Minimally invasive approach for retrieval of retropharyngeal foreign body

Abstract

Ingested fish bone at times can migrate extraluminally into the surrounding soft tissue, leading to complications. Conventionally, these migrated fish bones are retrieved by open procedures, which could add to the morbidity. We successfully retrieved one such foreign body by a minimally invasive transcervical approach in a 64-year-old female patient. The method offered an easy identification of the foreign body with minimal soft-tissue dissection, which ultimately aided in the early post-operative recovery. This is the first report of a minimally invasive approach to explore the retropharyngeal space, and we propose the technique even for sampling retropharyngeal lymph node.

INTRODUCTION

Fish bone is one of the commonly ingested foreign bodies. Most of them get lodged in the hypopharyngeal lumen and can easily be retrieved transorally.[1] Rarely, the sharp and irregularly shaped fish bones can pierce through the mucosa to migrate into the surrounding soft tissue, leading to unprecedented morbidity.[2] Such extraluminal migrated foreign bodies often mandate a transcervical approach for extraction, which imparts higher surgical morbidity than that of the endoscopic approach.[2,3] In order to overcome these shortcomings, we used a minimally invasive transcervical approach to retrieve a retropharyngeal fish bone, the details of which have been narrated in this case report.

CASE REPORT

A 64-year-old female, known diabetic, presented with painful swallowing that had started after alleged fish bone ingestion 3 days ago. Her examination findings were normal, and she had no signs of any foreign body or mucosal changes on flexible laryngoscopy. However, contrast-enhanced computed tomography revealed a slender radiopaque shadow in the retropharyngeal space with a widening of pre-vertebral soft tissue, as shown in Figure 1. With the diagnosis of extraluminally migrated fish bone with retropharyngeal abscess, the patient was taken up for exploration via a minimally invasive approach (MIA) under general anaesthesia. Through a small curvilinear incision along the anterior border of the right sternocleidomastoid, a soft-tissue tunnel was created to reach the parapharyngeal space. A 30° nasal endoscope (HOPKINS Telescope, KARL STORZ SE and Co. KG, Tuttlingen/Germany) was introduced through the dissected tract. The soft-tissue tunnel was extended further deep, medial to the carotid sheath outside the constrictor muscles to reach the retropharyngeal area. The pharynx–oesophagus was gently elevated of the pre-vertebral fascia, and a retractor was applied for keeping the surgical field exposed. The retropharyngeal space was carefully explored under the endoscopic guidance to drain out around 3–5 ml of purulent fluid, following which a slender fish bone of 15-mm length was retrieved amid the inflamed soft tissue, as shown in Figure 2. Further, the inflammatory exudates and necrotic tissues were cleared by giving a thorough wash, and the endoscopic evaluation was carried out to rule out any breach into the pharyngeal lumen. After confirming the absolute haemostasis, the neck incision was closed in layers. The patient was started on oral feeds the next morning and was discharged on the 4^th day after removal of the suction drain. Her blood sugar levels were under control throughout. She was completely asymptomatic with unhindered swallowing and speech by day 4 of the surgery.

Figure 1.

Contrast-enhanced computed tomography of the cervical region, (a) coronal and (b) sagittal sections showing a radio-dense foreign body (arrow) in the retropharyngeal space

Figure 2.

Intraoperative endoscopic pictures showing (a) collection of inflammatory exudates in the retropharyngeal soft tissue (arrow), (b) foreign body in the midst of the inflamed tissue and (c) the retrieved fish bone

DISCUSSION

The retropharyngeal space is located between the major vessels, pharynx and cervical vertebral body that could hamper the adequate exposure of the area, especially during open surgical procedures. An endoscope passed through a small transcervical incision, and a minimally dissected tract, provides an uninterrupted approach to this challenging area. The advantage offered by the endoscopic assistance could be attributed to the better illumination and the higher magnification provided and has been lauded in many critical and unconventional surgical fields.[4,5] Nevertheless, this MIA enabled comfortable retrieval of the fish bone in our case without any collateral damage that subsequently contributed to the early post-operative recovery of the patient. To our knowledge, ours is the first report to have used MIA for retropharyngeal space exploration. This approach to retropharyngeal space could also be used for other indications, such as for sampling or extracting the retropharyngeal lymph nodes. However, the persuading surgeon must be well versed with the anatomical orientation of the neck and the endoscopic techniques to prevent any untoward intraoperative event.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.