Paediatric radiology
Case TypeClinical Cases
Authors
Andre Tjie Wijaya, Ni Nyoman Margiani, Firman Parulian Sitanggang
12 years, male
A 12-year-old boy came with an impacted fishbone when he ate a fish six days before. He felt pain, dysphagia with swelling, and redness on his neck. The patient underwent enhanced neck CT followed by drainage and tracheostomy procedures due to airway narrowing. There were no complications during the inpatient care, and the patient went home. One month later, he came back with a hole on the left side of his neck with pus and fluid flowing out.
Scout CT:
An enlarged prevertebral soft tissue with air-fluid level and multiple air bubbles is shown. There is also a foreign body in the prevertebral soft tissue at level C4-5 (Fig. 1).
Enhanced neck CT:
There is a lesion with a component of fluid and air on the prevertebral soft tissue at the level of C2-C7 with enhancement on its wall (Fig. 2a, b). The size of the lesion is 5.5 x 7.6 x 4.2 cm.
There is a foreign body with the size of ± 2 cm in the prevertebral soft tissue.
On volume rendering (Fig. 3), the foreign body has a sickle-like shape.
Cervical radiograph:
There is a thickening of the prevertebral soft tissue with an air-fluid level at level C2-C7. No sign of a radioopaque foreign body (Fig. 4). Note that there is also a tracheostomy tube.
Fistulography:
Contrast media from a hole at the left side of the neck is entering the oesophagus through a tract (Fig. 4).
Background
Fishbone foreign body (FFB) is a common clinical problem, especially in the area with high consumption of fish [1]. Most fish bones pass through the gastrointestinal tract and pass spontaneously without symptoms or complications. However, in a few cases, it can lead to complications. The most common location of impaction is proximal oesophagus at the level of the cricopharyngeus muscle [2, 3, 4]. Foreign body (FB) ingestion is more common in children and patients with psychiatric conditions [1, 3, 5, 6].
Fistula is an abnormal track that connects two different body parts with epithelialised surfaces. Some types of fistula because of FFB have been described, including oesophago-aortic, tracheo-oesophagus, carotid, or gastrointestinal fistula. Oesophagocutaneous fistula is an uncommon fistula due to FFB [6, 7].
Clinical Perspective
Symptoms of FB are in the oesophagus, including FB sensation, dysphagia, nausea, vomiting, hypersalivation, and even respiratory distress [1, 6, 8]. FB impaction is an emergency case because delay in treatment decreases the chance of successful removal and increases the risk of complications [1].
Imaging plays an essential role in FB ingestion cases, especially if physical examination fails to visualise or localise FB. Imaging plays a vital role in identifying FB and detecting complications [8].
Imaging Perspective
Enhanced neck CT shows an enlarged prevertebral soft tissue with air-fluid level and enhancement on its wall, representing an abscess, and a FB within it. The patient underwent neck CT first because of our concern about airway obstruction.
The identification of fish bones on the plain radiograph is challenging because the majority of the fish bones are radiolucent material. The absence of fish bones on plain radiograph does not exclude their presence. As in this case, his cervical radiograph did not show a radioopaque foreign body. CT has greater sensitivity to detect FB compared to radiographs [1, 4, 5, 6]. CT is also capable of assessing foreign body effects on the tissue around.
Oral contrast examination should be avoided as an initial evaluation, especially before endoscopy, because of the risk of aspiration and interference with endoscopic visualisation [1, 8]. However, oesophagography remains the standard examination for complications such as perforation or fistula. A fistulography study confirmed the diagnosis of oesophagocutaneous fistula in this case.
Outcome
Imaging examinations confirmed the diagnosis of a retropharyngeal abscess and oesophagocutaneous fistula. The clinician did surgeries for the abscess and the fistula as treatment. The patient continued his care on an outpatient basis, and the prognosis was good.
Take-Home Message / Teaching Points
Written informed patient consent for publication has been obtained.
[1] Kim HU (2016) Oroesophageal fish bone foreign body. Clin Endosc 49: 318-26 (PMID: 101576886)
[2] Bathla G, Teo LLS, Dhanda S (2011) Pictorial essay: complications of a swallowed fish bone. Indian J Radiol Imaging 21(1): 63-8 (PMID: 8503873)
[3] Lee JH (2018) Foreign body ingestion in children. Clin Endosc 51: 129-36 (PMID: 101576886)
[4] Venkatesh SH, Karaddi NKV (2015) CT findings of accidental fish bone ingestion and its complications. Diagn Interv Radiol doi: 10.5152/dir.2015.15187 (PMID: 101241152)
[5] Hunter TB, Taljanovic MS (2003) Foreign bodies. Radiographics 23: 731-757
[6] Guelfguat M, Kaplinskiy V, Reddy SH, DiPoce J (2014) Clinical guidelines for imaging and reporting ingested foreign bodies. AJR 203: 37-53 (PMID: 7708173)
[7] Correa S, Valero JJ, Torres JP, Fierro F (2016) Common carotid perforation secondary to an ingested fish bone In a child case report. J Ped Surg Case Reports 8: 7-9 (PMID: 101628383)
[8] Tseng HJ, Hanna TN, Shuaib W, Aized M, Khosa F, Linnau KF (2015) Imaging foreign bodies: ingested, aspirated, and inserted. Ann Emerg Med 66(6): 570-582 (PMID: 8002646)
| URL: | https://www.eurorad.org/case/16698 |
| DOI: | 10.35100/eurorad/case.16698 |
| ISSN: | 1563-4086 |
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