Antibiotherapy Removal of an Ingested Fish Bone with Inflammation and Mild Abscess: A Case Report

Antibiotherapy Removal of an Ingested Fish Bone with Inflammation and Mild Abscess: A Case Report

Introduction

Accidental ingestion of a foreign body is a common complaint among patients in the emergency department, account for up to 84% of the which is fish bone [1]. Patients present with pain on swallowing, rest pain, blood-stained saliva, and sense of obstruction. Although most ingested fish bone will pass through the gastrointestinal tract uneventfully, and the above symptom relieves in a couple of days, approximately 10 to 20% require endoscopic removal and approximately 1% require surgery [2]. Even more, delayed diagnosis may lead to sever consequences including deep neck infection or abscess, or even fistula. We herein report a case of an ingested fish bone that caused laryngopharyngeal abscess and eliminated by itself after antibiotic therapy.

Case Presentation

A 55-year-old male was admitted to our hospital because of pain on swallowing that had begun after accidental fish bone ingestion 3 days before admission. On examination, his body temperature was 38.6 °C, heart rate was 94 beats per minute, blood pressure was 126/80 mmHg, respiratory rate was 19 breaths per minute. Severe throat pain and difficulty in swallowing were present. We inserted gastric tube from nose to keep the energy supply. The laboratory data showed white blood count 10600/mm3,the C-reactive protein level 35.5 mg/dl. A careful oral examination and flexible endoscopy under local pharyngeal anesthesia were performed, nothing was detected except significant soft tissue edema on the left lateral laryngopharynx. Contrast-enhanced computed tomography scan（CT）images of the neck demonstrated a linear hyperdensity with the length of 19.5mm,lying in the left lateral laryngopharyngeal space, surrounded by a low-density area with fluid, suggestive of ingested fish bone with abscess (Figure 1). Significant edema and mild abscess showed in the left lateral laryngophary, resulting in mild narrowing of the airway. We therefore assumed that the fish bone completely resided inside the edema. Only when the edema gradually vanished, the operation to remove the fish bone can be performed. After 5 days of antibiotherapy, we found the edema on the left lateral laryngopharynx was disappeared under the flexible endoscopy. CT was conducted agained to clarify the accurate spot of the fish bone right before the operation when we detected completely free of fish bone in original position (Figure 2). The patient recovered uneventfully and was discharged on the seventh day.

Figure 1: Ingested fish bone on the left hypopharynx. contrast-enhanced CT images of the neck demonstrate a linear hyperdensity lying in the left extra laryngopharyngeal space (long arrows) suggestive of ingested fish bone.

a. Axial and

b. Sagittal.

Figure 2: Soft tissue edmema and mild abscess caused by fish bone ingestion vanished and fish bones dislodged.

a. Axial and

b. Sagittal.

Discussion

Foreign body, especially the fish bone ingestion remains a common clinical problem. About 80%-90% of ingested foreign bodies pass through the gut without discovery within 1 week [3]. Most of fish bones encountered are found above the cricopharyngeal sphincter. A comprehensive physical examination of the oral cavity, oropharynx, and hypopharynx assist by a flexible laryngoscope would detect and remove the fish bone as long as timely treatment. Complications range from mild inflammatory changes to abscess formation, viscus perforation, intestinal obstruction, and bleeding are mostly induced by the delayed visiting time and unaware of the ingestion history. In such cases, surgical intervention is required. CT plays a critical role in diagnosis as it reveals the image of a linear, hyperdense, foreign body corresponding to a bone clearly, let alone its non-invasiveness, early detection of complications and delineation of adjacent structures [4]. Back to our case, instead of seeking clinical attention immediately after the fish bone ingestion, the patient chose to neglect the discomfort and kept a normal diet afterwards, which caused local inflammation and abscess formation. We first attempted to remove the foreign body endoscopically but failed because nothing was detected but the soft tissue edema on the left lateral laryngopharynx.

Contrast-enhanced CT was conducted, a linear hyperdensity with the length of 19.5 mm at C3 and mild mild abscess formation were demonstrated. After antibiotic therapy for 5 days, pharyngeal symptoms were significantly relieved, both the laryngoscope and CT revealed disappearance of local tissue edema as well as the fish bone. Hence, we suggest an endoscopic examination would be attempted first not only for the diagnosis but also for the removal of the detected foreign body. In the case of fish bone impaction, CT image is important for making a pre-operative plan and an accurate preoperative diagnosis in case there is a high degree of suspicion that the operation is whether indispensable. The treatment consists of endoscopic removal, surgical removal, abscess drainage if necessary, and administration of appropriate antibiotics. Collectively, our case demonstrated that soft tissue edema and mild abscess caused by fish bone ingestion would vanished and fish bones dislodged and passed after treatment with antibiotics. Therefore, early diagnosis and treatment is important, specially medication including antibiotics for the infection which might avoid surgery.

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