While ingestion and lodgement of foreign bodies in the upper aerodigestive tract is commonplace, extraluminal migration, requiring an external approach for removal, is unusual. 1,2 A foreign body (FB) in the parapharyngeal tissues may lead to abscess formation either locally or within one of the deep spaces of the neck. It presents the challenge of removal without further pharyngo-oesophageal trauma. A sharp foreign body compounds these risks for the patient and exposes the surgical team to the hazard of needlestick injury. Management of this awkward problem is assisted by the use of imaging modalities and requires a cautious surgical approach. We present a case of an accidental ingestion of a sharp metal shard, with complete extraluminal migration, by a hepatitis C-positive intravenous drug user.
CASE REPORTA 33-year-old woman was referred by her local doctor to the emergency department of Concord Hospital with a 3-day history of a sudden onset of sharp left-sided throat pain after eating a tuna casserole. The meal had been prepared by her family with only soft ingredients including packet pasta, cheese and tinned processed tuna. Over the ensuing hours the pain gradually increased and was associated with odynophagia and progressive dysphagia. Although she initially ate large food boluses in an attempt to dislodge a possible foreign body, at presentation, 72 h later, she was unable to swallow her saliva. She had no otalgia, dysphonia, cough or respiratory difficulties.On examination there was no stridor. The patient was afebrile and haemodynamically stable. Pain was localized to the middle of the left anterior triangle of the neck. Palpation on the left of the cricoid cartilage area elicited tenderness. There were no neck masses, cellulitis or lymphadenopathy. The oropharynx was unremarkable.Indirect laryngoscopy and flexible direct laryngoscopy did not reveal any pathology of the pharynx, hypopharynx or larynx other than some postglottic redness. No foreign body could be seen in the upper airway.Lateral and anterio-posterior neck X-rays were taken. These demonstrated a thin sharp radiopaque metallic foreign body at the level of the sixth cervical vertebra towards the left side of the neck (Fig. 1).The patient was admitted for examination under anaesthetic. Intravenous rehydration and broad spectrum intravenous antibiotics, including anaerobic cover, were commenced. A detailed history was taken and previous tetanus vaccination confirmed. Prior to this episode the patient had been essentially well with no aerodigestive complaints or operations. While admitting to using intravenous drugs, she denied any known exposure to HIV or hepatitis B or C.Direct pharyngolaryngoscopy and rigid oesophagoscopy were performed under general anaesthetic. The pharynx and larynx were examined with a Lindholm laryngoscope (Stortz, Germany) and a short oesophagoscope was used for the proximal oesophagus. The pharynx, larynx, and pyriform fossae were unremarkable. The postcricoid mucosa was inflamed and oedematous but no foreign body or...
