Recurrent neck Abscess by Migrating Fishbone Penetrating Thyroid Found in Subcutaneous Tissue: Case Report

Abstract

Extraluminal foreign bodies are rare. Fish bone is the most common foreign body ingested by adults, while coin is the most common foreign body ingested among children. Sharp pricking pain is a sign of sharp foreign body (FB) ingestion. If the symptom persists, one should keep in mind the possibility of a migratory foreign body, even if the esophagoscopy results are negative. In order to ensure that foreign bodies are not missed radiologically, there is the role of consultation from a second radiologist to correlate with the patient’s symptoms. Here we present an atypical case of recurrent neck abscess due to a migrating fishbone that penetrated the left thyroid lobe and settled in the left lower third neck subcutaneous tissue within two months.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-024-04779-5.

Introduction

Fish bone is the most common migratory foreign body [1]. Sharp point of bone makes it possible to penetrate soft tissue from upper part of the esophagus. Deglutination and neck movement will propel the bone in one direction till the sharp end reaches the path of least resistance to the outside world, often the subcutaneous tissue. CT scan is useful in locating intruded foreign body and superior to plain radiograph [2, 3]. Sun et al. [2] revealed CT scan had 100% diagnostic accuracy followed by ultrasonography and X-rays.

The authors report a fish bone found in the subcutaneous tissue as the sharp end of bone was unable to penetrate the overlying skin due to scar fibrosis. Surprisingly, the migrating foreign body was not detected on a CT scan that led to a recurrent neck abscess. Therefore, this article discusses the pathway of a fish bone foreign body and its associated complications if left undetected.

Case Report

A 52-year-old lady presented to the emergency department with persistent odynophagia on day ten after ingesting a fish bone. She felt an immediate, sharp, pricking pain in the throat while eating rice with a fried yellow stripe scad fish ten days prior. She was able to finger-point the pain to the left lower third of the neck. Otherwise, she had no history of fever, neck swelling, shortness of breath, shoulder tip pain, or dysphonia. She had multiple visits to a private medical centre and was prescribed an oral antibiotic; however, the symptom persisted. She was newly diagnosed with diabetes mellitus, and a known case of left breast invasive carcinoma underwent a modified radical mastectomy with chemoradiotherapy five years ago. Recently, she developed metastatic left axillary lymphadenopathy and started hormonal therapy. She had a history of incisions and drainage on the left lower neck due to a neck abscess 40 years ago, which was well healed.

On neck examination, the skin over the left lower third of the neck was erythematous and matted, with nodes palpable over the level IV of the left neck that were firm in consistency and non-tender. Indirect laryngoscopy performed was unremarkable. She underwent a CECT of the neck. CECT of the neck revealed a small peripherally enhancing hypodense lesion seen at inferior aspect of the left sternocleidomastoid muscle at the left supraclavicular region measuring approximately 0.8 × 1.3 × 1.6 cm (AP x W x CC) suggestive of an abscess. The muscle was bulky and streaky as compared to the contralateral side. Otherwise, no foreign body was seen. The patient was admitted and received intravenous antibiotics. An incision and drainage for abscess and external approach wound exploration were performed; however, no foreign body was found, and two millilitres of thick pus were evacuated. Tuberculosis investigation and pus for culture were negative. Tissue of abscess wall was consistent with an abscess with no malignancy. She was discharged well with a clean wound after completing ten days of antibiotics.

She was seen at the ear, nose, and throat (ENT) clinic in the next two weeks. She complained of discharging of the neck from the previous wound site for the past four days. She was unable to sleep due to worsening neck pain. On neck examination, we observed thick pus emanating from the previous wound site, accompanied by an indurated surrounding area. Pus for culture and sensitivity sent was sterile. She was instructed to engage in daily self-dressing at her residence. Unfortunately, she had been having persistent pus discharge with unresolving neck pain. Neck examination noted thick pus discharge produced from the previous incision site and left neck swelling about 2 × 2 cm with erythematous overlying skin. She underwent incision and drainage under local anaesthesia, with the incision extending from the previous wound site. A fishbone approximately 1.5 cm in length was lodged within the subcutaneous tissue and removed in one piece (Fig. 1). The patient had no more pricking pain. Retrospectively, CECT of the neck revealed fishbone foreign body as in Fig. 2.

Fig. 1.

(a) FB length about 1.5 cm. (b) FB (black arrow) expose during incision made, overlying skin was raised with old linear scar

Fig. 2.

a (Coronal oblique of CECT neck) FB fishbone (black arrow) about 1.5 cm in length. b (Axial of CECT neck) FB from LT IJV about 1.3 cm. c (Sagittal of CECT neck) FB in left thyroid lobe

Discussion

Foreign body ingestion is frequently seen at primary care and emergency department. Adults between 15 and 59 years of age most common for foreign body ingestion compare to children and elderly [4]. Gender is insignificant among those ingested foreign body at any age [5].

The most common foreign body ingested by children are coin followed by pin, marble and last fish bone [5, 6]. Gendeh et al. [7] found that children’s food habits influenced the probability of inhaling foreign bodies. It was reported that peanuts were the most prevalent among food-related products, followed by watermelon seed and coconut kernel. While in adult, fish bone is the most common other than chicken bone and food bolus [5]. Main chief complaint usually dysphagia and majority will be presented at medical center within 24 h [6]. After ingesting a fish bone, many people in the community who consume fish consult their general practitioner (GP) for the first time. However, overlooking the seriousness of the primary complaint increases the likelihood of complications for the patient. In this case, patient sought treatment immediately on the same day of incident at GP clinic however was told no foreign body seen and discharge home. She went for second visit to another GP and discharge home with oral antibiotic without referral to tertiary hospital.

Zhang et al. [5] reported foreign body sensation was the chief complaint right after the foreign body ingested followed by odynophagia, retrosternal pain and dysphasia. Foreign body impacted in pharynx and esophagus give more significant pain compare to stomach and duodenum due to anatomical structure and sharpness of foreign body [5]. Fish bones were most frequently found in pharynx and upper esophagus while food bolus seen below the middle of the esophagus [2]. Tonsillar region often impacted by fish bone as well as tongue base and vallecula [8]. Fish bone ingestion will highlight the main symptom of foreign body sensation with pain localization by pointing finger [8].

All these symptoms were highlight by patient at the first medical visit, however she was not referred to tertiary hospital for further work out. On her initial presentation, she had typical sign of sharp foreign body ingestion however due to late presentation at tertiary hospital, she developed indurated area of the left neck on day ten of illness. She even admitted for further investigations and all were negative except CECT of the neck revealed the small collection at left intrasternocleodomastoid muscle same site as she experienced pain from beginning. She was not subjected to esophagoscopy examination as foreign body not reported on CECT of the neck and she was treated for left intrasternocleidomastoid abscess. Moreover, the pricking pain symptom become lessen and more to throbbing pain. Besides, she had multiple comorbid which gave wide differential diagnosis including infected metastatic node. Despite all, after drainage of the abscess and external approach of wound exploration for foreign body result the wound responded to a course of antibiotic. Initially intravenous Augmentin was commenced and escalate to intravenous Cefuroxime. Since she also had diabetes mellitus, she prone for infection higher than healthy person. Thus, she was reassessing back during ENT clinic follow up.

Occasionally fish bones are not detected on imaging due to radiolucency. Yet, fishbone ingestion must correlate with clinical history and examination as the symptom persists. In our case, patient underwent CECT of the neck with 5 mm slices. CT scan of the neck with 1 mm cuts is useful in localizing the size, type, orientation and relationship of foreign body to other vital structures such as the thyroid gland, carotid sheath, hyoid bone and cricoid cartilage as landmarks in neck exploration [9]. Revised back the CECT coronal oblique view with 1 mm slices noted about 1.5 cm fish bone embedded in the left thyroid lobe. After a month of penetrating left thyroid lobe and developed intrasternocleidomastoid abscess, fortunately it migrated to subcutaneous tissue.

It was reported about 50% complications arise from esophageal foreign body such as esophageal ulcer, lacerations, erosions and perforations however none of fatal case [4]. Average group that developed complications about 51.6 years and increase as the age increased. However, migrating fish bone is uncommon. Fish bone increased risk of perforation due to sharp and linear in shape [9]. It could travel through the soft tissue and follow the gravity besides combination of esophageal peristalsis and neck movement make it possible. However, extraluminal migrating foreign body had lower mortality compare to intraluminal penetrating foreign body unless it was complicated with vascular complication due to suppurative process [10]. Our migrating fish bone was found in left thyroid lobe which 1.3 cm from left internal jugular vein. Fortunately, it migrated out of the left thyroid lobe and settled down in subcutaneous tissue.

Conclusion

Sharp pricking pointing finger pain is a sign of sharp foreign body ingestion. This important sign should be elicited at first medical visit and by referring to the tertiary hospital may allow further assessment to be performed. Despite on negative finding of esophagoscopy, migratory foreign body should be in mind if the symptom persists. Furthermore, performed CT imaging with thick cuts without reporting foreign body need to be revised with another radiologist to correlate with symptomatic patient [1].

Electronic Supplementary Material

Below is the link to the electronic supplementary material.

Abbreviations

CECT

Contrast-enhanced computed tomography

ENT

Ear, nose, throat

GP

General practitioner

FB

Foreign body

LT CCA

Left common carotid artery

LT IJV

Left internal jugular vein

LT SCM

Left sternocleidomastoid muscle

LT THYROID LOBE

Left thyroid lobe

Funding

Not applicable.

Declarations

Ethical Approval

All the procedures being performed were part of the routine care.

Conflict of Interest

The authors declare that they have no conflict of interest. The participant has consented to the submission of the case report to the journal and the publication of the images in Figs. 1 and 2.