Microscopic removal of an embedded foreign body from the hypopharynx: Report of two cases. (Original Article).
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 wall and cannot be located, even by fiberoptic endoscopy 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.
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.
Patient 1. A 47-year-old woman came to us with a sore throat and dysphagia 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. 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 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.
The patient underwent rigid esophagoscopy under general anesthesia but, again, no foreign body was detected between the oropharynx 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 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.
Among the many reported complications of an intractable hypopharyngeal foreign body are cervical abscess, medi-astinal abscess, rupture of the cervical artery, and arterial aneurysm. (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 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 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.
(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. 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 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.