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Microscopic removal of an embedded foreign body from the hypopharynx: Report of two cases. (Original Article).



Abstract

Incidents of foreign bodies in the hypopharynx, especially fish bones, are very common. In most cases, these bones can be easily located and removed. However, in other cases, they become embedded in the pharyngeal pharyngeal /pha·ryn·ge·al/ (fah-rin´je-al) pertaining to the pharynx.

pha·ryn·geal or pha·ryn·gal
adj.
Of, relating to, located in, or coming from the pharynx.
 wall and cannot be located, even by fiberoptic endoscopy endoscopy

Examination of the body's interior through an instrument inserted into a natural opening or an incision, usually as an outpatient procedure. Endoscopes include the upper gastrointestinal endoscope (for the esophagus, stomach, and duodenum), the colonoscope (for the
 and rigid esophagoscopy. Left in place, these foreign bodies can eventually cause serious complications. We treated two patients who had an embedded foreign body in the hypopharyngeal wall that we were unable to locate by fiberoptic endoscopy and rigid esophagoscopy. Ultimately, we performed direct laryngoscopy and were able to locate and remove the foreign bodies with the aid of a microscope.

Introduction

Hypopharyngeal and esophageal foreign bodies, particularly fish bones, are a

relatively common complaint in otolaryngologic practice, especially in Asia. With the help of instruments, most of these foreign bodies can be easily located and removed by indirect or fiberoptic laryngoscopy. (1) However, in some cases, fish bones become embedded in the pharyngeal wall and cannot be seen, even on rigid esophagoscopy. In such circumstances, serious complications can occur and some patients must undergo neck exploration. (2) In this article, we describe our experience with removing embedded fish bones from the hypopharyngeal wall in two patients.

Case reports

Patient 1. A 47-year-old woman came to us with a sore throat Sore Throat Definition

Sore throat, also called pharyngitis, is a painful inflammation of the mucous membranes lining the pharynx. It is a symptom of many conditions, but most often is associated with colds or influenza.
 and dysphagia dysphagia /dys·pha·gia/ (-fa´jah) difficulty in swallowing.

dys·pha·gia or dys·pha·gy
n.
Difficulty in swallowing or inability to swallow.
 as a result of swallowing a fish bone 3 days earlier. She had tried unsuccessfully to dislodge the bone by swallowing rice and by retching retching /retch·ing/ (rech´ing) strong involuntary effort to vomit.

retching

an unproductive effort to vomit.
. Her pain persisted to the point that she could take only a liquid diet. Her medical history was significant for diabetes, for which treatment was only intermittent.

Physical examination revealed tenderness of the right neck. Indirect laryngoscopy indicated that the mucosa of the right posterior wall of the hypopharynx was erythematous erythematous

characterized by erythema.
 and swollen, but no foreign body was visible. On lateral-view x-ray of the neck, a bone-like shadow was seen over the posterior wall of the hypopharynx at the level of the third cervical vertebra vertebra /ver·te·bra/ (ver´te-brah) pl. ver´tebrae   [L.] any of the 33 bones of the vertebral (spinal) column, comprising 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 4 coccygeal vertebrae . .

The patient underwent rigid esophagoscopy under general anesthesia but, again, no foreign body was detected between the oropharynx oropharynx /oro·phar·ynx/ (-far´inks) the part of the pharynx between the soft palate and the upper edge of the epiglottis.

o·ro·phar·ynx
n.
 and the esophagus. Using the x-ray as a guide, laryngoscopy with the aid of a microscope was performed, and a small ulcer on the posterior wall of the hypopharynx was discovered (figure 1). Within the ulcer was a very sharp, 1.5-cm fish bone, which was extracted with long forceps. The patient was discharged on antibiotics but was readmitted the following day for treatment of ketoacidosis. She was hospitalized for 2 weeks, then released.

Patient 2. A 41-year-old man was referred to us for a complaint of odynophagia, which had begun after he had swallowed a fish bone 10 days earlier. He attempted self-treatment by swallowing a large bolus bolus /bo·lus/ (bo´lus)
1. a rounded mass of food or pharmaceutical preparation ready to swallow, or such a mass passing through the gastrointestinal tract.

2. a concentrated mass of pharmaceutical preparation, e.
 of rice, but this failed to dislodge the bone. Limited to a soft diet, he sought care from a primary care physician, who was unable to locate the bone.

Our physical examination revealed a tender point in the right anterior neck. Indirect laryngoscopy detected an ulcer on the right posterior wall of the hypopharynx. However, no foreign body was seen, even on fiberoptic laryngoscopy. A subsequent x-ray detected a suspicious shadow, and computed tomography (CT) was performed. CT showed the presence of the foreign body inside the swollen soft tissue of the hypopharynx (figure 2, A).

Rigid esophagoscopy administered under general anesthesia detected nothing between the oropharynx and the esophagus. Subsequent laryngoscopy with microscopy identified the 2-cm bone beneath the ulcer of the swollen soft tissue. The bone was secured by long forceps and removed (figure 2, B). The patient was put on antibiotics and discharged 3 days later.

Discussion

Among the many reported complications of an intractable hypopharyngeal foreign body are cervical abscess abscess, localized inflamation associated with tissue necrosis. Abscesses are characterized by inflamation, which is due to the accumulation of pus in the local tissues, and often painful swelling. , medi-astinal abscess, rupture of the cervical artery, and arterial aneurysm aneurysm (ăn`yrĭzəm), localized dilatation of a blood vessel, particularly an artery, or the heart. . (1,3-5) Some patients attempt to dislodge a foreign body from the hypopharynx by swallowing a bolus of food or by retching. However, this is not recommended because the food might push the foreign body deeper and impale it in soft tissue. The patient's best course is to seek treatment immediately while the foreign body is still in the hypopharynx. Most complicated cases of an embedded foreign body are the result of a patient's own inappropriate treatment.

The patient's description of the traumatic event, the intensity of the pain, and findings on palpation palpation /pal·pa·tion/ (pal-pa´shun) the act of feeling with the hand; the application of the fingers with light pressure to the surface of the body for the purpose of determining the condition of the parts beneath in physical diagnosis.  of the neck can all provide clues to the location of the foreign body and the seriousness of the situation. Most cases of foreign body ingestion ingestion /in·ges·tion/ (-chun) the taking of food, drugs, etc., into the body by mouth.

in·ges·tion
n.
1. The act of taking food and drink into the body by the mouth.

2.
 can be resolved with a prudent examination, but such is not the case with an embedded hypopharyngeal foreign body. (2) Its appearance on lateral-view x-ray of the neck is not always distinct. (6) CT can provide better information, including the depth to which the instrument must extend to effect removal.

Even fiberoptic laryngoscopy and rigid esophagoscopy can fail to detect an embedded hypopharyngeal foreign body. Conservative treatment can worsen the situation and eventually lead to the need for surgical exploration. (2) Therefore, if esophagoscopy should fail, the next prudent step is direct laryngoscopy with the aid of a microscope.

References

(1.) Goldstein SI, Weiss MH. Fiberendoseopic removal of pharyngeal foreign bodies. Laryngoseope 1987;97:108-9.

(2.) Okafor BC. Aneurysm of the external carotid artery following a foreign body in the pharynx pharynx (fâr`ĭngks), area of the gastrointestinal and respiratory tracts which lies between the mouth and the esophagus. In humans, the pharynx is a cone-shaped tube about 4 1-2 in. (11.43 cm) long. . J Laryngol Otol 1978;92:429-34.

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

(4.) Bizakis JG, Segas J, Skoulakis H, et al. Retropharyngoesophageal abscess associated with a swallowed bone. Am J Otolaryngol 1993;14:354-7.

(5.) Bass RM, Hurshman LF, Winkler Winkler may refer to:
  • Winkler, Manitoba, a Canadian city
  • Winkler (novel), by Giles Coren
  • Winkler (crater), a crater on the Moon
  • Winkler (surname), people with the surname Winkler or Winckler
See also
 LF. Rupture of the carotid artery from a hypopharyngeal foreign body. Arch Otolaryngol 1978;104:471-3.

(6.) Sundgren PC, Burnett A, Maly PV. Value of radiography in the management of possible fishbone ingestion. Ann Otol Rhinol Laryngol 1994;103:628-31.
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Comment:Microscopic removal of an embedded foreign body from the hypopharynx: Report of two cases. (Original Article).
Author:Leu, Yi-Shing
Publication:Ear, Nose and Throat Journal
Geographic Code:1USA
Date:Dec 1, 2001
Words:980
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