|Year : 2015 | Volume
| Issue : 1 | Page : 81-83
An unsuspected foreign body: How we managed it
Vishnu Prasad1, Vijendra S Shenoy1, Panduranga M Kamath1, Santhosh P. V. Rai2, Neethu Mary Mathew1
1 Department of ENT and Head and Neck Surgery, Kasturba Medical College, Manipal University, Mangalore, Karnataka, India
2 Department of Radiodiagnosis, Kasturba Medical College, Manipal University, Mangalore, Karnataka, India
|Date of Web Publication||8-Dec-2014|
Vijendra S Shenoy
Department of Otolaryngology, Kasturba Medical College Hospital, Manipal University, Attavar, Mangalore - 575 001, Karnataka
Source of Support: None, Conflict of Interest: None
Ingestion or inhalation of foreign bodies can prove to be a diagnostic challenge. Unexplained throat pain and acute onset of dysphagia in an elderly patient should alert the clinician to the possibility of accidental foreign body ingestion. A patient presented with complaints of sudden onset of difficulty and pain in swallowing associated with ear pain, neck pain, and hypersalivation. The examination was within normal limits. It was on radiology that the suspicion of a foreign body was aroused. During esophagoscopy, an unsuspecting foreign body was discovered; a lower partial denture, swallowed unknowingly by the patient four days previously. Postoperatively the patient was stable. The case demonstrates how the clinician must have a high index of suspicion of foreign body ingestion, should a patient present with such symptoms. It also demonstrates the need for immediate and prompt intervention in order to prevent progression to fatal complications.
Keywords: Dysphagia, foreign body, dentures
|How to cite this article:|
Prasad V, Shenoy VS, Kamath PM, Rai SP, Mathew NM. An unsuspected foreign body: How we managed it. Muller J Med Sci Res 2015;6:81-3
|How to cite this URL:|
Prasad V, Shenoy VS, Kamath PM, Rai SP, Mathew NM. An unsuspected foreign body: How we managed it. Muller J Med Sci Res [serial online] 2015 [cited 2020 May 26];6:81-3. Available from: http://www.mjmsr.net/text.asp?2015/6/1/81/146473
| Introduction|| |
Ingestion and / or aspiration of foreign bodies are avoidable incidents. However, it is a common occurrence and carries significant morbidity and mortality. Although most of the ingested foreign bodies tend to be spontaneously expelled out, a large proportion of cases present with foreign bodies that get impacted within the aerodigestive tract. With respect to symptoms of foreign body ingestion and in aspiration there are three clinical phases. The initial or first stage, which happens during impaction of the foreign body, usually demonstrates choking, gagging, and paroxysms of coughing, vomiting, obstruction of the airway, occurring at the time of aspiration or ingestion. These signs tend to calm down when the foreign body lodges, and the reflexes grow weary. This is the second stage or the asymptomatic phase.
Complications occur in the third stage (also defined as complications phase), when the obstruction, erosion or infection causes pneumonia, atelectasis, abscess, fever or dysphagia, or mediastinal abscess, perforation or erosion into the esophagus. However, the first symptoms that are usually met with at a medical care center tend to be a complication as a result of impaction of a foreign body. We report the case of unknown accidental foreign body ingestion (denture), following which there was development of a retropharyngeal abscess.
| Case Report|| |
A 56-year-old male patient, with no comorbid illnesses, presented with a chief complaint of a three-day history of sudden difficulty in swallowing and severe pain on swallowing, which developed following one episode of vomiting during travel. The vomiting was attributed to motion sickness. There was also a history of associated bilateral ear pain. He also gave a history of neck pain and stiffness, which developed two days later. A history of excessive salivation was also elicited. There was no history of fever, blood-stained sputum, cough or neck swelling. On examination the vitals of the patient were stable and systemic and ear, nose, and throat (ENT) examination of the patient was within normal limits. A videolaryngoscopy done showed a bulge on the left side of the posterior pharyngeal wall. The bilateral vocal cords were mobile on respiration and phonation [Figure 1]. The patient was admitted for further evaluation and kept on an intravenous antibiotic cover during admission. An x-ray of the neck was taken, which showed a radiopaque shadow within the esophagus, suspicious of a foreign body. Further investigation of the patient in the form of a contrast-enhanced CT scan was taken, which revealed a thickening in the retropharyngeal space, extending from C5 to C8 levels, measuring 65 mm in length, and 18 mm in thickness. There was a hyperdense structure in the retropharyngeal tissue, which had a peculiar shape not conforming to a particular lesion [Figure 2]. The patient was posted for drainage of the potential abscess under general anesthesia. Prior to opening the retropharyngeal space a direct laryngoscopic examination of the upper aerodigestive tract was done. On direct scopy an unsuspecting foreign body was discovered impacted at the level of the cricopharynx causing an injury in the surrounding mucosa. The foreign body, a lower partial denture, 7 cm by 2 cm, [Figure 3] was retrieved, and a Ryles tube was secured for postoperative feeding [Figure 4]. Post surgery, on further probing, the patient revealed the use of lower partial dentures, which went missing following his episode of vomiting. He had, however, unknowingly swallowed it. The postoperative period was uneventful. On follow up, the patient presented with no complaints and had improved symptomatically and considerably.
|Figure 2: Contrast-enhanced CT imaging of the neck of the patient - Sagittal image (a) revealed widening of the retropharyngeal space due to the thickening, collection, and hyperdensity within. (b) The coronal reformat showed the hyperdensity to be of a peculiar shape|
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|Figure 3: Foreign body (lower partial denture) retrieved with a rigid esophagoscope|
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|Figure 4: Postoperative picture of the patient with a Ryles tube in situ, and missing the lower central incisors|
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| Discussion|| |
Accidental swallowing and ingestion of foreign bodies have often been reported in literature, with swallowing being more common than aspiration, and most often seen in the elderly.  Frequently, a history of accidental ingestion or clinical signs are not apparent. Careful examination and evaluation of the symptoms are, therefore, necessary to evaluate the possibility of the presence of a foreign body. A high index of suspicion should arise based on the clinical picture. Very often the size and configuration of these objects compound their impaction and removal.  Ingestion usually occurs after trauma, intoxication, and loss of consciousness or sleep, so there may not be a definite history of ingestion.  Following foreign body ingestion, the patients usually present with dysphagia (92%) and tenderness of the neck (60%).  Other symptoms include: Inability to swallow oral secretions, throat pain, painful swallowing, hypersalivation, retrosternal fullness and regurgitation of undigested food. Indirect laryngoscopy will usually reveal pooling of saliva in the pyriform fossa.
In a study by Kamath et al.,  on foreign bodies in the aerodigestive tract, 86.2% of the cases were found to have a foreign body lodged in the pharyngoesophagus and in 13.7% of the cases it was lodged in the tracheobronchial tree. The study brought to light that pharyngoesophageal foreign bodies commonly presented with symptoms of dysphagia (64%) and odynophagia (45%).
Radiological imaging can to a certain degree determine the exact site of a radiopaque foreign body. Impacted dentures are usually difficult to localize unless there is a wire attached to it and if there are associated features of complications, such as, emphysema, mediastinitis, increased prevertebral shadow, and loss of cervical lordosis. Their radiolucence makes radiological localization almost impossible, and because of their rigidity, large size, irregular, and unyielding edges, impacted dentures are apt to produce lacerations during endoscopic removal from the esophagus rendered friable by impaction.  However, in the absence of a positive history, radiological imaging is advisable, as it provides either a direct or indirect evidence of a foreign body (in at least 81.2% of the cases).  Jones et al.,  depicted radiographs to be useful in only 11.9% of their cases. Although radiographs may not confirm or rule out the presence of a foreign body, the advantages of finding one on a radiograph far outweigh the disadvantages of missing one. They also provide additional information regarding the condition of the cervical spine for rigid endoscopy.
Sharp foreign bodies are especially prone to cause perforation, and thereby, lead to complications. The commonly encountered complications are retropharyngeal abscess, perforation to the esophagus, aorta, pericardium, and gastrointestinal tract. There is a also possibility of damage to the vital structures along the path of migration of the object. ,,, The esophageal foreign bodies are commonly impacted at the level of the cervical esophagus and are usually amenable to extraction via rigid endoscopy. Other methods include esophagostomy; however, the procedure is associated with a higher rate of postoperative complications.
A foreign body impacted in the esophagus should be removed as soon as the diagnosis is made, for the following reasons: The chance of spontaneous passage is small; edema from the local trauma grips the object firmly, making later manipulation difficult; and perforation of the esophagus is a very serious complication, with high mortality and morbidity. In a case report by Kamath et al.,  a fascinating and potentially life-threatening complication of mediastinitis with empyema was reported that resulted from delayed diagnosis of an upper esophageal foreign body, further highlighting the need for early intervention rather than conservative management of symptoms.
The case brings to light certain changes that may be done to avoid such a situation. Careful thought should be placed when a dental prosthesis is planned. Possible embedding of a radiopaque marker into the denture must be considered. Care workers should be wary of possible ingestion or inhalation of dentures in the event of a missing prosthesis.
| Conclusion|| |
In the presence of a positive history, prompt management is safe and effective, to reduce the significant morbidity and mortality. This case exhibits the importance of a high index of suspicion when a patient presents with such an acute history of grave symptoms, in the absence of a positive history. The case reveals the importance and need for immediate and prompt diagnosis of foreign body ingestion, prior to the development of extensive complications. It also exhibits the significance of instant radical surgery for the removal of such large incriminating foreign bodies.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]