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Clinical Problem Solving: Radiology
September 15, 2008

Radiology Quiz Case 1: Diagnosis

Author Affiliations
 

PATRICIA A.HUDGINSMD

Arch Otolaryngol Head Neck Surg. 2008;134(9):1010. doi:10.1001/archotol.134.9.1010

A neck x-ray film showed a linear opacity anterior to the vertebrae at the C6 level (Figure 1, arrow) with marked soft tissue swelling and a loss of cervical lordosis, leading to the tentative diagnosis of esophageal foreign body.1Rigid endoscopy failed to find any foreign body in the esophagus, and there were persistent symptoms suggesting the presence of a migrating foreign body. An axial CT scan of the neck showed a 3-cm-long, thin, linear hyperdensity pointing to the right thyroid gland laterally in the right paraesophageal space (Figure 2). Increased soft tissue density with heterogeneous enhancement in the right paraesophageal space, extending to the right paratracheal space, was also evident (Figure 3). A whitish, sharp-ended fish bone was found in the right paraesophageal space and removed during the lateral neck exploration. The fish bone was embedded beneath the right lobe of thyroid gland and surrounded by puslike material. The esophageal perforation was endoscopically localized and then externally repaired at the time of the bone removal. A Penrose drain was placed for external drainage. After surgery, intravenous antibiotic therapy with ampicillin sodium–sulbactam sodium (1 g and 0.5 g, respectively) (Unasyn [Pfizer Inc, New York, New York], 6 g/d) was initiated, and nasogastric feeding was started after the patient took nothing by mouth for 24 hours. After esophagography showed no leakage of water-soluble contrast medium 1 week after surgery, the nasogastric tube and then the Penrose drain were removed. The next day, the patient was discharged on a 1-week oral antibiotic regimen.

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