Case Report Auris·Nasus·Larynx (Tokyo) 19, 193-197 (1992)

MIGRATION OF FISHBONE FOLLOWING PENETRATION OF THE CERVICAL ESOPHAGUS PRESENTING

AS A THYROID MASS

Erez BENDET, M.D., Zeev HOROWITZ, M.D., Zahava HEYMAN, M.D.,* Meir FAIBEL, M.D.,* and Jona KRONENBERG, M.D.

Departments of Otolaryngology and *Radiology, Chaim Sheba Medical Center, Tel-Hashomer, and Tel-Aviv University Sackler School of Medicine, Israel

Fishbones are among the commonest foreign bodies lodged in the cervical esophagus. A small percentage of them will penetrate the esophageal wall and will be found either intra- or extraluminally. Migration of esophageal foreign bodies to the thyroid gland, and presentation as a mass, is extremely rare. We present such a case and review the relevant literature.

CASE REPORT

A 39-year-old, generally healthy, female reported to the emergency room several hours after a fish meal, complaining about dysphagia and cervical odyno­phagia. The physical examination and indirect hypopharyngoscopy and laryngo­scopy were normal. Lateral cervical X-rays were interpreted as normal. Fluo­roscopy of barium impregnated cotton wool swallowing did not show any obstruc­tion or a foreign body. The patient was discharged with instructions for follow-up visit in case the symptoms persist.

The patient reported back 5 days later complaining about dysphagia and pain in the left neck on swallowing. On examination, a tender, erythematous, goitrous swelling was noted in the left lower neck (Fig. 1 ). In fact, the clinical picture resembled acute thyroiditis. The rest of the physical examination was unremark­able.

Repeat lateral cervical X-rays demonstrated an elongated radioopaque foreign body superimposed on the tracheal silhouette (Fig. 2). Anteroposterior films failed to demonstrate the foreign body. She was put on a regimen of intravenous fluids and antibiotics. The patient underwent rigid esophagoscopy and laryngo­bronchoscopy, under general anesthesia, which did not reveal any foreign body or mucosal damage.

Received for publication January 24, 1992

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194 E. BENDET et a!

Fig. I. Goitrous swelling in the left lower neck.

Fig. 2. Lateral cervical film showing the fishbone (arrowheads) against the tracheal silhouette.

Ultrasonography demonstrated a 1.5 X 2.5 em, unclear fluid collection, just superficial and superoanterior to the left thyroid lobe. Within this lesion, a solid, linear, 2.6-cm-long object was described (Fig. 3). CT scan showed the fishbone just superoanterior to the left thyroid (Fig. 4). It was therefore elected to explore the region.

At the time of surgery, the bone was found right beneath the thyroid capsule

THYROID MASS-LIKE MIGRATED FISHBONE 195

Fig. 3. Longitudinal ultrasound scan showing an elongated solid object ( + ), with fluid collection, cranial to the left lobe of the thyroid gland.

Fig. 4. CT scan with the fishbone (arrowhead) anterior to the left thyroid. Left, soft tissue window; right, bone window.

and was removed without any need for thyroid lobectomy (Fig. 5). A drain was left for 24 hours. The postoperative course was uneventful and the patient was discharged after 4 days.

DISCUSSION

Only a small percentage of ingested foreign bodies perforate the esophagus and

196 E. BENDET et a!

Fig. 5. The extracted fishbone.

an even smaller fraction migrate extraluminally. Jackson and Jackson presented a series of 2,902 esophageal foreign bodies; only 31 were penetrating and none was extraluminal. 1 Nandi and Ong reported a series of 2,394 esophageal foreign bodies, of which 25 were penetrating, and only 1 was extraluminal. 2 In this series they found the cervical esophagus to be the commonest site for perforation: 22 out of 25 penetrations. Taylor also claims the cevical esophagus to be the most common site for perforation-70% of all esophageal perforations. 3

Remsen et al described four cases of penetrating-migrating foreign bodies and reviewed the world literature between 1818 and 1983 on penetrating foreign bodies. 4 This review includes 321 cases of penetrating foreign bodies, of which 252 remained intraluminal, and 43 were found extraluminally, with the status of the remainder indeterminate. Bones were the most common object for perforation both intra- and extraluminally. The cervical esophagus was the commonest site for penetration, either intraluminally (94 of 207) or extraluminally (22 of 40). The overall mortality associated with perforating foreign bodies was 45% in Remsen et al series.4 In the antibiotic era, the mortality was 44% for intraluminal penetrating foreign bodies, and 7% for those located extraluminally. The main causes of death were vascular ( aortoesophageal fistula, innominate-esophageal fistula, carotid rupture) and diffuse suppurative processes (mediastinitis, pericarditis). Interest­ingly, the mortality associated with extraluminallocation of pentrating foreign bodies of the cervical esophagus was very low-only one case out of 22 (4.5%).

Migration of penetrating esophageal foreign bodies is usually limited to the immediate vicinity of this organ. Migration to the thyroid is extremely rare. Jemerin and Aronoff reported, for the first time, three cases of thyroid abscesses caused by two chicken bones and one fish bone. 5 Remsen et al reported one case of thyroid abscess 3 years after swallowing dislodged incisor tooth.4 Recently, AI Muhanna et al described a case of penetrating-migrating fishbone which necessi­tated thyroid lobectomy.6

THYROID MASS-LIKE MIGRATED FISHBONE 197

CONCLUSION

The case reported here is unusual and demonstrates the migrating capacity of penetrating fishbones. This is the sixth case reported so far of a foreign body which penetrate the cervical esophagus, migrate, and become lodged in the thyroid gland. The clinical picture presented by this patient was that of acute thyroidis.

A novelty is the use of ultrasonography in this case. This imaging mode was never reported for the diagnosis and location of penetrating-migrating esophageal foreign bodies and its use is described here for the first time. Most solid foreign bodies will have acoustic shadow, and foreign bodies which are radioluscent (e.g. glass, plastics, etc.), can be located by the use of ultrasound.

Surgeons should be aware that fishbones can become lodged in the thyroid gland. Local neck swelling or pain with history of foreign body ingestion should alert the physician to the possibility of penetrating-migrating forein body. Even if esophagoscopy does not reveal any mucosal damage, a penetrating foreign body cannot be ruled out.

REFERENCES

I. Jackson C, Jackson CL: Diseases of the Air and Food Passages of Foreign Body Origin, Saunders, Philadelphia, 1936.

2. Nandi P, Ong GB: Foreign body in the esophagus: Review of 2394 cases. Br J Surg 65:5-9, 1978. 3. Taylor RB: Esophageal foreign bodies. Emer Med Clin North Am 5:301-311, 1987. 4. Remsen K, Lawson W, Biller HF, et al: Unusual presentations of penetrating foreign bodies of the

upper aerodigestive tract. Ann Otol Rhino] Laryngol (Suppl) 105:32-44, 1983. 5. Jemerin EE, Aronoff J: Foreign body in thyroid following penetration of esophagus. Surgery 25:

52-59, 1949. 6. AI Muhanna A, Abu Chra KA, Dashti H, et a!: Thyroid lobectomy for removal of a fish bone. J

Laryngol Otol 104:511-512, 1990.

Request reprints to: Dr. E. Bendet, Department of Otolaryngology, Chaim Sheba Medical Center, Tel-Hashomer, 52621 Israel