Cervical cellulitis and mediastinitis following esophageal perforation: A case report

A case of mediastinitis accompanied with hyperosmolar nonketotic coma

Mediastinitis is a serious infection involving mediastinal spaces after cervical infections spread along the facial planes. A late diagnosis of mediastinitis may result in death. Here we present a diabetic patient suffered from mediastinit accompanied with hyperosmolar nonketotic coma. A 61 years old male patient with type 2 diabetes was admitted to our hospital, with complaint of generalized worsening and fever. A diagnosis of nonketotic hyperosmolar coma was done and proper treatment started immediately. Neck tomography revealed abscess formation in the upper mediastinum. The needle aspirat culture failed to show bacterial growth. After five days of antibiotic treatment the patient's symptoms resolved. The abscess formation and pleural effusion almost disappeared on control tomography. No similar case presentation was seen in the current literature. Apart from this case, mediastinit should be keep in mind when a patient suffered from dysphagia, fever and cervical swelling.

Esophageal wishbone extraction: not for the chicken-hearted

OBJECTIVE

Ingestion of foreign bodies in the pediatric population is common and in the majority of cases involves spontaneous passage through the esophagus; however, they can become lodged in spaces of anatomical narrowing. Sharp foreign bodies are of particular concern due to a higher chance of perforation and other complications. The goal of this case report is to describe the safe removal of a chicken wishbone and 3 alternate options in the event that the initial choice was unsuccessful.

METHODS

We report the case of a 2-year-old boy who presented to our pediatric tertiary center after unsuccessful endoscopic removal of a chicken wishbone from the esophagus.

RESULTS

Radiologically, the wishbone was oriented with the tines pointing up. Endoscopic examination revealed the tips of both tines to be embedded deeply into the lateral walls of the esophageal mucosa. Esophagoscopy and protecting the sharp points of the wishbone were used to successfully extract the intact wishbone.

CONCLUSION

Previous techniques have involved cutting the bone; however, in this case, tension was so high that it was felt that cutting the bone would result in perforation. Proper management of such cases requires planning and often multiple strategies.

Esophageal large fish bone (sea bream jawbone) impaction successfully managed with endoscopy and safely excreted through the intestinal tract

A 68-year-old man consulted our hospital because of back pain. A chest computed tomography (CT) demonstrated a high-density foreign body in the esophageal wall. There was no evidence of pneumomediastinum. Endoscopic examination demonstrated a large fish bone that was stuck in the esophageal wall. It was dislodged and moved into the stomach. The bone was excreted through the intestinal tract on the seventh hospital day. Unintentional ingestion of large fish bones must be considered potentially dangerous. Complications such as esophageal perforation or mediastinitis should be confirmed by CT; and then, the esophageal foreign body should be removed as soon as possible.

[Foreign body perforation of the thoracic esophagus]

BACKGROUND

Esophageal perforation due to foreign body (FB) ingestion is an unusual occurrence. This study aims to define diagnostic difficulties of esophageal perforation by FB.

PATIENTS AND METHODS

A chart review of patients on our service with FB esophageal perforation was carried out. Diagnosis of perforation was made by CT scan and/or esophagoscopy. Surgery was indicated when a FB could not be removed endoscopically or on a case-by-case basis according to clinical/laboratory, radiologic, and/or endoscopic findings.

RESULTS

Seven patients (age range: 27 to 80 years) were admitted for esophageal FB perforation. All patients presented with dysphagia. Two patients presented with signs of sepsis more than 24 hours after FB ingestion. Perforation was diagnosed at initial evaluation in five cases (three by endoscopy, two by CT) and after FB extraction in two cases. Six patients underwent surgery (suture repair: n=4; esophageal exclusion: n=1; mediastinal drainage: n=1). Five surgeries were performed at the initial diagnosis and one after failure of medical management. Mortality was zero; one patient developed esophageal fistula.

CONCLUSION

Diagnosis of FB esophageal perforation is difficult and is delayed in up to a quarter of patients. The perforation can be due to the FB itself or may be incurred during endoscopic extraction. Both CT and endoscopy are necessary for diagnosis and treatment. Most patients require surgical intervention.