A swallowed fishbone penetrating the oesophagus into the sternomastoid muscle A swallowed fishbone penetrating the oesophagus into the sternomastoid muscle Sabah M Al-Shukry SQU JOURNAL FOR SCIENTIFIC RESEARCH: MEDICAL SCIENCES 2003 VOL 5, NO. –2, 5–52 ©SULTAN QABOOS UNIVERSIT Y C A S E R E P O R T Department of Surgery, Rustaq Hospital, PO box 2, Rustaq-239, Sultanate of Oman. Email: Sabah45@omantel.net.om. ABSTRACT. A 40-year-old woman presented with the history of swallowing a fishbone one hour earlier. Since the patient was swallow- ing normally and the X-ray results were negative, she was reassured and sent home. Twenty days later, when the patient again presented with pain and tenderness in her neck, the fishbone was detected in the left sternomastoid muscle, and removed under local anaesthesia. ACCIDENTAL SWALLOWING OF FISHBONE IS very common in fish eating communities and usually the swallowed bone is small or soft and will pass down the gut without consequences. Still the medical literature contains many reports of fishbone or similar foreign bodies stuck in the throat or penetrat- ing the pharynx, oesophagus or stomach1 causing ret- ropharyngeal abscesses,2,3,4 mediastinal abscesses,5 or even penetrating the pericardium causing cardiac tam- ponade.6 This report documents an unusual case where a fishbone penetrated the oesophagus and settled in the left sternomastoid muscle. T H E C A S E A 40-year-old woman presented to the casualty depart- ment of Rustaq Hospital, Rustaq, Sultanate of Oman, with a history of swallowing a fishbone one hour ear- lier with the bone stuck in the upper oesophagus at the level of suprasternal notch. Examination of the throat did not show any abnormality and no foreign body could be detected. As the patient was swallowing flu- ids and solids normally and X-ray of the neck did not show a shadow in the neck, the patient was reassured and sent home .Two days later she came back with per- sisting pain in the anterior aspect of the left lower neck but she reported that she was taking food normally. On examination there was diffused tenderness over the left side of the lower neck but no palpable lymph nodes or mass. Examination of hypopharynx was negative. Ten days later she was reviewed at the ENT clinic and only tenderness over the lower part of the left sternomastoid muscle was noticed. The patient presented on the 20th day after the inci- dent with a painful swelling in the left lower neck and was referred to the surgical clinic as cervical lymph node enlargement. The patient was in good general condi- tion and vital signs were normal. Local examination of the neck revealed tender induration of the lower part of the left sternomastoid muscle [Figure 1]. Aspiration was non productive but during examination, the pres- ence of a sharp point was felt in the subcutaneous plane. Exploration under local anaesthesia showed localised inflammatory indurations in the muscle just above its attachment to the clavicle. A 3 cm long thin fishbone with one sharp end was located and removed from the indurated area in the muscle. Post operatively the patient developed a serosanguinous fluid collection of 3 ml in the wound. This was aspirated, and the culture yielded negative results. On further follow up, the area of tender indurations resolved completely. D I S C U S S I O N A N D C O N C L U S I O N In this case the patient was fortunate in that the fishbone did not penetrate into more vital tissue or structure and no deep infection developed. The forces driving a foreign body through the wall of Swallowed fiash bone ���������������������������������������� �������������� ��������:� ������������������������������������������ ������ ��� ������ ��������������������� ������������������������������������������������������������������������������������������������� ��������������������������������������������������������. 52 AL-SHUKRI the oesophagus and the forces directing its passage to the ultimate site need some consideration. () The intralumi- nal pressure in the oesophagus may force a transverse or oblique positioned sharp foreign body through the wall of the gut. (2) The site of penetration in the oesophagus may play a role in the track of movement and site of set- tlement. (3) A foreign body under the forces of gravity and pressure in the surrounding tissues tends to move towards planes of least resistance, and like pus, will find its way out. X ray, especially routine exposures, does not always help detect a relatively delicate object such as a fishbone. An ultrasound study of the neck and intraoesophageal probe may yield better results. When patients present with persistent complaint of a foreign body sticking in the throat or oesophagus, the physician should conduct a direct examination of the pharynx and oesophagus and even the stomach, to trace the foreign body and check for the site of penetration, and take all possible measures to retrieve the object. R E F E R E N C E S . Polcrova A, Wiedermann J, Vomacka J. Foreign bodies in the deglutition tract and their complications. Cas Lek Cesk, 990, 29, 467–468. 2. Swoniski H, Gracz J. Foreign bodies in the retro pharyngeal space. Otolaryngol Pol, 983, 37, 59–6. 3. BizakisJG, Sega J, Skoulakis H, Voludakis A, Velegrakis G, Christodoulou P, Helidonis E. Retropharyngoesophageal abscess associated with a swallowed bone. Am J Otolaryngol- ogy, 993, 4, 354–357. 4. Janecka V. Voluminous retropharyngo-esophageal abscesses resulting from neglected foreign bodies (fish bones) in the hypopharyngo-esophageal region. Cesk Otolaryngol, 973, 22, 49–52. 5. Mateo S, BlazquezC, Ortega J, Cabajo M, Hernandez M, Torre W. Mediastinal abscess secondary to esophageal perfo- ration caused by foreign body. Med Cli (Barc), 984, 82, 779– 780. 6. Sharland MG, McCaughan BC. Perforation of the esophagus by fish bone leading to cardiac temponade. Ann Thorac Surg, 993, 56, 969–97. Figure 1. Induration visible as on the 20th day of fishbone impaction A swallowed fishbone penetrating the oesophagus into the sternomastoid muscle Sabah M Al-Shukry The Case Discussion and conclusion REFERENCES