Long-term systemic antibiotics treatment of iatrogenic embedded chicken bone fragment in the hypopharynx

Sami A Alkindy

doi:10.4103/2320-3846.175214

CASE REPORT

Year : 2015 | Volume : 3 | Issue : 2 | Page : 56-59

Long-term systemic antibiotics treatment of iatrogenic embedded chicken bone fragment in the hypopharynx

Sami A Alkindy
Department of Surgery, College of Medicine, Taif University, P. O. Box 888, Taif 21944, Kingdom of Saudi Arabia

Date of Web Publication

1-Feb-2016

Correspondence Address:
Sami A Alkindy
Department of Surgery, College of Medicine, Taif University, P. O. Box 888, Taif 21944
Kingdom of Saudi Arabia

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/2320-3846.175214

Abstract

Iatrogenic embedding of foreign body (FB) in the hypopharynx during retrieval process is not uncommon, and its management can be quite challenging. Left in situ, it may lead to serious complications including retropharyngeal, neck abscesses, and mediastinitis. We present an unusual case of a 75-year-old female who presented late with a chicken bone impacted in the hypopharynx and had a fragment iatrogenic embedded that was not noted by the surgeon. It was complicated by a recurrent retropharyngeal abscess. Attempts to remove it endoscopically and surgically failed, prompting us to treat it with long-term systemic antibiotics. More than 6 months later, the patient had no further complaints. Follow-up computed tomography scan showed no change in FB position. However, there was a decrease in its thickness. We suggest long-term systemic antibiotics as a first line of management for embedded bone fragments in the pharynx with expected surgical retrieval difficulties, once diagnosed early before the onset of complications.

Keywords: Complications, hypopharyngeal foreign body, management

How to cite this article:
Alkindy SA. Long-term systemic antibiotics treatment of iatrogenic embedded chicken bone fragment in the hypopharynx. Saudi Surg J 2015;3:56-9

How to cite this URL:
Alkindy SA. Long-term systemic antibiotics treatment of iatrogenic embedded chicken bone fragment in the hypopharynx. Saudi Surg J [serial online] 2015 [cited 2023 Feb 6];3:56-9. Available from: https://www.saudisurgj.org/text.asp?2015/3/2/56/175214

Introduction

Foreign body (FB) impaction in the hypopharynx is ^[1],[2] a common otolaryngological emergency ^{[1],[2],[3],[4]} its seen in infants, pediatrics, adults, edentulous elderly patients, psychiatric patients, and prisoners.^[5],[6] Management difficulties may arise when sharp objects penetrate the pharyngeal mucosa ^[7],[8] or there is a delay in diagnosis,^{[9],[10],[11]} that may lead to potential fatal outcomes that is, retropharyngeal and neck abscess.^{[7],[12],[13],[14]} The case presented had an iatrogenic bone fragment embedded in the hypopharynx which was not recognized early and later complicated with a recurrent retropharyngeal abscess. To relieve her symptoms, she was managed with multiple long-term systemic antibiotics after unsuccessful retrieval attempts.

Case Report

A 75-year-old female presented with a 3-day history of dysphagia following impaction of a chicken bone in the hypopharynx, it was retrieved with difficulty by another specialty. However, dysphagia and odynophagia failed to resolve, hypopharyngeal injury was suspected, albeit, gastrografin study done by the team postoperatively did not report any pathological findings.

Patient was referred to our department for further management.

Clinically, there was tenderness in the front of her neck, and flexible naso-pharyngo-laryngoscopic examination was intolerable. Plain lateral neck X-ray showed a large collection in the retropharyngeal space [Figure 1]. Urgent endoscopic examination and drainage of the pus under general anesthesia were done. The collected specimen for culture sensitivity showed no growth. Postoperatively, the patient was elected to be intubated with Intensive Care Unit admission for Twenty-four hours.

Figure 1: Lateral X-ray neck demonstrating large retropharyngeal collection (arrow)

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On postextubation, she was still in status quo and lateral X-ray neck done demonstrated recollection [Figure 2]. Multi detector computed tomography (MDCT) of the neck was done as so as FB impaction in the hypopharynx was suspected. A <½ cm (3.9 mm) chicken bone fragment was noted to be embedded in the posterior hypopharyngeal wall just posterior to the cricopharynx with fluid recollection [Figure 3].

Figure 2: Lateral X-ray neck demonstrating recollection, fluid level (vertical arrow) and nasogastric tube (horizontal arrow)

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Figure 3: Axial multi detector computed tomography of the neck demonstrating the bony fragment (arrow)

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Neck exploration with drain and tracheostomy was planned after failed endoscopic retrieval attempt. However, due to the FB's size and location, the attempt was unsuccessful in spite of using computerized radiology (CR) in both procedures.

Patient was continued on multiple long-term systemic antibiotics that included augmentin, flagyl and vancomycin with continuous nasogastric feeding for 6 weeks.

Eventually, she was decannulated, and gradually, her dysphagia and odynophagia resolved. A repeat computed tomography (CT) neck showed no recollection and Gastrografin study demonstrated smooth flow of dye through the aerodigestive tract.

Six months later, she had no further complaints and the follow-up CT neck showed no change in the position of the FB, however, there was a decrease in its thickness [Figure 4].

Figure 4: Axial computed tomography 6 months lateral, demonstrating reduction of foreign body thickness (arrow)

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Discussion

Hypopharyngeal part of the pharynx, probably due to its anatomical nature, is the most common site of FB impactions.^[15]

These cases often present at odd hours, when expert otolaryngology operative nurses familiar with the required instruments are off and senior surgeon's assistance that may be sought is not readily available. Therefore, it is wise to delay the procedure till next working hours unless the risk out weights this policy.

Depending on surgeon's experience and preference a number of devices and instruments are used including rigid endoscope, Glide Scope, Macintosh laryngoscope, flexible laryngo-esophagoscopy, video endoscope.^{[16],[17],[18],[19]}

Among these, rigid endoscope is the tool of choice as it has a high success rate. However, it is not risk-free, mucosal injury, and iatrogenic embedding of FB ^[2] is among the reported complications ^[16] the former can be quite challenging to manage.

In the case presented, report given by the first surgeon indicated that in spite of difficulties faced, chicken bone was completely retrieved. This, however, lead us to suspect that the pharyngeal injury was the cause of retropharyngeal abscess.

Indeed, failure to relieve patient's symptoms and recollection of the abscess raised the suspicious of a bony fragment embedded in the pharynx, which was confirmed by Multi-detector Computed Tomography, a protocol recommended in such cases.^[20] The plan for exploration was meant to drain the recollection and retrieve the FB, which for given reasons failed, even with the help of CR. Size and location of the FB including fibrosis formed around it were probably the contributory factors in making tactical sensation difficult intra operatively.

Surgical removal of the FB meant excision of the soft tissue involved and for expected complications was not sound. Tracheostomy was a temporary measure to avoid airway compromise and aspiration which was later decannulated successfully.

It was no surprise to have a “no growth” report of the collected specimen as the patient had been on multiple systemic antibiotics that covered aerobic, anaerobic, Gram-positive and negative microorganisms including methicillin-resistant staphylococcus antibiotics. It is worth noting that the patient was on irregular systemic antibiotics prior to our care.

Our decision to explore the neck was fair and warranted so as to give a full possible chance to remove the FB and prevent further complications.

The pathophysiology of any given FB in the soft tissue is a foreign type chronic inflammation (cellular inflammation, fibrous encapsulation with macrophages), this mechanism tends to eliminate the material by rejection, dissolution, resorption or demarcation.^[21]

This may explain the cessation of further infections seen here. Nevertheless, the role of systemic antibiotics cannot be ignored, but could not be fully explained.

Retrospectively, we believe that had the patient put on continuous multiple systemic antibiotics this complication could have been averted.

We suggest for small size embedded FBs in the pharynx with expected extraction difficulties, recognized early and before the onset of complications. Long-term systemic antibiotics may be considered as a first line of management, thus allowing pathophysiology process to take place and saving surgical intervention as a last resort, however, under close observation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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