FISH BONE INJURIES OF THE UPPER AERODIGESTIVE TRACT
Ketan R Vagholkar
Lecturer, Department of Surgery, Padmashree Dr. DY Patil Medical College and Rajawadi Municipal General Hospital, Ghatkopar, Mumbai 400 077, India.
Fish bones are amongst the commonest of foreign bodies causing complications in the upper aerodigestive tract. The complications range from perforation to formation of pseudoaneurysms of the external carotid artery. An atypical presentation of transmigration of the fish bone across the neck is presented. Awareness of all possible complications due to fish bones is essential to avoid misdiagnosis.
Fish bones are amongst the commonest of foreign bodies in the upper aerodigestive tract. An acute presentation of a fish bone impaction calls for prompt diagnosis and treatment, whereas a subacute or chronic presentation is invariably overlooked and as a result misdiagnosed. This can lead to lethal complications. Awareness of the various lesions caused by fish bone injuries is therefore necessary to avert complications. An atypical presentation of transmigration of a fish bone from the oropharynx to the exterior across the neck is presented.
A 58 year old male patient presented with complaints of a swelling in the neck, since 6 months. There were no other systemic or local symptoms. Patient gave a history of fish bone injury 4 years back which caused pain for a short duration. However since his symptoms subsided within a short time, the patient did not seek surgical advice. On examination of the neck there was a nodular swelling on the right side of the neck. It was firm in consistency and immobile. Intra oral examination did not reveal any abnormality. An X-ray of the neck region revealed a foreign body of a shape of a fish bone (Fig. 1). The foreign body was excised under local anaesthesia. The foreign body was a fish bone (Fig. 2).
Fish bone injuries can cause considerable trauma not only to the upper aerodigestive tract but also to any other portion of the gastrointestinal tract. The morbidity associated with these lesions is quite high. This is due to the fact that a foreign body ingestion is invariably overlooked in a subacute or delayed presentation. Due to the long duration of existence of the fish bone in the body, considerable damage is caused. The severity of damage caused by a fish bone may be attributed to certain predisposing factors. These include age of the patient, and radiological characteristics of the fish bone. Paediatric age group patients usually present with pulmonary complications while older patients present with retropharyngeal abscesses. Delayed presentation is usually to be seen in younger age group of patients. Radiolucency of the fish bone has been shown to be associated with a high incidence of complications. Careful observation is therefore essential in all cases of foreign body injuries irrespective of the age and mode of presentation. The complication may take the form of perforation, retropharyngeal abscesses, pulmonary complications or pseudoaneurysms formation. Perforations may occur at any level of the gastrointestinal tract. These include perforation of the oesophagus, stomach, duodenum, small bowel especially the ileum with injuries to the mesenteric vessels resulting in massive bleeding. On rare occasions even the caecum and colon may be affected. These fish bones if left untreated may tansmigrate and cause damage to the intervening structures. Various atypical presentations have been reported. A case of false aneurysm of the external carotid artery following impaction of a fish bone in the pharynx has been reported by Okafor. An incorrect diagnosis in this case reported by Okafor led to a near fatal accident. In the case presented the phenomenon of transmigration of the foreign body has been documented. Therefore the possibility of damage to the structures along the path of migration should be borne in mind. It is therefore concluded that it is possible to make a preoperative diagnosis of complication arising from fish bone injury given sufficient awareness of its possibilities. In case of delayed presentation where a definitive diagnosis is not made and surgical intervention is not warranted yet close observation is essential to avert complications.
Fig. 1 : X-ray of the neck showing a radioopaque fish bone.
Fig. 2 : Fish bone projecting from the surface of the skin
I thank Dr. Suvarna Vagholkar for her help in preparing the manuscript and photographs.
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