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Non-invasive diagnostic tools in the field of head and neck oncology : A liquid biopsy for head and neck cancers

The development of a liquid biopsy for head and neck cancers via  ScienceDirect Publication: Oral Oncology Publication ...

Τρίτη, 1 Νοεμβρίου 2016

Migrated pharyngeal foreign body to the prevertebral muscle

The travelling fish bone: 
Source:Egyptian Journal of Ear, Nose, Throat and Allied Sciences
Author(s): Reuben Abraham Thomas, Chiun Kian Chai, Ing Ping Tang
Foreign bodies that are impacted in the upper aerodigestive tract are often encountered in a day to day ENT practice. Most of them could usually be removed in a clinic setting but some may require comprehensive imaging and surgery to extricate them. This paper depicts a patient’s self-induced traumatic attempt to remove a huge serrated fish bone that was lodged at the hypopharynx which made its way to the prevertebral soft tissue space compelling an open surgical procedure with neck exploration for definite treatment.

1. Introduction

Impaction of foreign bodies in the upper aerodigestive tract is a serious condition in ENT practice; if left untreated, it can lead to potentially fatal complications including retropharyngeal or prevertebral abcesses, mediastinitis and tracheoesophageal fistula which may cause septicaemia and shock. If a patient presents early to an ENT setting without prior tampering or blindly attempting to remove it, it could most of the time be removed endoscopically but this may not always be the case.

2. Case report

A 66-year-old female patient was presented to the emergency department of a local district hospital with severe symptoms of dysphagia and diffuse anterior and posterior neck pain with limited and fixed range of motion of the neck after a day’s history of ingesting a large fish bone. A radiograph of the lateral neck revealed a fish bone at the level of the 4th and 5th cervical vertebrae and she underwent a flexible nasopharyngolaryngoscopy in the clinic for diagnostic and therapeutic reasons; unfortunately, there was no pooling of saliva and no foreign body was seen.
Further history revealed that upon ingestion of the fish bone, the patient was vigorously attempting to swallow and push the foreign body down by gouging and stuffing her mouth with large boluses of rice prior to seeking medical attention. As there was widening of prevertebral space from the neck X-ray with increasing pain at the neck, a computed tomography (CT) scan was performed. From the CT scan the foreign body was visualised in the prevertebral soft tissue space from the midpoint of the C4 vertebral body extending inferiorly towards the left side of the C5 vertebral body. No CT evidence of retropharyngeal collection or abcess was present (Fig. 1).
Plain lateral neck X-ray showed fish bone at C4-C5 region as well as CT scans ...
Fig. 1. 
Plain lateral neck X-ray showed fish bone at C4-C5 region as well as CT scans (axial & 3D reconstruction views) revealed fish bone traversing adjacent to the C4-C5 vertebral body.
She underwent removal of foreign body under general anaesthesia in view of the location. The surgeon performed an initial neck exploration but could not locate the fishbone. A CT 3D reconstruction (Fig. 1) was performed to relocate the fish bone with skin marking prior to transfer to a tertiary centre for further exploration.
Further neck exploration at a tertiary centre, with extension of the previous incision posteriorly, retraction of the sternocleidomastoid muscle and carotid sheath posteriorly, the fish bone was found piercing through the prevertebral muscles most likely the longus colli muscle (Fig. 2). The fish bone was removed. Fortunately, there were no injuries noted at the neighbouring vital structures. Postoperatively she was well without any complications and was discharged on the third day. Her follow-up a week after surgery was uneventful.
Intraoperative view of the wide surgical field to retrieve the serrated fish ...
Fig. 2. 
Intraoperative view of the wide surgical field to retrieve the serrated fish bone which has pierced the pre-vertebral muscles.

3. Discussion

Foreign bodies that are lodged in the upper aerodigestive tract which are most common in South-East Asian regions are fish bones, because fish are prepared and cooked as a whole with bones, compared to the western countries where fish are cooked in the form of fillets or patties. The number of ingested foreign bodies that perforated the upper gastrointestinal tract is small and the incidence of foreign body that migrated extraluminally is rare. Chee and Sethi1 reported the largest series of 24 migrated foreign bodies in the neck. They noted that 18 (75%) of these objects had been removed within 24 h. All of the foreign bodies in their series were sharp and linear. In the series published by Remsen et al.2, out of the 321 cases of penetrating foreign bodies reviewed, only 43 were found extraluminally.
The nature by which these foreign bodies propel through the delicate tissues of the neck is not known but rather it has been proposed to be because of a sequence of esophageal peristalsis and neck movements with the combination of carotid pulsations. Tissue response to the foreign body, abcess and infection could likewise have an impact in propulsion extraluminally. Some Asians believe that gulping some rice will push the foreign body into the stomach which was what the patient attempted. Whether this practice will increase the prospect of foreign bodies migrating extraluminally remains debatable.
Usually a plain X-ray is used to affirm the diagnosis of an ingested fish bone, but it is challenging to tell if it has migrated extraluminally. In our case, an urgent plain CT scan was done but it was difficult to determine the fish bone’s distance and orientation. Lue et al.3reported a sensitivity and specificity of 39% and 72%, respectively, for their plain radiographs to identify fish bone foreign bodies. A CT scan of the neck utilizes extra fine cuts of 1 mm of choice and is invaluable in confirming the presence of the foreign body.1Yoo et al.4 proposed that the axial CT image or 3D images are both useful and best for calculating distance, shape, size, location and orientation from the reference point.
Potentially fatal complications may arise depending on the direction and site of the migrating fish bone. In our case, the patient was fortunate that the fish bone did not pierce or damage vital structures of the neck despite vigorous attempts to swallow the fish bone. The shape of the foreign body is the most important factor in the pathology of migration.[5] and [6]The literature describes saw-toothed fish bones (Fig. 3) as being capable of penetrating deeper into the retropharyngeal space. The fixed and limited movements of the neck together with diffuse posterior neck pain in our patient could have been due to the inflammation of surrounding tissues around the longus colli muscle to where the fish bone has travelled and lodged.
Serrated fish bone measuring 4.4cm.
Fig. 3. 
Serrated fish bone measuring 4.4 cm.

4. Conclusion

Good clinical judgement is needed to diagnose a migrating foreign body. Early intervention should be taken if a foreign body is not located endoscopically and suspected extraluminally. Exploration for a migrated foreign body has been described by some otolaryngologists to be like finding a needle in a haystack. Our case report would help to create an understanding of these conditions and therefore a CT scan, be it plain, contrasted or with 3D reconstruction is useful in locating such foreign bodies preoperatively.


    • [2]
    • K. Remsen, W. Lawson, H.F. Biller, M.L. Som
    • Unusual presentations of penetrating foreign bodies of the upper aerodigestive tract
    • Ann Otol Rhinol Laryngol Suppl, 105 (1983), pp. 32–44
    •  | 
    • [3]
    • A.J. Lue, W.D. Fang, S. Manolidis
    • Use of plain radiograph and computed tomography to identify fish bone foreign bodies
    • Otolaryngol Head Neck Surg, 123 (4) (2000), pp. 435–438
    •  | 
    •  PDF (135 K)
 |   | 
    • [4]
    • Y.S. Yoo, H.B. Lee, J.H. Choi, K.R. Cho
    • 3D Reconstruction to detect fish bones in foreign body models
    • Otolaryngol Head Neck Surg, 147 (2 suppl) (2012), pp. P71–P72
    • [5]
    • Y.C. Cheng, W.C. Lee, L.C. Kuo, C.W. Chen, H.L. Lin
    • Protrusion of a migrated fish bone in the neck
    • Am J Otolaryngol, 30 (3) (2009), pp. 203–205
    •  | 
    •  PDF (298 K)
  •  |   | 
    • [6]
    • E. Maseda, A. Ablanedo, C. Baldo, M.J. Fernandez
    • Migration and extrusion from the upper digestive tract to the skin of the neck of a foreign body (fish bone)
    • Acta Otorrinolaringol Esp, 57 (10) (2006), pp. 474–476
    •  | 
    •  PDF (105 K)
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    Below is an alphabetical list of the educational picture slideshows available on eMedicineHealth. Each slideshow covers a medical or health topic and includes images, illustrations, or pictures and summary information discussing the topic. Scroll through each slide by clicking on the Next button. At the end of each slideshow you'll find links to additional related information on the topic.



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    "I swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgment, the following Oath and agreement:

    To consider dear to me, as my parents, him who taught me this art; to live in common with him and, if necessary, to share my goods with him; To look upon his children as my own brothers, to teach them this art.

    I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.

    I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessaryto cause an abortion.

    But I will preserve the purity of my life and my arts.

    I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art.

    In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with men, be they free or slaves.

    All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal.

    If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot."


    "Almighty God, Thou has created the human body with infinite wisdom. Ten thousand times ten thousand organs hast Thou combined in it that act unceasingly and harmoniously to preserve the whole in all its beauty the body which is the envelope of the immortal soul. They are ever acting in perfect order, agreement and accord. Yet, when the frailty of matter or the unbridling of passions deranges this order or interrupts this accord, then forces clash and the body crumbles into the primal dust from which it came. Thou sendest to man diseases as beneficent messengers to foretell approaching danger and to urge him to avert it.

    "Thou has blest Thine earth, Thy rivers and Thy mountains with healing substances; they enable Thy creatures to alleviate their sufferings and to heal their illnesses. Thou hast endowed man with the wisdom to relieve the suffering of his brother, to recognize his disorders, to extract the healing substances, to discover their powers and to prepare and to apply them to suit every ill. In Thine Eternal Providence Thou hast chosen me to watch over the life and health of Thy creatures. I am now about to apply myself to the duties of my profession. Support me, Almighty God, in these great labors that they may benefit mankind, for without Thy help not even the least thing will succeed.

    "Inspire me with love for my art and for Thy creatures. Do not allow thirst for profit, ambition for renown and admiration, to interfere with my profession, for these are the enemies of truth and of love for mankind and they can lead astray in the great task of attending to the welfare of Thy creatures. Preserve the strength of my body and of my soul that they ever be ready to cheerfully help and support rich and poor, good and bad, enemy as well as friend. In the sufferer let me see only the human being. Illumine my mind that it recognize what presents itself and that it may comprehend what is absent or hidden. Let it not fail to see what is visible, but do not permit it to arrogate to itself the power to see what cannot be seen, for delicate and indefinite are the bounds of the great art of caring for the lives and health of Thy creatures. Let me never be absent- minded. May no strange thoughts divert my attention at the bedside of the sick, or disturb my mind in its silent labors, for great and sacred are the thoughtful deliberations required to preserve the lives and health of Thy creatures.

    "Grant that my patients have confidence in me and my art and follow my directions and my counsel. Remove from their midst all charlatans and the whole host of officious relatives and know-all nurses, cruel people who arrogantly frustrate the wisest purposes of our art and often lead Thy creatures to their death.

    "Should those who are wiser than I wish to improve and instruct me, let my soul gratefully follow their guidance; for vast is the extent of our art. Should conceited fools, however, censure me, then let love for my profession steel me against them, so that I remain steadfast without regard for age, for reputation, or for honor, because surrender would bring to Thy creatures sickness and death.

    "Imbue my soul with gentleness and calmness when older colleagues, proud of their age, wish to displace me or to scorn me or disdainfully to teach me. May even this be of advantage to me, for they know many things of which I am ignorant, but let not their arrogance give me pain. For they are old and old age is not master of the passions. I also hope to attain old age upon this earth, before Thee, Almighty God!

    "Let me be contented in everything except in the great science of my profession. Never allow the thought to arise in me that I have attained to sufficient knowledge, but vouchsafe to me the strength, the leisure and the ambition ever to extend my knowledge. For art is great, but the mind of man is ever expanding.

    "Almighty God! Thou hast chosen me in Thy mercy to watch over the life and death of Thy creatures. I now apply myself to my profession. Support me in this great task so that it may benefit mankind, for without Thy help not even the least thing will succeed."

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    Modern challenged parts of the oath:

    1. To teach medicine to the sons of my teacher. In the past, medical schools gave preferential consideration to the children of physicians.
    2. To practice and prescribe to the best of my ability for the good of my patients, and to try to avoid harming them. This beneficial intention is the purpose of the physician. However, this item is still invoked in the modern discussions of euthanasia.
    3. I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan. Physician organizations in most countries have strongly denounced physician participation in legal executions. However, in a small number of cases, most notably the U.S. states of Oregon,[10] Washington,[11]Montana,[12] and in the Kingdom of the Netherlands,[13] a doctor can prescribe euthanasia with the patient's consent.
    4. Similarly, I will not give a woman a pessary to cause an abortion. Since the legalization of abortion in many countries, the inclusion of the anti-abortion sentence of the Hippocratic oath has been a source of contention.
    5. To avoid violating the morals of my community. Many licensing agencies will revoke a physician's license for offending the morals of the community ("moral turpitude").
    6. I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art. The "stones" referred to are kidney stones or bladder stones, removal of which was judged too menial for physicians, and therefore was left for barbers (the forerunners of modern surgeons). Surgery was not recognized as a specialty at that time. This sentence is now interpreted as acknowledging that it is impossible for any single physician to maintain expertise in all areas. It also highlights the different historical origins of the surgeon and the physician.
    7. To keep the good of the patient as the highest priority. There may be other conflicting 'good purposes,' such as community welfare, conserving economic resources, supporting the criminal justice system, or simply making money for the physician or his employer that provide recurring challenges to physicians


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