esophagus. J Ped Surg 1986;21(9):794–7. [5] Nahman BJ, Mueller CF. Asymptomatic esophageal perforation by a coin in a child. Ann Emerg Med 1984;13:627–9.
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[6] Mendelson MH. Esophageal emergencies. In: Tintinally JE, Kelen DG, Stapczynski JS, editors. Emergency medicine: a comprehensive study guide. 5th ed. New York: McGraw-Hill; 2000. p. 523–9. [7] Port JL, Kent MS, Korst RJ, Bacchetta M, Altorki N. Thoracic esophageal perforations: a decade of experience. Ann Thorac Surg 2003;75:1071–4.