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|LETTER TO EDITOR
|Year : 2021 | Volume
| Issue : 3 | Page : 759-761
Foreign Body Induced Infective Cervical Spondylodiscitis with Compressive Myelopathy with Quadriparesis
Ashish Gupta, Rajesh K Bharti, Bidyanand Kumar
Department of Neurosurgery and Spine, Fortis Escorts Hospital, Faridabad 121001, Delhi-NCR, India
|Date of Submission||30-May-2017|
|Date of Decision||18-Oct-2017|
|Date of Acceptance||13-Jul-2019|
|Date of Web Publication||24-Jun-2021|
Dr. Ashish Gupta
R-44, Greater Kailash, Part-1, New Delhi - 110 048
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Gupta A, Bharti RK, Kumar B. Foreign Body Induced Infective Cervical Spondylodiscitis with Compressive Myelopathy with Quadriparesis. Neurol India 2021;69:759-61
Accidental ingestion of foreign bodies is common in otorhinolaryngological surgical practice. In few cases, the ingested foreign bodies penetrated the esophagus and migrated into the soft tissues of the neck. In most of the cases reported in the literature, the foreign body was either fish bones or metallic button battery. Herein, we report a case presented with pre-vertebral soft tissue mass with infective spondylodiscitis and compressive myelopathy leading to quadriparesis due to non-metallic foreign body (plastic cap of an ointment tube) impacted in the pre-vertebral space of the neck.
Accidental ingestion of foreign bodies is one of the most common otorhinolaryngological emergency. However, esophageal penetration and migration of foreign bodies into soft tissues of the neck is rare occurrences. Most reported cases in the literature involved fish bones and metallic foreign bodies found in the soft tissue of the neck. Migrated foreign bodies into the soft tissue of the neck may remain quiescent or may cause life-threatening infective or vascular complications.
An elderly lady presented in emergency with weakness of all four limbs for 3 days. She was a known case of eczema and was on local steroid ointment.
The patient gave past history of choking sensation and neck swelling 3 weeks ago for which the patient consulted an otorhinolaryngological surgeon, indirect and direct laryngoscopy was performed and found normal, she managed conservatively. Now, physical examination revealed eczematous lesions on limbs and forehead and quadriparesis 2/5.
MRI cervical spine [Figure 1], [Figure 2], [Figure 3], [Figure 4] showed features consistent with infective compressive myelopathy likely to be tubercular etiology.
|Figure 4: Coronal image. Red arrow showing foreign body (Figures 1 to 4) in prevertebral space at C5-C6 level|
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Patient was operated using right anterior cervical corpectomy and fixation fusion done using implant and bone graft. It revealed a firm mass underneath sternocleidomastoid muscle, then sternocleidomuscle and right carotid artery were retracted laterally and esophagus medially. The pre-vertebral fascia was found thickened about 1 cm. It was densely adhered to longus colli muscle. A firm lump was felt at the level of C5-C6, which was radiolucent on intraoperative C-arm imaging. It was removed by doing blunt dissection, which revealed plastic ointment cap [operative video] covered with granulomatous tissue. Bone was found soft and necrotic, disc material came out with pus, granulation tissue was found over the dura, posterior longitudinal ligament was thickened, and densely adhered to dura at C5 and C6 levels. C5 and C6 corpectomies and discectomies were done. After adequate decompression, titanium expandable cage with bone graft placed and fixation was done with plate and screws from C4 to C7. Esophagus and trachea were examined, no perforation noted. The operative wound was closed in layers. On second postoperative day, the patient developed surgical emphysema at right supraclavicular region and on the face. On bronchoscopy, a lobulated mass was occluding the vocal cord, arising from right aryepiglottic fold [Figure 5], but no obvious perforation seen in tracheobronchial tree. Esophagoscopy was normal. Neurologically, she showed improvement with power in limbs 3/5.
|Figure 5: Bronchoscopy view, red arrow showing swollen right aryepiglottic fold|
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Pus for Gram's stain and acid fast bacilli stain was negative. A histopathological examination of pre-vertebral soft tissue revealed predominately purulent exudates and no well-defined granuloma/atypical cells. Emphysema resolved by itself, neck wound healed. At six months follow-up, power in both upper limbs 4/5; both lower limbs 3/5.
Foreign bodies of the aerodigestive tract are one of the most common emergencies in otorhinolaryngological surgical practice. Commonly reported foreign bodies include fish bones, chicken bone, metallic button battery, pieces of glass, dentures, coins, and needles. These foreign bodies can impact in the tonsils, vallecula, pyriform fossa, and the cervical esophagus.
Review of literature showed no case of perforation of aryepiglottic fold by plastic foreign body and impaction in pre-vertebral space leading to suppuration, spondylodiscitis, and compressive cervical myelopathy with quadriparesis [Figure 6]. The exact mechanism of perforation is still unknown.
On reviewing the literature, no case has been reported with perforation of aryepiglottic fold owing to plastic foreign body and found migrated in pre-vertebral space outside trachea and esophagus; leading to suppuration, spondylodiscitis and compressive cervical myelopathy with quadriparesis. The exact mechanism of perforation is still unknown. However, it was proposed that there might be careless manipulation of the foreign body while attempting to remove it. It might have resulted in perforation of aryepiglottic fold and resulted in foreign body tissue reaction and abscess formation.
Spondylodiscitis is a recognized complication of sharp esophageal foreign bodies. Wadie et al. reported a case of spondylodiscitis in an adolescent girl following the accidental ingestion of a sewing pin.
Fonga-Djimi et al. described the esophageal perforation leading to mediastinitis, and C6-7 spondylodiscitis resulting from a radiolucent foreign body (a rigid plastic gear wheel) in a 6-year-old boy.
Spondylodiscitis secondary to phonatory prosthesis insertion or endotracheal intubation have also been reported.,
A migrated foreign body may remain quiescent or may lead to life-threatening complications, which may include suppurative complications such as retropharygeal and parapharyngeal abscess, epidural abscess, thyroid abscess, and mediastinitis. Vascular complications such as carotid rupture, penetration of facial artery, aortoesophageal, and in nominate esophageal fistula have also been reported. Patients with penetrating foreign bodies present with foreign body sensation, odynophagia or hemoptysis, and sometimes with fever and neck swelling. Nasogastric tube must be placed in all cases to allow for healing of the perforation.
A high index of suspicion is needed to diagnose a migrating foreign body in an elderly patient presenting with a history of choking sensation in neck. Early intervention is crucial in such cases to prevent complications. A thorough brochoscopy, esophagoscopy, and CT/MRI scan of the neck with and without oral contrast are the gold standards for diagnosis. A careful and systematic approach during exploration of the neck is needed. Intraoperative radiography can be of great help in locating the radio-opaque foreign body.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]