ACTA MEDICA MARTINIANA 2023 23/1 DOI: 10.

2478/acm-2023-0006 45

FISH BONE AS A CAUSE OF RETROPHARYNGEAL ABSCESS

CERENSKÁ KRISTINA, HAJTMAN ANDREJ, CALKOVSKÝ VLADIMIR, HANZEL PAVEL

Clinic of Otorhinolaryngology and Head and Neck Surgery, Jessenius Faculty of Medicine,
Comenius University and University Hospital, Martin, Slovakia

Abstract

In this work, we describe the case of a 68-year-old female patient with an injury to the back wall of the pharynx
by a foreign body and its atypical placement in the retropharyngeal space, causing a retropharyngeal abscess. The
foreign body was extracted during a transorally direct pharyngolaryngoscopy under general anesthesia. The sympto-
matology, diagnosis, and therapy of retropharyngeal abscess are the topics of discussion. We emphasize the necessity
of timely and thorough localization of the foreign body and its extraction.

Key words: Retropharyngeal abscess, Foreign body, Lymphadenitis, Odynophagia

INTRODUCTION

The retropharyngeal space is located between the back wall of the pharynx, the front
wall of the cervical spine, and extends from the base of the skull to the mediastinum. Due
to its anatomical relationship to many structures, it can cause the infection to spread to
the deep cervical and interthoracic spaces. The most common pathogens are Strepto-
coccus pyogenes, Staphylococcus aureus, Streptococcus pneumoniae, and anaerobes.
The disability is mostly paramedian and unilateral (1). The result of the inflammatory
process is a retropharyngeal abscess. This is a deep throat infection that typically occurs
in children between the ages of 2. and 4. year of life, most often on the basis of an abscessing
lymphadenitis and after a previous infection of the upper respiratory tract. The retropha-
ryngeal nodes often swell to the point of abscessing and can be seen as a paramedian
bulge on the back wall of the pharynx /see fig.1/. Its symptoms are very similar to epi-
glottitis. The symptoms are dominated by fever, odynophagia, stridor, and torticollis (2).
Other symptoms are headache, shortness of breath, loss of appetite, otalgia, adenopathy.
A child often comes with a picture of sepsis of unclear etiology, or with symptoms of toxic
laryngitis (2).

Corresponding author: MUDr. Kristína Čerenská; e-mail: [email protected]

© 2023 Cerenska K. et al.
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 License
(https://creativecommons.org/licenses/by-nc-nd/4.0/)
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Fig. 1 CT scan of sagittal section: prevertebral soft tissue swelling with a fish bone – arrow

The incidence of retropharyngeal abscess in the adult population is lower compared to

children. A foreign body can also be the cause of a retropharyngeal abscess. Foreign bodies
are inorganic (needles, pins, parts of toys, dentures, etc.) or organic (fish bones, vegetables
and other parts of food, etc.) (3). After ingestion, the fish bone usually gets stuck in the tissue
of the tonsils, root of the tongue, valleculae, or in the side wall of the pharynx, where it
subsequently causes sensations of a foreign body, pricking, scratching in the throat, or
localized pain. If it is recognized late, it causes a chronic inflammation and rarely causes a
deep throat infection (1). The danger of a retropharyngeal abscess lies in the obstruction of
the airways, in the spread of the infection to the mediastinum with the development of
mediastinitis, and a septic state. Other possible complications are aspiration pneumonia,
epiglottitis, meningitis, necrotizing fasciitis, pericarditis, pyopneumothorax, and others (4).
The diagnostic standard in a patient with a suspected retropharyngeal abscess is history,
physical examination, and imaging methods. An ultrasound of the neck, or a CT or MRI exa-
mination is used. CT and MRI are able to accurately localize the abscess, including potential
complications such as venous thrombosis (5). The basis of the treatment is surgical drainage,
administration of broad-spectrum antibiotics, analgesics, antipyretics, and monitoring of
airway patency or securing it by orotracheal intubation/tracheostomy (6).

CASE HISTORY

In our work, we describe the case of a 68-year-old female patient who had a history of
swallowing a fish bone during the Christmas period and, due to a persistent scratchy feeling
in her throat and drooling, consulted an otorhinolaryngologist, who did not find a foreign
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body during the examination. Her difficulties subsided over time, and after about a month
she consulted a general practitioner due to difficulty in swallowing and pain in her throat.
She was taking Klacid 500 every 24 hours, despite this, her clinical condition worsened.
She was subsequently treated by an outpatient otorhinolaryngologist, who suspected a re-
tropharyngeal abscess. He sent the patient to a local hospital, where Clindamycin,
Dexamethasone + Dithiaden was administered intravenously, and she was immediately
transferred to our clinic. Based on the CT examination, we found an atypically located
retropharyngeal abscess, practically in the middle plane, starting from the level of the ton-
gue, spreading caudally to the left, skeletotopically to the level of C3-4, the vertebrae were
without visible lesions. Under general anesthesia, we performed a direct pharyngolaryn-
goscopy with confirmation of an inflammatory focus. We identified a palpable soft arching
approximately at the level of the upper third of the flap in the midline, after pressing, purulent
contents spontaneously flowed out, from which we took a swab for bacteriological examina-
tion. We performed a wide incision and drainage of the abscess. Due to the risk of a possible
postoperative swelling and suffocation with the impossibility of per os intake, we subsequently
performed a tracheostomy and introduced a nasogastric tube. The operation went without
complications. Postoperatively, due to subjective persistent problems, we completed a control
CT examination of the neck and chest /see fig.2/, where a residual abscess collection of the
retropharynx was confirmed in the form of a streak with a discrete suspicious foreign body.
A small seepage was detected around the tracheostomy cannula and the fat of the upper
mediastinum, where suspicious inflammatory changes were identified without confirmation
of an abscess.

Fig. 2 CT scan, axial section, foreign body – fish bone 15 mm – arrow

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During the revision operation, we removed the fibrin coating in the place of the original
incision with a Kleinsasser laryngoscope. We dilated the incision and revised the soft tissues
up to the prevertebral fascia – in depth we identified the foreign body described according
to the CT scan (approx. 15 mm long thin fish bone), which we removed /see fig. 3/. We did
not find purulent content, we only aspirated a minimal amount of calcified content. Initially,
in the laboratory parameters, significant leukocytosis and elevation of C-reactive protein.
Doses of antibiotics (Clindamycin 600 mg IV every 8 hours and Metronidazole 500 mg IV
every 12 hours) were not changed during the hospitalization, they corresponded to the culture
findings. Postoperatively, the laboratory parameters are adjusted, the subjective problems
subsided. On the 5th postoperative day, we extracted the nasogastric tube. The process of
realimentation per os was without difficulties. We decannulated the patient on the 6th
postoperative day – without breathing difficulties. In a stabilized condition, we discharged
the patient to outpatient care on the 8th postoperative day.

Fig. 3 Foreign body – fish bone 15 mm

DISCUSSION

As otorhinolaryngologists, we come into contact with foreign bodies most often after their
ingestion or traumatic penetration. After ingestion, the fish bone usually gets stuck in the
tissue of the tonsils, root of the tongue, valleculae, or in the side wall of the pharynx, where
it subsequently causes sensations of a foreign body, pricking, scratching in the throat, or
localized pain (1). In the case of our patient, a foreign body stuck atypically in the area of
the retropharynx and caused an abscess collection. The diagnosis of foreign bodies is
important, so do not underestimate the situation and perform an imaging examination, or
repeat it in case of an ambiguous result. It will reveal the exact location and help assess
which anatomical structures are affected. CT examination is better available in our count-
ry, but NMR can also be used. Foreign bodies are often metallic, plastic, glass and are easi-
ly detected by X-ray (5). A foreign body made of wooden material can sometimes escape our
attention because it is of lower density and because gas bubbles form around it (6). In open
injuries, NMR examination is controversial because of the possible occurrence of metallic
foreign bodies. In the mentioned literature, in some cases, a foreign bodies – metal frag-
ments smaller than 1x1 mm – were not shown on the CT examination (7). Some authors
also use angiographic methods when there is no clarity of vascular involvement and the risk
of major bleeding. In the patient we presented, the diagnosis was established on the basis
of a clinical suspicion (persistent lymphadenopathy of the neck, dysphagia, odynophagia),
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physical examination, and CT of the neck and chest with contrast. The foreign body must
always be removed completely, including its particles. There may be chronic inflammation,
recurrences with fistulation and suppuration, or the formation of inflammatory granulomas
(5,8). When extracting foreign bodies, the correct operative approach is important. We
consider the size, extent, location, type of material of the foreign body, and possible com-
plications. We choose an approach that can remove a complex foreign body and we also
consider mini-invasiveness (9). However, foreign bodies made of organic material are often
fragile and their complete extraction is more difficult compared to e.g. with metal material
(6,12). Operations in the stage of acute inflammatory manifestations should be performed
under the cover of antibiotics (10). If an abscess is not formed and there are signs of celluli-
tis, conservative treatment is sufficient. We choose antibiotics with sensitivity to gram-posi-
tive bacteria and anaerobes, i.e. clindamycin, cephalosporins II.-III. generation or potentized
aminopenicillins. (1.11) When the surgical intervention is delayed, there is a risk of infection
penetrating from the retropharyngeal space into other spaces (“danger space”, parapha-
rynx, mediastinum) with the risk of fatal complications (3). In the case presented by us, the
initial foreign body was not expected due to the atypical localization at the site of the abscess
collection, and it was not possible to immediately identify the fish bone. On the basis of
persistent clinical problems and elevated inflammatory parameters in the laboratory, we
added control CT scans of the neck and chest. A residual abscess collection of the retrop-
harynx with a foreign body and subsequent revision surgery is described here. In our patient,
the foreign body was accessible due to its atypical placement, with good visualization and
manipulation, sufficient control of possible bleeding, and inspection after the removal of the
body. As part of the surgical treatment, we primarily chose a transoral approach for the
diagnosed abscess, as in tonsillectomy, or using instrumentation for mini-invasive surgery
of head and neck tumors. Some authors choose an external approach as safer and more
beneficial. Dissection begins at the front edge of the rocker into the parapharyngeal space
and can continue directly to the vertebral bodies into the retropharyngeal or prevertebral
space (1).
According to the Czech authors, the transoral approach can be used in the absence of
signs of parapharyngeal spread. The incision should be wide enough to drain and below the
apex of the arch to avoid creating a pocket with the possibility of secretion retention (1).
Surgical drainage of an abscess through an external approach involves a wide opening of
the fascial spaces of the abscess cavity, identification of the major jugular vessels and their
control, drainage of all separated abscess pockets, irrigation of the wound, and insertion of
wide tubular drains (1). We always take material for bacteriological examination. Depending
on the extent of the finding, they eventually introduce a nasogastric tube to ensure posto-
perative nutrition (13). Therefore, the external approach should be used in case of extensive
infections with a spread to the parapharyngeal space or mediastinum or an oppression of
the respiratory tract. Secure the elector's airway in case of shortness of breath. Exceptio-
nally, only intravenous antibiotics are used in the treatment of retropharyngeal abscesses
and are not identified with this procedure (1). In the Austrian literature, transoral is chosen
as the primary approach. They also recommend an external approach when the abscess
spreads to other spaces ("danger space", parapharynx, mediastinum) or in case of compli-
cations. For larger abscesses, food intake must be ensured using a nasogastric tube. Good
visualization is necessary during the procedure and also hemostasis after the extraction
(11). At our workplace, according to the clinical findings, we also indicated the securing of
the airways using a tracheostomy. The mentioned authors consider this procedure in the
case of shortness of breath. Bleeding from large vessels, or the risk of fatal complications,
is also a feared complication (14). Postoperatively, inflammatory complications may occur,
which may be local or general. Among the most feared are mediastinitis or the development
of a septic condition. Other possible complications are aspiration pneumonia, epiglottitis,
meningitis, necrotizing fasciitis, pericarditis, pyopneumothorax, and others (4,13). Therefore,
it is important to consult a thoracic surgeon. Due to the absence of an abscess in the chest
cavity, our patient's case did not require a collar mediastinotomy.
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CONCLUSION

Traumatic penetration of a foreign body into the retropharyngeal space is rare for otorhino-
laryngologists. Diagnostics using imaging examinations to determine the size and location
of the foreign body, as well as possible inflammatory complications in the area of the neck
and mediastinum, as in our case report, is important. We always choose the surgical approach
to remove the foreign body in such a way that a complete extraction is possible. Subsequently,
we consider the mini-invasiveness of the surgical procedure while keeping in mind the
possibility of bleeding, so we choose an approach with good visualization. We try to prevent
damage to important anatomical structures and prevent postoperative complications. It is
necessary to think about this diagnosis especially in the framework of differential diagnosis.
In addition to the occurrence of a foreign body in this area, other causes of diseases such
as injuries, developmental or tumor diseases should be considered (2).

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Received: February 12, 2023

Accepted: March 1, 2023