Removal of a fish bone in the thyroid gland without the need for thyroid lobectomy.

Abstract

We report the first published case of the removal of a migratory fish bone from the thyroid gland that did not necessitate a thyroid lobectomy.

Introduction

Migration of a fish bone to the thyroid gland has been reported earlier. [1-5 In all these cases, the bones were removed by thyroid lobectomy. We report a case in which a fish bone lodged in the thyroid was removed without the need to remove the entire gland. We emphasize the importance of maintaining a high level of clinical suspicion in cases when endoscopy is negative but radiography is positive, and we recommend the use of axial computed tomography (CT), which we found to be very helpful.

Case report

A 38-year-old woman came to the department of otorhinolaryngology complaining of a 5-day history of dysphagia, which began after she had eaten a meal that included fish. She had first sought treatment at a private clinic, where a lateral neck x-ray revealed a radio-opaque shadow near the cervical spine at C5-C6. Rigid esophagoscopy failed to detect a foreign body, but a repeat x-ray was still positive. The woman was offered further tests, but she refused and sought treatment at our center.

Clinically, the patient was afebrile. Indirect laryngoscopy revealed a small area of ulceration at the posterior pharyngeal wall. There was no palpable mass in the neck. Axial CT revealed the presence of a radio-opaque fish bone, which extended from the thyroid cartilage inferolaterally through the left thyroid gland (figure 1). The surrounding area was marked by inflammation and edema. A lateral neck x-ray also showed the bone in the soft tissue (figure 2).

The patient underwent surgical exploration (thyroidotomy) of the left neck. The 2-mm, serrated bone was observed in the inferolateral aspect of the left thyroid gland, with one end protruding toward the pyriform fossa. The bone was easily extracted. Because there was minimal damage to the thyroid gland, a lobectomy was not necessary. The postoperative period was uneventful.

Discussion

Although this is not the first report of a migratory fish bone in the thyroid gland, it is the first case reported in which the bone was removed without a thyroid lobectomy. The earliest reported case of a migratory fish bone in the thyroid was published in 1949. [1] To date, there have been five reported cases, all of which involved the left lobe. [1-5] The mechanics of spontaneous penetration and migration of small bones has been explained. [1,6] In all reported cases, a lobectomy was necessary because an abscess had formed on the thyroid and the surrounding area had become inflamed. In our patient, the bone could be palpated through the thyroid. A small thyroidotomy exposed one end of the serrated bone, which was simply grasped and pulled straight out toward the pyriform fossa.

Ingested fish bones are common in Malaysia, and ENT surgeons rarely encounter much difficulty in removing them. The ENT surgeon should be aware of the possibility of a migrating fish bone, especially when radiography is positive and endoscopy is negative. CT is valuable in locating the exact site of migration.

From the Department of Otorhinolaryngology (Dr. Arumainathan, Dr. Tan, and Mr. Raman), and the Department of Radiology (Dr. Lwin), University of Malaya Medical Centre, Kuala Lumpur.

References

(1.) Jemerin EF, Arnoff JS. Foreign body in the thyroid following perforation of oesophagus. Surgery 1949;25:52-9.

(2.) al Muhanna A. Abu Chra KA, Dashti H, et al. Thyroid lobectomy for removal of a fish bone. J Laryngol Oto] 1990;104:511-2.

(3.) Bendet E. Thyroid lobectomy for removal of a fish bone. J Laryngol Otol 1991;105:157.

(4.) Foo TH. Migratory fish bone in the thyroid gland. Singapore Med J 1993;34:142-4.

(5.) Coret A, Heyman Z, Bendet E, et al. Thyroid abscess resulting from transesophageal migration of a fish bone: Ultrasound appearance. J Clin Ultrasound 1993;21:152-4.

(6.) Nandi P, Ong GB. Foreign body in the oesophagus: Review of 2394 cases. Br J Surg 1978;65:5-9.