Endoscopically Assisted Removal of a Fish Bone Penetrating the Parotid Duct: An Unusual Case

Fish Bone Foreign Body: The Role of Imaging

Introduction  Fish bone foreign body (FFB) impaction in the upper aerodigestive tract is a common cause for emergency department referral. Its management varies in both diagnosis and treatment paradigms. Fish bone foreign bodies are more commonly found in the oropharynx in cases of patients < 40 years old, and in the esophagus in cases of patients > 40 years old. Symptoms are typically non-indicative for the location of the FFB, with the exception of foreign body sensation at/superior to the cervical esophagus. A lack of findings during the physical examination is routinely followed by imaging, with computed tomography (CT) being the preferred modality. In practice, many patients undergo unnecessary imaging studies, including CT scans.

Objectives  To identify patients with suspected fish bone impaction who do not require CT imaging and can be safely discharged.

Data Synthesis  We have searched the PubMed database for the following medical subject headings (MeSH) terms: fish bone , fish foreign body AND oropharynx , hypopharynx , esophagus , flexibleesophagoscopy , and rigidesophagoscopy . Our search in the English language yielded 32 papers. Case reports were included, since they highlighted rare and serious complications.

Conclusion  In patients > 40 years old suspected of fish bone impaction, non-contrast CT is recommended and should be urgently performed, even in the presence of ambiguous symptoms. However, in patients < 40 years old presenting within 24 hours from ingestion, imaging has little diagnostic value due to the low probability of esophageal fish bones. For this specific subgroup, in the absence of clinical findings, discharge without imaging studies may be considered safe.

Use of sialendoscopy as an aid to identify a large retained foreign body

We describe the novel use of sialendoscopy in a 51-year-old man to identify a large and long-standing foreign body (wood) within the facial soft tissues that had eluded detection on previous imaging and surgical exploration. The identification of this foreign body was elusive on both computed tomography and magnetic resonance imaging, illustrating the limitations of imaging in identifying vegetable matter within soft tissues.

Dynamic imaging with sialography combined with sialendoscopy to manage a foreign body in Stensen's duct

OBJECTIVE

We describe sialography as a dynamic imaging modality useful in establishing the diagnosis and planning for treatment of a parotid gland ductal foreign body.

METHODS

Chart and radiographic imaging review of a 75 year-old male who had obstructive sialadenitis symptoms two years after welding slag pierced the cheek skin and identified as a 'piece of steel stuck in his cheek'.

RESULTS

Sialography was used to demonstrate a foreign body adjacent to the parotid gland to indicate its presence as a mobile element within the ductal system associated with marked pre-obstructive duct dilation. Sialendoscopy was used to successfully remove the foreign body.

CONCLUSIONS

In selected cases, the management of obstructive sialadenitis can be improved with sialography in permitting dynamic imaging of salivary duct anatomy. Although ultrasound has evolved as a standard component of salivary gland assessment, sialography may complement imaging with ultrasound (or CT as in this case) to offer the highest acuity definition of the salivary ducts.

Sialendoscopy as a management tool in patients with foreign body impaction of the salivary gland

PURPOSE

It has been long known that sialendoscopy has both diagnostic and therapeutic benefits in the identification and treatment of sialadenitis. Sialendoscopy can also be used to triage patients with traumatic injury or foreign bodies lodged in the parotid gland.

PROCEDURES

We present a case of traumatic insertion a fishbone into the parotid gland parenchyma that was evaluated with sialendoscopy and successfully managed on the basis of stable endoscopy findings that correlated with improving symptomatology.

MAIN FINDINGS

We find that sialendoscopy presents a useful tool to help guide management.

CONCLUSIONS

We demonstrate that in an asymptomatic patient, foreign body impaction with absence of ductal obstruction on endoscopy can successfully be followed with simple observation.

Sialendoscopy-assisted transfacial surgery for the removal of an iatrogenic foreign body in Stensen's duct: a stone and broken wire basket

Background:

A foreign body is a rare cause of parotid gland obstructive sialadenitis; intra-oral penetration via Stensen's duct is unusual. The relatively recent introduction of interventional sialendoscopy to treat obstructive sialadenitis has allowed surgeons to adopt a gland-sparing approach by means of miniaturised endoscopes and instruments. However, unusual anatomy or pathological conditions can give rise to a risk of intraductal rupture that may lead to a subsequent iatrogenic foreign body.

Case report:

This paper describes the case of a patient with a 4 mm stone engaged by a broken wire basket stuck in a secondary branch of Stensen's duct.

Results:

The iatrogenic foreign body was successfully retrieved by means of sialendoscopy-assisted transfacial surgery.

Conclusion:

This is the first reported case of an intraductal rupture of a miniaturised device during interventional sialendoscopy successfully resolved by means of combined endoscopy and external surgery. This proved to be an effective method of rescuing a foreign body stuck in Stensen's duct.