Endgames Case Review

Lamb ingestion and odynophagia

BMJ 2016; 355 doi: http://dx.doi.org/10.1136/bmj.i5506 (Published 02 November 2016) Cite this as: BMJ 2016;355:i5506
  1. Raghav C Dwivedi, senior head and, neck fellow1,
  2. Bruno Kenway, specialty registrar in ear, nose, and throat surgery1,
  3. K Haribaskaran, consultant ear, nose, and throat surgeon1,
  4. Piyush Jani, consultant head and neck surgeon1
  1. 1Department of Otolaryngology, Head and Neck Surgery, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK
  1. Correspondence to: R C Dwivedi raghav.rmh{at}gmail.com

A 40 year old man presented to his local emergency department a few hours after swallowing a piece of lamb that felt immediately sharp on the left side of his throat. He was unable to finish the meal but was able to swallow saliva. He underwent lateral radiography of soft neck tissue (fig 1) and no food bolus or foreign body was visualised. He was reassured and referred to the local ear, nose, and throat (ENT) department the next day. His odynophagia persisted; no foreign body was evident on flexible nasendoscopy but the left arytenoid region showed mild oedema. The patient was again reassured and discharged by the ENT team. Fifteen days later the patient re-presented to the emergency department with increasing left neck pain on swallowing. He was able to swallow solids and liquids and was systemically well. No foreign body or pooling of saliva was evident on flexible nasendoscopy. Neck examination did not show any subcutaneous emphysema, but a slight fullness and tenderness was noted in the left thyroid region.

Fig 1 Lateral radiograph of soft tissue in neck

Questions

  • 1. What is the most likely diagnosis?

  • 2. How will you manage this case?

  • 3. How can cases like this be avoided?

Answers

1. What is the most likely diagnosis?

Short answer

Missed ingested foreign body with possible complications.

Discussion

Based on the clinical presentation, the possibility of a missed foreign body with complications that are suppurative (deep neck space abscess) or vascular (injury to internal jugular vein/tributaries, carotid artery/branches) should always be considered, especially in patients presenting with persistent, worsening, or evolving symptoms. On close inspection a foreign body can be seen in the lateral radiograph (fig 1). Sharp foreign bodies, such as fish bones, food boluses containing bone, metal, or glass are notorious as they can penetrate the lining of the pharynx or oesophagus and lodge …

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