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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 3  |  Issue : 2  |  Page : 82-84

An unusual cause of long-standing foreign body sensation in throat


1 Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha ‘O’ Anusandhan University (Deemed to be), Bhubaneswar, Odisha, India
2 Division of Microbiology, ICMR-NIOH, Ahmedabad, Gujurat, India

Date of Submission20-Sep-2018
Date of Acceptance19-May-2019
Date of Web Publication25-Nov-2019

Correspondence Address:
Dr. Santosh Kumar Swain
Department of Otorhinolaryngology, IMS and SUM Hospital, Bhubaneswar - 751 003, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aiao.aiao_23_18

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  Abstract 


Foreign body (FB) sensation in the throat is often a common symptom encountered in clinical practice. FB sensation in throat has numerous causes. Long-standing FB in the soft tissue of the neck is sometimes asymptomatic and presents only with throat irritation or FB sensation, although it is an extremely rare incidence. The diagnosis of this clinical event is based on the clinical presentations and imaging. The treatment is done by securing the airway, removal of FB, and antibiotic coverage. Here, we report the case of a 16-year-old boy presenting with chicken bone embedded in the soft tissue of the posterior pharyngeal wall and retropharyngeal space for 2 months in the throat without any major symptoms except FB sensation. Imaging confirmed the diagnosis of chicken bone in the retropharyngeal space with mild abscess formation, which was removed by transoral approach.

Keywords: Chicken bone, foreign body sensation, retropharyngeal space, throat


How to cite this article:
Swain SK, Bhattacharyya B, Sahu MC. An unusual cause of long-standing foreign body sensation in throat. Ann Indian Acad Otorhinolaryngol Head Neck Surg 2019;3:82-4

How to cite this URL:
Swain SK, Bhattacharyya B, Sahu MC. An unusual cause of long-standing foreign body sensation in throat. Ann Indian Acad Otorhinolaryngol Head Neck Surg [serial online] 2019 [cited 2019 Dec 9];3:82-4. Available from: http://www.aiaohns.in/text.asp?2019/3/2/82/271599




  Introduction Top


Foreign body (FB) ingestion is a common clinical problem seen in otorhinolaryngological practice. FBs at the aerodigestive tract mostly occur when the objects are swallowed accidentally and sometimes act as a cause for morbidity and mortality both in the pediatric and elderly age group. It can be encountered in any age group and often seen in children, drug addicts, alcoholics, and psychiatric patients.[1] Most of the FBs pass through the gastrointestinal tract spontaneously. The clinical symptoms depend on the nature, size, site, and amount of time that has passed between the entry of FB and treatment.[2] However, sharp or large FBs are sometimes lodged at the aerodigestive tract, leading to the fatal complications. Potential fatal complications may happen on the basis of site and direction of movement. The shape of the FB is an important factor leading to fatal outcome. FB in the aerodigestive tract can lead to complications such as retropharyngeal or prevertebral abscess, tracheoesophageal fistula, mediastinitis, septicemia, and sometimes shock. Early diagnosis and removal of FB is essential for preventing severe complications. Penetration of retropharyngeal space by FB is a rare clinical incidence. The presence of FB in the retropharyngeal space is often accidental and leads to serious cause of morbidity and mortality in both adult and children. Here, we are presenting a case of sharp FB, i.e., chicken bone in the retropharyngeal space for prolonged period without any major symptom except FB sensation in the throat and the patient discharged with uneventful postoperative period.


  Case Report Top


A 16-year-old boy attended the outpatient department of otolaryngology with complaints of FB sensation in the throat for 2 months. He was also complaining intermittent mild pain during swallowing. The symptoms were not relieved by taking repeated medications from local physicians. By taking detailed history, he told these symptoms were occurring after taking chicken meal 2 months back. Indirect laryngoscopy examination showed normal oropharynx, hypopharynx, and larynx. Fiberoptic nasopharyngolaryngoscopy revealed normal larynx, oropharynx, and pyriform fossa except mild bulging on the posterior pharyngeal wall. Then, CT scan of the soft tissue of the neck was advised to rule out any neck or retropharyngeal pathology which showed mild widening of the prevertebral space with a radiopaque sharp FB without frank abscess [Figure 1]. Then, the patient was started with intravenous fluid and broad-spectrum antibiotics. He was planned for transoral incision over the posterior pharyngeal wall and FB removal. Under general anesthesia with oral intubation, a vertical incision was made over bulging area; a small white structure was seen with bony feeling FB. The FB was removed with the help of microlaryngeal forcep and found out as a bone which was nothing but chicken bone [Figure 2]. Scanty and very minimal amount of pus come out from the retropharyngeal space which was sent for culture and sensitivity. A Ryle's tube was kept for feeding and helping for healing of the wound. Postoperatively, the patient was started with broad-spectrum antibiotics and anti-inflammatory agents. The patient was discharged on the 4th postoperative day after removal of Ryle's tube without any symptoms.
Figure 1: Computed tomography scan of the soft tissue of the neck (lateral view) showing radiopaque foreign body at the retropharyngeal space

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Figure 2: Chicken bone extracted from the retropharyngeal space

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  Discussion Top


FB ingestion is a common clinical problem encountered in all age groups. Common FBs encountered are coins, button batteries, dentures, or bones.[3] Common sites for FB retention at the upper aerodigestive tract are palatine tonsils, base of the tongue, and upper part of the esophagus.[4] Retropharyngeal space is an uncommon location for FB impaction. The retropharyngeal space is present between the middle and deep layers of deep cervical fascia. The retropharyngeal space is seen posteriorly to the pharynx and bounded by the buccopharyngeal fascia anteriorly, prevertebral fascia posteriorly, and carotid sheath laterally. It extends from skull base superiorly to the mediastinum inferiorly. FB penetration into the retropharyngeal space may lead to secondary infection followed by abscess formation. Sometimes, the iatrogenic infections occur at the retropharyngeal space during instrumental injury, during laryngoscopy, Ryle's tube insertion and dental injection procedures where inoculation of microorganisms may occur directly into retropharyngeal space. In children, suppurative lymphadenitis at retropharyngeal space may lead to retropharyngeal abscess. Retropharyngeal abscess often results from infections of the upper aerodigestive tract or trauma such as accidental swallowing of FB or traumatic orotracheal intubation. The clinical presentations of the retropharyngeal abscess are often nonspecific in the initial period, such as irritability, decreased appetite, and fever. As the retropharyngeal abscess progresses, there may be odynophagia, dysphagia, hot-potato voice, sialorrhea, and muffled speech.[5] The severity of the symptoms is directly related to the amount of the abscess. It leads to respiratory distress if occludes the oropharyngeal or laryngopharyngeal airway.[6] Duration of the FB impaction is directly related to the appearance of complications.[7] If the FB is not extracted, it leads to pressure necrosis followed by perforation or abscess formation. Robotic process automation (RPA) is usually polymicrobial, and common microorganisms are Group A beta-hemolytic Streptococcus, Staphylococcus aureus, and upper respiratory tract anaerobic organisms.[8] Early removal of FB is an important step to control complications. FB ingestion may lead to fatal complications such as pharyngoesophageal perforation, carotid artery rupture, aortoesophageal fistula, and deep neck space infections.[9] These fatal complications are usually avoided if FB is removed immediately. A piece of chicken bone staying at the retropharyngeal space for prolonged period without any major complications is an extremely rare clinical entity. The retropharyngeal abscess with chicken bone requires prompt diagnosis and early treatment for achieving the best outcome. Investigation is usually done by imaging, which helps for detection of the source of infection and extent and progression of the pathology at the retropharyngeal space. X-ray of the soft tissue of the neck with lateral view makes diagnosis of FB in the retropharyngeal space or abscess at this space. Computed tomography and magnetic resonance imaging will reveal the infections of other neck spaces and monitor the abscess spread into different compartment of the neck.[10] Starting early parenteral broad-spectrum antibiotics is an important step for preventing the infection and abscess formation. Treatment of retropharyngeal abscess needs intravenous antibiotics, rehydration, and abscess drainage with the help of general anesthesia under guidance of expert anesthetist.[11] In case of large RPA, securing adequate airway is an important step during treatment. There are different approaches for drainage abscess and removals of FB are transoral, transcervical, endoscopic transnasal, or combined.[12] The transoral approach is often helpful in acute RPA. If the RPA spreads into parapharyngeal abscess or recurrent RPA after transoral approach, transcervical approach is a good option. If there is only cellulitis in retropharyngeal space, parenteral antibiotics are alone helpful for management and carefully monitored for future development of an abscess. In this case, under general anesthesia, an incision was made on the posteriorly bulged retropharyngeal wall and then FB/chicken bone removed with minimal drainage of pus. The cold abscess at the retropharyngeal space due to tuberculosis is better managed by the transcervical approach. Combined approach such as transoral and transcervical is rarely needed in RPA. FB at the retropharyngeal space is a serious cause for morbidity and mortality among children and adults. Due to possibility of fatal complications such as abscess compromising the airway or rupture of the abscess and aspiration into the lungs, rapid and accurate diagnosis are necessary for early treatment. The fatal outcome of RPA can be avoided by vigilance, proper evaluation, and aggressive management.


  Conclusion Top


Long-standing FB sensation of throat delays the diagnosis which results in retropharyngeal abscess. FB penetrating into retropharyngeal space accidentally staying for long time without any symptoms is extremely rare. The delayed diagnosis and retropharyngeal abscess may result in high morbidity and mortality. It needs prompt diagnosis and immediate surgery is mandatory. Physicians should maintain a high index of suspicion when encountering the unexplained FB sensation in throat or throat pain and should do needful investigations for delaying diagnosis, which may lead to fatal complications.

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.



 
  References Top

1.
Krišto B, Krželj I. Foreign body in the esophagus: Chronically impacted partial denture without serious complication. Otolaryngol Case Rep 2016;1:5-7.  Back to cited text no. 1
    
2.
Emara MH, Darwiesh EM, Refaey MM, Galal SM. Endoscopic removal of foreign bodies from the upper gastrointestinal tract: 5-year experience. Clin Exp Gastroenterol 2014;7:249-53.  Back to cited text no. 2
    
3.
Shivkumar AM, Naik AS, Prashanth KB, Girish F, Hongal GF, Chaturvedy G. Foreign bodies in upper digestive tract. Indian J Otolaryngol Head Neck Surg 2006;58:63-8.  Back to cited text no. 3
    
4.
Swain SK, Singh N, Sahu MC. An unusual presentation of fish bone ingestion in an adolescent girl-a case report. Egypt J Ear Nose Throat Allied Sci 2016;17:95-7.  Back to cited text no. 4
    
5.
Soong WJ, Jeng MJ, Hwang B. Respiratory support of children with a retropharyngeal abscess with nasal CPAP. Clin Pediatr (Phila) 2001;40:55-6.  Back to cited text no. 5
    
6.
Kirse DJ, Roberson DW. Surgical management of retropharyngeal space infections in children. Laryngoscope 2001;111:1413-22.  Back to cited text no. 6
    
7.
Gregori D, Scarinzi C, Morra B, Salerni L, Berchialla P, Snidero S, et al. Ingested foreign bodies causing complications and requiring hospitalization in European children: Results from the ESFBI study. Pediatr Int 2010;52:26-32.  Back to cited text no. 7
    
8.
Courtney MJ, Mahadevan M, Miteff A. Management of paediatric retropharyngeal infections: Non-surgical versus surgical. ANZ J Surg 2007;77:985-7.  Back to cited text no. 8
    
9.
Wang S, Liu J, Chen Y, Yang X, Xie D, Li S, et al. Diagnosis and treatment of nine cases with carotid artery rupture due to hypopharyngeal and cervical esophageal foreign body ingestion. Eur Arch Otorhinolaryngol 2013;270:1125-30.  Back to cited text no. 9
    
10.
Swain SK, Sahu MC. Retropharyngeal abscess leading to fatal airway obstruction in a child-a case report. Pediatr Pol 2016;91:370-3.  Back to cited text no. 10
    
11.
Wong DK, Brown C, Mills N, Spielmann P, Neeff M. To drain or not to drain – Management of pediatric deep neck abscesses: A case-control study. Int J Pediatr Otorhinolaryngol 2012;76:1810-3.  Back to cited text no. 11
    
12.
Schuler PJ, Cohnen M, Greve J, Plettenberg C, Chereath J, Bas M, et al. Surgical management of retropharyngeal abscesses. Acta Otolaryngol 2009;129:1274-9.  Back to cited text no. 12
    


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