A foreign body embedded in the mobile tongue masquerading as a neoplasm

Foreign bodies in a mobile tongue are rarely presented to the laryngologist, because such bodies are commonly lodged superficially and are easily removed by the patients themselves or by general practitioners. Thus, it is rare that a foreign body totally embedded in the mobile part of the tongue presents as an enlarged tongue mass. We have described a 64-year-old female with a 3-month history of an enlarged mass in the anterior right tongue. Physical examination showed a mass located in the anterior right tongue, with intact mucosa and normal color. A benign tongue neoplasm was considered first. However, a fish bone totally embedded in the mobile tongue with granuloma formation was encountered during the incisional biopsy operation. Complete removal of the foreign body with granuloma was achieved under local anesthesia. There was no neuromuscular or neurosensory deficit of the tongue in the follow-up period of 2 years. Although an embedded foreign body in the mobile tongue is a rare condition, it should be considered in the work-up of a patient with an enlarged tongue mass, with or without a history of swallowing a foreign body.     

Endoscopic removal of esophageal foreign body and drainage of thyroid abscess

This is a 58 year old male who presented to our institution with foreign body sensation after eating fish the night before. Although lateral soft tissue films of the neck demonstrated a linear foreign body, this was missed and the patient was discharged home. One week later, he re-presented with persistent throat pain. A computed tomography scan of the neck demonstrated erosion of the foreign body through the esophageal wall and a rim enhancing collection in the right thyroid lobe. The patient was admitted and broad spectrum antibiotics were started. Using a transoral endoscopic approach the abscess was drained and a 2.0 cm sharp fishbone was successfully removed from a perforation at the esophageal inlet. A nasogastric tube was placed and the patient was kept NPO for 14 days postoperatively while his perforation healed. He had improvement in his symptoms and was stable in follow up.     

Vocal cord fixation caused by an impacted fish bone in hypopharynx: report of a rare case

We report a rare case of vocal cord fixation caused by a fish bone in the hypopharynx. The patient was a 72-year-old woman. She presented with hoarseness that had appeared suddenly while eating baked fish. The diagnosis was suggested by a clinical history and confirmed by a computed tomography scan. The fish bone was removed via microlaryngoscopic operation under general anesthesia. The restoration of her vocal cord mobility required a few months. Vocal cord fixation is an extremely rare complication of a pharyngeal foreign body. In all of the few cases reported previously, the fixation was caused by mechanical obstruction of vocal cord movement or by recurrent nerve palsy secondary to inflammation. Our case is not typical of mechanical or inflammatory fixation. It is possible that the recurrent nerve was damaged directly by the fish bone.     

Esophageal fish bone migration induced thyroid abscess: case report and review of the literature

A thyroid abscess is a rare condition, and it is so infrequently encountered. A migrated fish bone is a rare otolaryngologic emergency indicated when the foreign body penetrates through the esophageal mucosa into the thyroid gland space of the neck after several weeks of swallowing. We present the case of a 50-year-old woman who had fever and anterior neck painful mass. An intrathyroid abscess was diagnosed; and she underwent thyrotomy with transcervical approach. A foreign body, which proved to be a fish bone and which fortunately did not cause any adverse effects, was removed.     

A submucosal esophageal fish bone foreign body surgically removed using intraoperative ultrasonography

A 68 year-old female was referred to our department with a history of swallowing a fish bone, she reported continuous pain when swallowing. The bone was not evident on endoscopic examination; however, on CT scans a foreign body was identified in the upper esophagus. The bone was buried in the mucosa of the upper esophagus and an emergent rigid esophagoscopy was performed under general anesthesia in order to remove it. The fish bone was successfully removed with the use of intraoperative cervical ultrasonography.     

Thyroid lobectomy for removal of a fish bone

A 42-year-old female Jordanian patient presented with a history of sudden painful dysphagia following swallowing of a fish bone. Though soft tissue X-rays showed a foreign body in the neck, repeated oesophagoscopies failed to reveal it. Computed axial tomography was done and showed a fish bone embedded in the left thyroid lobe. Left thyroid lobectomy was carried out and the fish bone was seen within the lobe surrounded by an area of acute inflammation.     

Analysis of Clinical Feature and Management of Fish Bone Ingestion of Upper Gastrointestinal Tract

Objectives

Fish bone impaction in the upper gastrointestinal tract is a common reason for patients to seek emergent care. The aim of this study was to find a clinical characteristics of patients with fish bone impaction in the upper gastrointestinal tract.

Methods

The study was conducted on 286 fish bone ingestion patients who complained of dysphagia and irritation after eating fish. The patients were treated according to the hospital protocol regarding the removal of fish bone. The parameters for the analysis included the age and sex of the patients, location and characteristics of the foreign body, method of removal, and type of fish.

Results

The fish bone could be observed by the physical examination in the oral cavity and laryngopharynx in 198 patients (69.23%). For those patients in whom the foreign body could not be observed in oral cavity and laryngopharynx, noncontrast computed tomography (CT) (from nasopharynx to diaphragm) was performed. The fish bone was discovered in the esophagus of 66 patients (23.08%). The esophageal fish bone was successfully removed by transnasal flexible esophagoscopy (TNE) in 55 patients, the fish bone moved to the stomach in 10 patients and one fish bone was removed by rigid esophagoscopy due to esophageal abscess. The esophageal fish bone was mostly found in patients aged 50 years and older.

Conclusion

Fish bone foreign body ingestion in the esophagus appeared to be more common in older patients. Incorporating noncontrast CT and TNE can facilitate decision-making and adequate treatment for patients with fish bone impactions.     

A rare case of a foreign body migration from the upper digestive tract to the subcutaneous neck

Ingested foreign bodies are not unusual in Singapore. The most common of these objects are fish bones, which typically become lodged in the tonsils or in the base of the tongue. We report a rare case of an ingested fish bone that migrated from the upper digestive tract and into the soft tissues of the neck just below the skin.     

迁移性咽和颈段食管异物4例

目的：探讨迁移性咽和颈段食管异物的临床特征、诊断及治疗方法。方法：对位于腔壁内的异物，应尽量选用内镜下切开黏膜取出；若异物已移至腔外，则采用颈侧切开术。结果：4例患者均顺利取出异物，3例无并发症发生，1例声带麻痹。结论：颈部薄层CT扫描是证实异物迁移的重要手段，并对手术时定位异物有重要价值；食入异物出现迁移者，可产生致命性并发症，应及时处理。     

Migrating pharyngeal foreign bodies: a series of four cases of saw-toothed fish bones

Pharyngeal foreign bodies are common problems seen at emergency rooms or ENT outpatient clinics, and fish bones are the most common foreign bodies encountered in East Asia and in Korea. One of the rare complications of a swallowed sharp fish bone is its migration from the site of entry into the subcutaneous tissues of the neck. We present four unusual cases of ingested fish bones that migrated out of the upper digestive tract to the neck. In the first case, this caused a recurrent deep neck infection for 2 years; in the second case, there was penetration of the facial artery; in the third case, there was a hematoma of the floor of the mouth; in the fourth case, there was a retropharyngeal abscess.     

A case of migratory fish bone in the thyroid gland

Fish-bone foreign bodies represent a common condition readily identified in the pharynx. We encountered a case of fish bone in the thyroid gland. Only three other such cases have been reported in the English-language literature. This foreign body was identified by computed tomography and ultrasonography 16 days after onset, and removed through a cervical skin incision. The diagnosis and treatment of extrapharyngeal foreign bodies are discussed.     

Efficacy of radiologic screening for distant metastases and second primaries in newly diagnosed patients with head and neck cancer

OBJECTIVES: Detection of distant metastases and second primary tumors in newly diagnosed patients with head and neck cancer has usually a major effect on prognosis but does not always influence clinical management. This must be considered when radiologic screening investigations are used. The present study particularly evaluates how often additional neoplastic lesions detected by screening had an impact on therapy. STUDY DESIGN: The authors conducted a single-institution retrospective analysis. METHODS: The medical records of 260 patients with newly diagnosed squamous cell carcinoma of the head and neck treated between 1999 and 2002 were retrospectively analyzed. Before therapy, all patients had undergone screening by computed tomography scan of the chest, abdominal ultrasound, and bone scintigraphy. RESULTS: Screening investigations identified 16 patients (6.2%) with distant metastases and six patients (2.3%) with simultaneous second primaries. Chest computed tomography scan detected 20 neoplastic lesions; abdominal ultrasound and bone scintigraphy each detected 2. Three findings of distant metastases proved to be false-positive during follow up. Of the 22 patients with positive screening results, clinical management was affected in 13 (59.1%). Twelve were originally scheduled for curative surgery and 10 had chest abnormalities. CONCLUSION: Chest computed tomography scan was the most effective screening investigation, which should be routinely used whenever curative surgery of head and neck cancer is planned. Abdominal ultrasound and bone scintigraphy may sometimes be valuable before extensive surgical treatment of far advanced disease. In patients scheduled for primary radiotherapy, radiologic screening had hardly any consequence and should be confined to conventional x-ray of the chest.     

Inflammatory nasal polyps: an unusual late complication of Silastic sheet repair of orbital floor fracture

Silastic implants are very widely used in surgical practice and are considered to be relatively inert. They do however present with complications, including infection, local foreign body inflammatory response,calcification, migration and failure of repair of the defect, which sometimes may necessitate explantation. Head and neck implants do present a special case, as complications can cause obstruction and disruption of function in small cavities. A pertinent history, clinical review and computed tomography scan are usually invaluable in obtaining a diagnosis. We present a rare case of migrated Silastic orbital sheet, presenting as a nasal polyp and causing maxillary antral pain and infection. A detailed search of the medical literature revealed no other such case.     

Dual ectopic thyroid: report of a case

Dual ectopic thyroid is very rare. We report a case of dual ectopic thyroid in the lingual and infrahyoid areas in a 20-year-old female patient with no thyroid gland in its normal anatomical location. On physical examination, there was a 7 x 5 cm anterior midline neck swelling just below the hyoid bone and a 2 x 2 cm mass in the base of the tongue. Triiodothyronine (T(3)), thyroxine (T(4)), and thyroid-stimulating hormone (TSH) levels were normal. A thyroid scan with technetium-99m sodium pertechnate confirmed dual ectopic thyroid with no iodine uptake in the normal anatomical location of the thyroid gland. The infrahyoid ectopic thyroid was surgically removed for cosmetic reasons, and the lingual thyroid, which was symptomatic, was left untouched. The importance of thyroid scanning in the evaluation of anterior midline neck swellings and treatment options are discussed.     

Lingual thyroid carcinoma with nodal metastasis

OBJECTIVES: To discuss treatment options and surgical management of lingual thyroid carcinoma with cervical metastasis. STUDY DESIGN: Lingual thyroid is relatively uncommon, and carcinoma of the lingual thyroid is extremely rare, with only 40 cases reported. We report a new case of a young female who presented with a cervical neck mass found to represent metastatic papillary thyroid carcinoma. Further workup revealed the patient's only thyroid tissue was located at the tongue base and was the site of the primary tumor. Management of lingual thyroid carcinoma and review of the literature is discussed. METHODS: A case report and review of the literature of lingual thyroid carcinoma. RESULTS: A young female presented with a left neck mass diagnosed as metastatic papillary thyroid carcinoma. Review of the computed tomography scan of the neck revealed a tongue base mass, absence of an othotopic thyroid gland and bilateral cervical lymphandenopathy. Bilateral selective neck dissections with removal of the tongue base lesion confirmed the diagnosis of lingual thyroid carcinoma with multiple left cervical nodal metastases. CONCLUSIONS: A case of lingual papillary thyroid carcinoma with cervical metastasis is reported. Treatment is best managed with surgical excision of all thyroid tissue followed by radioactive iodine ablation. Surgical approaches to the tongue base need to be considered based on the size of the lingual primary tumor and the need to address lymph node metastases gland. This is the first reported case in the literature of lingual papillary thyroid carcinoma presenting with cervical nodal metastasis in a female with absence of an orthotopic thyroid gland. This is also the first report to show that papillary and not follicular cell carcinoma is the predominating histopathology in lingual thyroid carcinoma.     

A case of unilateral hypoglossus nerve palsy associated with chordoma in the region of clivus

We had a rare case of 50-year-old woman with a unilateral hypoglossus nerve palsy as a sign of clival chordoma. A computed tomography (CT) scan of the skull base showed bone destruction at the anterior part of the foramen magnum and CT scan of the neck reveals asymmetrical area at the base of the tongue. Magnetic resonance imaging showed a mass at the skull base in the region of the clivus with bone destruction in the middle and right side of the clivus. The tumor was biopsied through transnasal biopsy from the region of the clivus using a navigation system and microscopical surgical technique. Postoperatively, the patient received radiotherapy. Surgery is the most effective treatment of chordomas. An endoscopic approach provides easy, rapid and direct access to the clivus. A postoperative radiation therapy is recommended. A carbon ion radiotherapy is an effective treatment for chordomas of the skull base with minimal side effects. Close interdisciplinary collaboration between ORL, neuroradiology, pathology and oncology is desirable for effective therapy.     

Did Ludwig's angina kill Ludwig?

Wilhelm Frederick von Ludwig first described in 1836 a potentially fatal, rapidly spreading soft tissue infection of the neck and floor of the mouth. The condition was later named 'Ludwig's angina', a term which persists in medicine to this day. A gold medallist at 19 and professor at 25, Ludwig also served as president of the Württemberg Medical Association and chief physician to the royal family. His outstanding contribution to medicine was rewarded with the title Excellence upon retiring in 1855. Ludwig died at the age of 75, ironically, days after developing an inflammation of the neck. Could it be that Ludwig died of his own condition? This article combines a biography of Wilhelm Frederick von Ludwig with an overview of his eponymous condition and its management.     

Ludwig's angina: a clinical review

Ludwig's angina is caused by a rapidly expanding cellulitis of the floor of the mouth and is characterized by a brawny induration of the floor and suprahyoid region (bilaterally), with an elevation of the tongue potentially obstructing the airway. In the pre-antibiotic era, Ludwig's angina was frequently fatal; however, antibiotics and aggressive surgical intervention have significantly reduced mortality. We reviewed nine patients with Ludwig's angina between July 1996 and June 2002, all of whom presented with fever, neck swelling, bilateral submandibular swelling and elevation of the tongue. In eight patients (89%) a dental infection appeared to be the underlying cause. High-dosage intravenous antibiotics directed towards the suspected causative microorganisms were given to all of the patients: two were treated successfully with conservative medical management, while seven underwent surgical drainage (a tracheotomy was necessary in one patient). Routine aerobic cultures were done on samples of drained material and the predominant microorganisms were Streptococcus species in two patients; there were none in the other five. Two patients had post-operative complications, but all recovered.     

Identification and removal of orbital foreign bodies using the CAS (Computer-Assisted-Surgery) system]

Identification and extraction of orbital foreign bodies can cause problems in special cases. Small, retroocular localized fragments can be hard to detect, severe bleeding and traumatically damaged anatomy can render orientation difficult. At the Department of Otolaryngology, Plastic Head and Neck Surgery of Aachen University Hospital we used the investigational new CAS (Computer-Assisted-Surgery) device in several such cases with good success. CAS is a new localizing technique designed to assist the head and neck surgeon during surgery providing real-time position information. The method is based upon a three dimensional volume model of the patient's skull generated by preceding computed tomography imaging procedures such as CT or MRI scan. Intraoperative correlation of 3D-model and the patient's skull allows for real-time position display of a surgical instrument on the monitor screen. Accuracy of the method has been experimentally determined to be within 1 mm. Thereby the surgeon is able to localize even small foreign bodies without extensive exploration. In the case of multiple foreign bodies the surgeon gets a simple documentation facility, which of the visible fragments have already been extracted. Medially placed foreign bodies could be removed via an endonasal approach. Encouraged by these results we recommend CAS for the extraction of orbital foreign bodies.     

Treatment of scattered glass foreign bodies in both the superficial and deep neck: a case report

There have not been any reports about scattered glass foreign bodies in the neck, while injuries of the head and neck region as a result of traffic accidents have been frequently reported. We report the case of a 17-year-old male injured in a traffic accident, with scattered glass foreign bodies in both the superficial and deep neck. A CT scan indicated the existence of numerous glass foreign bodies in the various layers of the neck. Most of the foreign bodies were very fine or sand-like. The wounded skin was keloidal and expected to lead to remarkable facial edema of the left side. The foreign bodies and cervical keloidal lesions with small pieces of glass were carefully removed, and then reconstruction was conducted in stages using tissue expanders. The facial edema was reversed and the aesthetic reconstruction satisfied the patient.