Neck and mediastinal hematoma caused by a foreign body in the esophagus with diagnostic difficulties:A case report

lNTRODUCTlON

Esophageal foreign body(FB),which typically presents with dysphagia,is a common clinical emergency.Patients with FBs sometimes attempt inappropriate clearance approaches,such as vigorous swallowing,which may lead to over-tightening or esophageal perforation,accompanied by lifethreatening complications such as mediastinal abscess and esophago-aortic fistula bleeding[1].Here,we report a case of esophageal perforation and cervical hematoma due to a FB in the esophagus.The uniqueness of this FB made rapid diagnosis difficult.

CASE PRESENTATlON

Chief complaints

The main complaints were a sudden shortness of breath,neck swelling and dyspnea.

History of present illness

A 42-year-old man,suddenly felt a FB stuck in his throat while eating breakfast(steamed stuffed bun,fried dough stick and seafood soup).Although he tried to clear the obstruction by swallowing steamed stuffed bun and drinking soup,the pharyngeal obstruction was not relieved.Consequently,he developed shortness of breath,neck swelling and dyspnea.

History of past illness

His past medical history was hypertension.

As to Tsar Dolmat, for two days he admired the false Horse with the Golden Mane, and on the third day he de sired to ride him. He gave orders, therefore, to saddle him, and mounting, rode to the open steppe. But as he was riding, it chanced that Tsarevitch Ivan, far away with Helen the Beautiful, all at once remembered his promise and cried:

Personal and family history

He was immediately subjected to mediastinal hematoma removal,peripheral nerve decompression,maxillofacial FB removal and esophageal reconstruction.This was approximately 10 h after onset of the condition.During surgery,an L-shaped incision was made along the sternocleidomastoid muscle of the right neck,followed by release and protection of the right recurrent laryngeal nerve.The posterior pharyngeal space was accessed through the right tracheoesophageal groove to reveal a large hematoma.The hematoma was aspirated,revealing a small arterial injury.Next,the vessel was closed using a surgical suture(ETHICON,polyglactin 910 suture).The wall of the right esophagus was then incised,and the FB at its entrance removed.This FB turned out to be a small crab,2 cm × 3 cm(Figure 3)with sharp ends that pierced the esophagus and measured 0.5 cm × 0.3 cm.The patient’s esophagus was repeatedly flushed with dilute iodine,then repaired with surgical sutures(ETHICON,polyglactin 910 suture).Next,two drains were placed in the mediastinum,one in the retropharyngeal space,and a vacuum device was placed to drain the nasogastric tube.After successful surgery,the patient was transferred to the intensive care unit.He regained respiratory and circulatory stability,1 d after surgery,after which the tracheal tube was removed.He was then transferred to the general ward and maintained on antibiotics.Mediastinal and retropharyngeal space catheters were removed on the fifth day,while the nasogastric tube was postoperatively removed after 11 d.

Physical examination

Physical examinations revealed presence of neck hematoma and low oxygen saturation.

Laboratory examinations

Laboratory results showed increased white blood cell counts 18.30 × 10/L and elevated levels of Creactive protein 21.20 mg/L.Nucleic acid-based analysis of the novel coronavirus at the local hospital revealed negative results.

Imaging examinations

He was immediately taken to the local hospital and subjected to computed tomography(CT)scan,30 min after onset of his illness.Results revealed presence of a large hematoma in his mediastinum and right neck(Figure 1).Due to the complexity of the problem,he was transferred from the local hospital to our hospital,where he was immediately treated with emergency tracheal intubation and respiratory support(3.5 h after onset of the condition).Results from CT angiography,performed on his thoracic aorta approximately 4 h after onset of the condition,revealed a black shadow of approximately 2.5 cm in diameter in the upper esophagus.The object was surrounded by a sharp end and a faint needle-like high-density shadow around it(Figure 2).

FlNAL DlAGNOSlS

The patient was discharged when he was free of severe symptoms and is being followed up in the outpatient clinic.

20.The Princess was meek: Meekness75, whatever the personal cost, was a highly prized quality in women in times past. While the princess may seem less sympathetic by today s standards thanks to her meekness/weakness, she would be a model of womenly virtue76 in some cultures. Other critics state that she is timid in confronting her maid thanks to her own immaturity77. This is not a woman who is prepared to become a wife and queen.Return to place in story.

Here rests a happy man, that is to say, a man of high birth and position, which was very lucky for him, otherwise he would have been scarcely worth notice

TREATMENT

Home medications included hydrochlorothiazide.He denied any family history of lung diseases and esophageal diseases.

OUTCOME AND FOLLOW-UP

Through a multidisciplinary discussion,we considered that the patient had a cavernous esophageal FB.

DlSCUSSlON

Although approximately 20% of all adult patients with esophageal FBs require clinical interventions,most of these FBs will spontaneously pass[2,3].Esophageal perforation caused by FBs is a relatively rare occurrence,accounting for only 1%-4% of all reported cases.Sharp polygonal or pin-like pointed FBs have been strongly linked with esophageal perforation or rupture,with a risk of up to 35%[4].Results from a prospective single-center study found that CT was 90%-100% sensitive and 93.7%-100% specific,indicating that it is highly effective in diagnosing accidental ingestions or suspected bone fragments in patients that return negative X-ray results[5-7].

Wang LP and Di S contributed equally to this case,both wrote and revised the text;Zhou ZY,Huang XP,Bai YJ,and Shi HX contributed equally in this case report;all were part of the clinical team that treated the patient,and all contributed to the text.

The FB lodged in the esophagus of the patient in the present study was a small crab,a sharp polygonal FB with only a thin shell and a small amount of crab meat inside.Notably,it looked like an air bubble,based on the CT image,which contrasts with solid FBs such as fish and poultry bones that appear as opaque objects on the CT image.This delayed rapid diagnosis of this patient.CT scans revealed the presence of a black shadow,about 2-3 cm in diameter,in the upper esophagus.In general,the gas-bearing shadow is for esophageal lacuna,but the gas shadow was bigger than normal and clear and sharp on both ends;the surrounding was a dimly visible linear high-density shadow,suggesting that it may not be the lacuna esophagus but a sharp FB.Although it was clinically confusing,a closer look at the shaded border revealed a sharp polygonal FB.

Chung[8]reported the first case of a crab-induced esophageal FB,albeit with less damage to the esophagus.Here,we report the second case of crab-associated FB lodged in the esophagus,and the first case of crab-associated esophageal perforation.Upon being stuck in the patient’s esophagus,he tried to push it into the stomach by eating steamed bread.However,this improper approach caused the FB to stick deeper in the esophagus.The FB pierced the esophageal wall and damaged blood vessels,thereby causing a huge hematoma and compressing the airway.Consequently,these phenomena resulted in life-threatening dyspnea and respiratory failure.Improper methods for clearance of esophageal FBs,especially sharp ones,are discouraged.Instead,patients are advised to seek timely treatment to reduce the risk of complications.Delayed treatment leads to esophageal necrosis and predisposes patients to general infection,a situation that has been linked to high mortality rates,ranging from 10%-20%[9,10].

CONCLUSlON

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers.It is distributed in accordance with the Creative Commons Attribution NonCommercial(CC BYNC 4.0)license,which permits others to distribute,remix,adapt,build upon this work non-commercially,and license their derivative works on different terms,provided the original work is properly cited and the use is noncommercial.See:https://creativecommons.org/Licenses/by-nc/4.0/

All study participants,or their legal guardian,provided informed written consent prior to study enrollment.

FOOTNOTES

In the Cupid and Psyche tale as recorded by Apuleius, Psyche is pregnant throughout her search for the missing Cupid. The baby, named Pleasure, is born after she is reunited with Cupid. Later versions of the tale, such as the one by Thomas Bulfinch, omit this detail.

56.If I may go to the Prince who is here, and be with him to-night, you shall have it: According to Maria Tatar: The true bride often tricks the false bride into letting her spend the night with the prince, or, as in this tale, she bribes114 her. The imposter bride is always eager to take possession of an object and will sacrifice the prince s welfare for material gain (Tatar 2002, 198). For a different type of tale with a false bride and a true bride, read The Goose Girl.Return to place in story.

No conflict of interests exists to any of the authors.

The authors have read the CARE Checklist(2016),and the manuscript was prepared and revised according to the CARE Checklist(2016).

Sharp FBs with cavities,which sometimes only appear as black shadows on CT scans,can easily be mistaken for esophageal lumens,thereby making clinical diagnosis difficult.This report elucidates on clinical diagnosis of cavernous FBs.Delayed treatment increases the risk of complications,thus timely performance of clinical management options,such as surgery,are encouraged.We recommend that patients with respiratory distress,caused by lodged FBs,first be subjected to airway stabilization prior to attempting removal or definitive management.

When she was tired she went back to the palace, and found a new room full of materials for every kind of work--ribbons to make into bows, and silks to work into flowers

China

Li-Ping Wang 0000-0002-5634-0384;Zhi-Ying Zhou 0000-0002-5634-0255;Xiao-Ping Huang 0000-0002-5636-0317;Yun-Juan Bai 0000-0002-5584-0189;Hai-Xia Shi 0000-0002-2856-4598;Di Sheng 0000-0002-0992-4715.

Wu YXJ

Filipodia

Won t you sit down? She blew up the fire on which she was cooking something in a little pot, and her daughter secretly warned the travellers to be very careful not to eat or drink anything, as the old woman s brews2 were apt to be dangerous

Wu YXJ