A rare case of a foreign body migration from the upper digestive tract to the subcutaneous neck. (Original Article).

Abstract

Ingested foreign bodies are not unusual in Singapore. The most common of these objects are fish bones, which typically become lodged in the tonsils or in the base of the tongue. We report a rare case of an ingested fish bone that migrated from the upper digestive tract and into the soft tissues of the neck just below the skin.

Introduction

Ingested foreign bodies represent a fairly common otolaryngologic emergency in Singapore. Approximately 85% of these foreign bodies are fish bones, most of which become lodged in the tonsils or in the base of the tongue. (1) Other sites of impaction include the epiglottis, valleculae, larynx, pyriform fossa, and esophagus. Occasionally, foreign bodies in the esophagus lead to esophageal perforation, retropharyngeal abscess, vascular complications, and even death. In this article, we report a rare case of an ingested fish bone that migrated from the upper digestive tract and into the soft tissues of the neck just below the skin.

Case report

A 40-year-old Chinese man came to us with a 2-day history of a left-sided neck mass. He recalled that he first experienced a sharp left-sided throat pain after he had eaten a serving of fish approximately 1 week earlier. Throughout the intervening week, he experienced a vague, persistent, left-sided neck discomfort upon swallowing. Five days following the onset of his initial discomfort, he developed a left-sided neck mass.

The patient was examined in the otolaryngology clinic, and findings were essentially normal. The oral cavity was clear, and the tonsils were not enlarged. The appearance of the tongue and tongue base, valleculae, epiglottis, posterior pharyngeal wall, larynx, and vocal folds were normal. Findings on nasopharyngoscopy were also normal.

Palpation of the neck mass revealed the presence of a small, sharp object in the subcutaneous tissue that was located anterior to the sternocleidomastoid muscle (figure 1). No other lesions were apparent. Findings on plain lateral neck radiography were normal. Based on these findings, we suspected that the object was a migrated foreign body. We administered local anesthesia and made an incision in the neck. We removed the object, which we identified as a fish bone (figure 2).

Discussion

Migration of a fish bone to the subcutaneous tissue of the neck is rare. Chee and Sethi reported the largest series of 24 migrated foreign bodies in the neck. (2) They found that 18 (75%) of these objects had been removed within 24 hours. All of the foreign bodies in their series were sharp and linear.

Lateral neck radiographs can be useful, but they do not help determine if migration has occurred. Foreign-body migration should be suspected if there is a suggestive history, a positive finding on lateral neck radiography, and a negative finding on rigid esophagoscopy. Subsequent computed tomography of the neck is helpful in identifying the location of the foreign body. Documented complications of foreign-body migration include retro-pharyngeal abscess, perforation of the esophagus, perforation of the aorta, embedment in the thyroid gland, and migration through the common carotid artery. (3) Occasionally, a foreign body simply disappears. (4)

References

(1.) Leong HK, Chan RK. Foreign bodies in the upper digestive tract. Singapore Med J 1987;28:162-5.

(2.) Chee LW, Sethi DS. Diagnostic and therapeutic approach to migrating foreign bodies. Ann Otol Rhinol Laryngol 1999;108:177-80.

(3.) Osinubi OA, Osiname AI, Pal A, et al. Foreign body in throat migrating through the common carotid artery. J Laryngol Otol 1996;110:793-5.

(4.) Canbay E, Prinsley P. The case of the disappearing fish bone. J Otolaryngol 1995;24:375-6.

Reprint requests: Dr. Kenny Pang, Department of Otolaryngology, National University Hospital, 5 Lower Kent Ridge Rd., Singapore 119074. Phone: [phone]; fax: [phone]; e-mail: [e-mail]