Impacted pharyngeal fish bone migrating to the retropharynx.

A 31-year-old woman was referred to our emergency department with a 2-day history of odynophagia and a globus sensation. She had earlier presented to the emergency department of another hospital, where staff had detected a fish bone in her throat (the patient had eaten a fish fillet 2 days earlier). Emergency personnel there had been unable to remove the bone via a transoral approach.

At our institution, plain film and computed tomography (CT) demonstrated a linear opacity consistent with the dimensions of a fish bone in the retropharyngeal soft tissue (figure 1). The patient was taken to the operating room for transoral retropharyngeal exploration and foreign-body removal. A 3-cm incision was made in the posterior pharyngeal mucosa, and a combination of sharp and blunt dissection was used to locate the fish bone. However, the fish bone was not found despite extensive dissection and intraoperative fluoroscopy. The procedure was terminated, and the patient was admitted and placed on intravenous antibiotics. An external cervical exploration was deferred at that time in order to prevent fistula formation.

[FIGURE 1 OMITTED]

The patient remained on IV antibiotics for 1 week, but then she left the hospital against medical advice. She presented to the otolaryngology clinic 1 day later, and a repeat x-ray revealed that the foreign body had remained in the retropharyngeal soft tissue. Eleven days after her initial presentation to the emergency department, she was taken back to the operating room for a transcervical neck exploration. The fish bone was found in the retropharyngeal musculature and removed in its entirety. The pharyngeal mucosa was not violated, and no communication with the previous pharyngeal incision was observed. Comparison of the actual fish bone and the linear density seen on x-ray revealed a perfect match (figure 2). Fluoroscopy confirmed the absence of any residual foreign body. The patient did well postoperatively without complications.

[FIGURE 2 OMITTED]

Fish bones are among the most common impacted foreign bodies found in the pharynx. (1) Most are amenable to transoral removal or are passed without further sequela. However, when they are left impacted, complications may ensue, particularly retropharyngeal abscess. (2) Cases of fish bone migration into the soft tissues of the neck (e.g., the retropharynx and parapharynx) have been reported; outcomes have ranged from dissolution of the bone without sequela (3) to the development of external carotid pseudoaneurysm. (4) Lai et al reported that higher complication rates are associated with a delay in presentation of more than 2 days and with a finding that a fish bone is radiopaque. (5) Both of these circumstances occurred in this case.

This case illustrates the potential for an impacted fish bone to rapidly migrate through the pharyngeal mucosa into the retropharynx, possibly evading initial detection by fiberoptic endoscopy. Plain films and CT may be helpful in the diagnosis and localization of a migrating foreign body, even though they yield false-negative results in many cases.

David A. Lehman, MD; Frank C. Astor, MD; Soham Roy, MD

References

(1.) Kumar M, Joseph G, Kumar S, Clayton M. Fish bone as a foreign body. J Laryngol Otol 2003;117:568-9.

(2.) Singh B, Kantu M, Har-E1 G, Lucente FE. Complications associated with 327 foreign bodies of the pharynx, larynx, and esophagus. Ann Otol Rhinol Laryngol 1997;106:301-4.

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

(4.) Okafor BC. Aneurysm of the external carotid artery following a foreign body in the pharynx. J Laryngol Otol 1978;92:429-34.

(5.) Lai AT, Chow TL, Lee DT, Kwok SP. Risk factors predicting the development of complications after foreign body ingestion. Br J Surg 2003;90:1531-5.

From the Department of Otolaryngology-Head and Neck Surgery, University of Miami School of Medicine.