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Foreign body in thyroid of 58-year-old male
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A 58-year-old man with a history of type 2 diabetes presented to the ED complaining of a foreign body sensation in his throat after eating fish the night before. Endoscopy with a Machida flexible nasopharyngoscope was unremarkable. Soft tissue films of the neck erroneously read by the ED was normal, and he was discharged home with instructions to return if his symptoms did not resolve.
Stephanie L. Lee
Foreign body identification
Six days later, the patient returned to the ED complaining of worsening neck pain. Repeat soft tissue neck films again showed a 1.8-cm linear, oblique, calcified density anterior to C6 and posterior to the thyroid cartilage (Figure 1; red arrow). Otolaryngology was consulted for further evaluation, and tenderness was found over the right thyroid lobe region with palpation. Fiberoptic laryngoscopy showed mild pooling of saliva at the esophageal inlet, but no foreign body was seen. A neck CT scan was obtained and showed that the foreign body perforated the anterior wall of the esophagus at the level of C6 and protruded laterally into the right lobe of the thyroid (Figure 2; red arrows) with a surrounding 1.5-cm peripherally enhancing fluid collection with small foci of air (Figure 2; arrowhead).
Figure 1. Lateral neck radiograph. The standard lateral neck X-ray shows a 1.8-cm linear, oblique, calcified density (red arrow) located anterior to C6 and posterior to the thyroid cartilage and the air column in the trachea.
The patient was started on broad-spectrum antibiotics and taken to the operating room for a direct laryngoscopy, direct esophagoscopy and drainage of deep neck abscess. Upon exposure, it was noted that at the level of the cricopharyngeus muscle, there was edema and some blood on the right side, but no foreign body was seen. Using optical forceps to explore the wound, a tract was found where the fishbone had migrated into the neck along with purulent discharge. A 2-cm fishbone was removed, the wound drained and a nasogastric tube was placed for nutrition and stenting. Postoperative course was uncomplicated. After a 14-day course of antibiotics, the nasogastric tube was discontinued after normal modified barium swallow. Outpatient follow-up thyroid-stimulating hormone remained normal, and a thyroid ultrasound showed a hypervascular tract adjacent to a nonspecific hypoechoic area in the medial portion of the right lobe, likely correlating with the course of the fishbone through the thyroid gland (Figure 3).
Figure 2. CT scan of the neck with contrast. A. Coronal image of the neck showing the fishbone (red arrow) penetrating the thyroid (relatively hyperdense, green arrow). Just superior to the fish bone is an abscess with air (blue arrowhead). B. Volume rendered soft tissue reformatted coronal view. The fishbone (red arrow) projects into the thyroid (outlined in blue). C. Reformatted volume rendered right anterior oblique image showing the fish bone (red arrow) extends from the esophagus located posterior to the trachea into the thyroid (outlined in blue).
Penetrating esophageal injuries
People frequently swallow foreign bodies that can pass through the digestive tract without any complications. Fortunately, penetrating esophageal injuries are uncommon, and an even smaller fraction of foreign objects migrate extraluminally. Remsen and colleagues performed analyses of 321 previously reported cases of penetrating ingested foreign bodies, of which 252 remained intraluminal and only 43 were found extraluminally. Approximately 90% of the fish bones are impacted in the suprahyoid location. This is the area of maximum soft tissue and bony density on the lateral cervical radiograph and, incidentally, a region that is ideally suited to examination by indirect laryngoscopy. Below the level of the oropharynx, common sites for foreign bodies are the valleculae, the pyriform sinuses, the cricopharyngeal region and the cervical esophagus. This patient demonstrates the uncommon occurrence of the foreign object penetrating the cricopharyngeal esophagus and even rarer occurrence of thyroid penetration.
The diagnosis of extraluminal foreign bodies is facilitated by a high index of suspicion. The lateral neck radiograph is the first imaging investigation to detect a fish bone, but interpretation of the lateral neck plain film can be difficult, as ingested foreign bodies can often be mistaken for calcified normal structures in the neck. A CT scan of the neck is helpful to determine the cause of unexplained neck abscess.
Figure 3. Thyroid ultrasound. Transverse view with Doppler of the right lobe of the thyroid. An area of increased vascular flow (red arrow) is located adjacent to a hypoechoic area (blue arrow) in the mid-posterior lobe that may represent changes after penetration and removal of the fishbone from the thyroid. The remainder of the thyroid ultrasound was normal.
The principles of management in esophageal perforation include elimination of septic focus, provision of adequate drainage, antibiotics and maintenance of adequate nutrition. This patient has no long-lasting effects of the fishbone esophageal penetration and abscess, with normal esophageal and thyroid function.