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 Table of Contents  
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


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

Date of Web Publication1-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
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2320-3846.175214

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  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 2022 May 27];3:56-9. Available from: https://www.saudisurgj.org/text.asp?2015/3/2/56/175214




  Introduction Top


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 Top


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 Top


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.

 
  References Top

1.
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2.
Hajiioannou J, Kousoulis P, Florou V, Stavrianou E. Iatrogenic migration of an impacted pharyngeal foreign body of the hypopharynx to the prevertebral space. Int J Otolaryngol 2011;2011:274102.  Back to cited text no. 2
    
3.
Selivanov V, Sheldon GF, Cello JP, Crass RA. Management of foreign body ingestion. Ann Surg 1984;199:187-91.  Back to cited text no. 3
    
4.
Postlethwait RW. Foreign bodies in surgery of the esophagus. New York: Appleton-Century-Craft; 1979.  Back to cited text no. 4
    
5.
Tsukuda T, Kudo F. Pharyngeal foreign bodies in infants persisting for two months: Two case reports. Nihon Jibiinkoka Gakkai Kaiho 2000;103:24-7.  Back to cited text no. 5
    
6.
Weissberg D. Foreign bodies in the gastro-intestinal tract. S Afr J Surg 1991;29:150-3.  Back to cited text no. 6
    
7.
Watanabe K, Amano M, Nakanome A, Saito D, Hashimoto S. The prolonged presence of a fish bone in the neck. Tohoku J Exp Med 2012;227:49-52.  Back to cited text no. 7
    
8.
Shu MT, Leu YS. Microscopic removal of an embedded foreign body from the hypopharynx: Report of two cases. Ear Nose Throat J 2001;80:889-90.  Back to cited text no. 8
    
9.
Hinojar AG, Díaz Díaz MA, Pun YW, Hinojar AA. Management of hypopharyngeal and cervical oesophageal perforations. Auris Nasus Larynx 2003;30:175-82.  Back to cited text no. 9
    
10.
Chaves DM, Ishioka S, Félix VN, Sakai P, Gama-Rodrigues JJ. Removal of a foreign body from the upper gastrointestinal tract with a flexible endoscope: A prospective study. Endoscopy 2004;36:887-92.  Back to cited text no. 10
    
11.
Shockley WW, Tate JL, Stucker FJ. Management of perforations of the hypopharynx and cervical esophagus. Laryngoscope 1985;95:939-41.  Back to cited text no. 11
    
12.
Berger S, Elidan J, Gay I. Retropharyngeal abscess caused by a traumatic perforation of the hypopharynx by a fishbone. Ann Otol Rhinol Laryngol 1990;99:927-8.  Back to cited text no. 12
    
13.
Tsai YS, Lui CC. Retropharyngeal and epidural abscess from a swallowed fish bone. An unusual case. Singapore Med J 2000;41:77-9.  Back to cited text no. 13
    
14.
Poluri A, Singh B, Sperling N, Har-El G, Lucente FE. Retropharyngeal abscess secondary to penetrating foreign bodies. J Craniomaxillofac Surg 2000;28:243-6.  Back to cited text no. 14
    
15.
Bhatia PL. Hypopharyngeal and oesophageal foreign bodies. East Afr Med J 1989;66:804-11.  Back to cited text no. 15
    
16.
Cagini L, Ragusa M, Vannucci J, Andolfi M, Cirulli P, Scialpi M, et al. Glide video laryngoscope for the management of foreign bodies impacted at the hypopharyngeal level in adults. Minerva Anestesiol 2013;79:1259-63.  Back to cited text no. 16
    
17.
Je SM, Kim MJ, Chung SP, Chung HS. Comparison of GlideScope(®) versus Macintosh laryngoscope for the removal of a hypopharyngeal foreign body: A randomized cross-over cadaver study. Resuscitation 2012;83:1277-80.  Back to cited text no. 17
    
18.
Bennett AM, Sharma A, Price T, Montgomery PQ. The management of foreign bodies in the pharynx and oesophagus using transnasal flexible laryngo-oesophagoscopy (TNFLO). Ann R Coll Surg Engl 2008;90:13-6.  Back to cited text no. 18
    
19.
Sato K, Nakashima T. Office-based foreign-body management using videoendoscope. Am J Otolaryngol 2004;25:167-72.  Back to cited text no. 19
    
20.
Ma J, Kang DK, Bae JI, Park KJ, Sun JS. Value of MDCT in diagnosis and management of esophageal sharp or pointed foreign bodies according to level of esophagus. AJR Am J Roentgenol 2013;201:W707-11.  Back to cited text no. 20
    
21.
Donath K, Laass M, Günzl HJ. The histopathology of different foreign-body reactions in oral soft tissue and bone tissue. Virchows Arch A Pathol Anat Histopathol 1992;420:131-7.  Back to cited text no. 21
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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