INTRODUCTION
Foreign bodies (FBs) in the pharynx and the esophagus is a relatively common incidence in clinical practice.[1] FB in the esophagus presents a medical emergency and needs immediate evaluation and treatment. FB may be metallic or non-metallic objects.[2] FBs usually pass spontaneously through the gastrointestinal tract and do not result in any complications. However, very sharp or pointed FB may cause perforation in the wall of the digestive tract. In addition, retained FB may result in erosion of the gastrointestinal wall and abrasions with bleeding. However, sharp FB of the esophagus migrating to the soft tissue of the neck is rare. Emergency surgery is needed because of the neck’s specific anatomy and the important physiological functions of the organs.[3]
Sharp FB in the hypopharynx rarely penetrates through its wall because of its peristaltic movements, which help to migrate the FB into surrounding tissue.[4] The migrated FB in the neck may remain silently or cause different complications. Here, we are reporting a sharp metallic FB ingested, which penetrated through the hypopharyngeal wall and presented as neck pain.
CASE REPORT
A 16-year-old male was reported to the outpatient department of otolaryngology with complaints of pain in the left side of the neck for three days. He had a history of swallowing a piece of sharp metallic wire four days back. On the day of ingestion of FB, he had the symptom of mild pain during swallowing, whereas he developed pain in the left side of the neck the day after ingestion of FB. On examination, the patient was anxious but hemodynamically stable. There was swelling or redness of the neck skin on the left side. The skin overlying the swelling was intact. Palpation of the neck showed mild tenderness on the left side of the neck with no obvious mass or enlarged lymph nodes in the neck. The patient underwent a flexible nasopharyngolaryngoscopy and showed no FB in the oropharynx and larynx. X-ray of the soft tissue of the neck showed a sharp radio-opaque sharp FB in the neck [Figure 1]. It was suspected that FB might have penetrated the hypopharynx and migrated to the neck. The patient was planned for FB removal from the neck under general anesthesia. An injection of 2% xylocaine with adrenaline (1 in 2,00,000) was administered locally. The neck was opened at the site of the swelling and tenderness. About 1 cm incision was made over the pointed area of swelling. Approximately one centimeter below the skin, a sharp metallic wire was detected [Figure 2]. The sharp FB was retrieved safely with the help of artery forceps. The removed FB was a sharp metallic wire of 3 cm in length [Figure 3]. The patient was comfortable postoperatively. A follow-up X-ray of the neck was done after two days of the surgery and showed no obvious FB in the neck, and the patient was discharged from the hospital.
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Figure 1: X-ray of the neck showing the migrated sharp FB on the left side of the neck
Figure 2: Intraoperative picture showing removal of the sharp FB
Figure 3: A sharp metallic wire recovered after the exploration of the neck
DISCUSSION
Ingestion of FB is a common occurrence in the pediatric age group.[5] FB ingestion is relatively uncommon in the adult population unless intoxicated with alcohol or drug, or having a psychiatric illness.[5] The most common cause of FB ingestion is the accidental swallowing of objects.[2] In the case of children, they often put any object into their mouths and may accidentally swallow them. In adult age groups, accidental swallowing usually involves toothpicks, dentures, and turban pins.[5] Psychiatric patients may swallow a wide range of objects, including large and bizarre items. Most FB ingestions often come to attention after witnessing a child consuming the item, though radiological examination confirms the metallic FB.[6] A swallowed FB can become embedded in the palatine tonsil, the base of the tongue, the pyriform fossa, or any area in the upper part of the esophagus. FB in the aerodigestive tract is often seen intra-luminal. However, if the FB is sharp, it may get impacted at any locations of aerodigestive passage or can migrate because of penetration of its sharp end. Penetration and migration of sharp FB is more commonly found in the hypopharynx because of its peristaltic movements.[7] An FB lodged in the pharynx or esophagus may cause local inflammation, resulting in pain, bleeding, scarring, and obstruction, or it may cause erosion through the upper digestive tract. The sites of perforation by sharp FB appear variable in the digestive tract. The FB which is oriented transversely is more likely to penetrate than a vertically oriented FB.[7] Migrated FB may remain silent or may cause suppurative complications such as deep neck abscess, mediastinitis, and thyroid gland abscess or vascular complications by penetration of jugular vein, carotid artery, or branches of these vessels.[8] In this present case, the patient was only presenting mild pain and swelling on the left side of the neck without any evidence of suppuration and was suspected of migrated FB from the hypopharynx.
Initially, patients with penetrating FB may be asymptomatic, but most eventually manifest with an FB sensation, a sharp pricking sensation during swallowing, odynophagia, and/or hemoptysis. There may be suppurative complications accompanied by migrating FB that might produce fever and neck swelling. A raised white blood cell (WBC) count often raises suspicion. In this case, the patient was not presenting with odynophagia, fever, or hemoptysis. The availability of sophisticated investigation tools and instruments has allowed the removal of the FB easily by indirect or direct laryngoscopy. However, in some patients, sharp FB may perforate the upper digestive tract and migrate into the soft tissue of the neck. It is impossible to find or remove these FBs with the help of direct laryngoscopy. In such a situation, serious complications may happen and result in a high degree of morbidity or even death, particularly if the treating surgeon fails to identify or anticipate such FB anywhere.[9] The diagnosis of a migrating FB requires a high index of suspicion, and early intervention is required to avoid complications. One of the important and common tools used for identifying the FB in the upper digestive tract is the lateral neck X-ray. Pathology can be suspected when the plain X-ray shows (1) an FB, (2) associated soft tissue swelling of the neck, (3) abnormal gas accumulation in the soft tissue of the neck, (4) and/or loss of cervical lordosis.[10] Plain radiography is an effective investigation tool for localizing most radio-opaque objects.[11] Computed tomography (CT) scan or magnetic resonance imaging (MRI) is rarely needed but may enhance the localization of FB or its complications like migrations or perforation in special cases of FB.
Although the majority of the ingested FBs pass through the gastrointestinal tract harmlessly and patients require conservative management, 10 to 20% of them will need nonoperative intervention like endoscopy, and approximately 1% of them need surgical procedures.[12] The treatment of a sharp FB migrating from hypopharynx to neck requires neck exploration. Meticulous dissection and careful palpation of the adjacent structures of the neck are needed to locate the sharp FB in the neck and also for removal in a safe manner.
CONCLUSION
Ingested FB infrequently causes severe problems. However, complications such as migration of FB should always be kept in mind, and close follow-up should be required. FB ingestion followed by acute development of swelling and pain in the neck favors the diagnosis of extraluminal migration of FB or its penetration to surrounding tissues. Migrated FB may remain asymptomatic or sometimes cause suppurative complications in the neck. FB ingestions require careful and continued observation because of their possible serious complications. Imaging is helpful for confirmation of the sharp metallic FB. Careful neck exploration is required for the safe removal of the migrated FB.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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