Transcervical Exploration via the Posterolateral Approach to Extract a Fishbone Embedded in the Paraglottic Space

Abstract

Ingested foreign bodies occasionally migrate to the paraglottic space. The external transcervical approach is almost always required to extract completely embedded foreign bodies. We report a case of an ingested fishbone embedded in the paraglottic space, which was successfully removed through transcervical exploration of the paraglottic space via the posterolateral approach. The posterolateral approach is safe and effective for the removal of foreign bodies completely embedded in the paraglottic space.

Introduction

Airway foreign bodies are one of the most common otorhinolaryngological emergencies. Laryngeal foreign bodies are rare and account for less than 4% of all foreign bodies; foreign body migration into the paraglottic space is even rarer. A review of the English medical literature revealed only 4 cases of foreign body migration to the paraglottic space.^1-4 We report a case of migration to the paraglottic space of an ingested foreign body, which was successfully removed through transcervical exploration of the paraglottic space via the posterolateral approach.

Case Presentation

A 51-year-old female presented to our otolaryngology department with persistent pharyngalgia 11 days after accidental ingestion of a fishbone. She did not have hoarseness, dyspnea, or dysphagia. She was treated with intravenous fluids for 1 week at a local hospital, but her symptoms did not improve. Subsequently, she developed face and neck redness and swelling, for which she was referred to our hospital. The patient had hypertension for more than 20 years that was well-controlled with medications.

Cervical palpation revealed mild neck swelling. Laryngostroboscopy showed a markedly swollen left-sided false vocal cord, aryepiglottic fold, and pyriform fossa, and normal vocal cord mobility (Figure 1). However, the foreign body was not visualized in the pharynx or larynx. Computed tomography (CT) of the neck revealed a 3.6 cm linear foreign body that was completely embedded in the left paraglottic space and marked edema of the surrounding soft tissue (Figure 2). Direct laryngoscopic examination using an endoscope failed to visualize the foreign body.

Figure 1.

Laryngostroboscopy showed markedly swelling of false vocal cord, aryepiglottic fold, and pyriform fossa on the left side, and the vocal cord mobility was normal.

Figure 2.

Computed tomography scan of the neck revealed a linear object of high density completely embedded in the left paraglottic space (A), with surrounding soft tissue marked edema (B).

Transcervical exploration was performed using the posterolateral approach. A platysma myocutaneous flap was raised to expose the strap muscles, and the lateral margin of the left strap muscles was dissected to expose the hypopharyngeal constrictor. The hypopharyngeal constrictor was detached to expose the posterolateral margin of the thyroid cartilage. The thyroid cartilage was approached from the medial side to access the left paraglottic space, which revealed the foreign body. Thereafter, the foreign body was successfully retrieved (Figure 3).

Figure 3.

The fishbone was successfully extracted.

The patient had an uneventful postoperative recovery and was discharged on the seventh postoperative day. She did not have any residual swallowing difficulty and her voice returned to normal. Computed tomography of the neck was repeated after 1 month and was normal (Figure 4).

Figure 4.

Computed tomography scan of the neck was reexamined and no abnormality was found.

Discussion

We searched the MEDLINE database for English medical literature using the search terms “intralaryngeal” OR “endolaryngeal” OR “larynx” OR “paraglottic space” AND “foreign body”.

To the best of our knowledge, five cases of migration of an ingested foreign body to the paraglottic space, including our case, have been described in the English literature (Table 1). All five cases were caused by fishbone ingestion. The foreign body migrated to the paraglottic space and pyriform sinus in one case, and to the paraglottic space in the remaining four cases. The route of migration of fishbone to the paraglottic space is unclear, but migration may occur through the anterior or medial wall of the pyriform sinus. Subsequently, repeated contractions of the pharyngeal constrictors during swallowing may have pushed the fishbone forward into the paraglottic space.^1,2,4 Vocal cord mobility was limited in three cases,^1,3,4 which may be attributed to mechanical articular fixation and/or inflammation of the branches of the recurrent laryngeal nerve passing through the paraglottic space. ¹ Hung et al ¹ reported full recovery of vocal cord function at 1 month postoperatively. In another patient, the vocal cord function recovered 2 weeks after discharge. ⁴ In patients with symptoms of foreign body ingestion but non-visualization of the foreign body on laryngoscopy, CT should be performed. In our patient, no foreign body was visualized on laryngostroboscopy, whereas the CT showed the foreign body, which was completely embedded in the left paraglottic space.

Table 1.

Migration of an Ingested Foreign Body into the Paraglottic Space Reported in English Medical Literature.

Case	Author, Date, Ref	Sex/age	Symptoms	Location	Laryngoscopy	Vocal cord mobility	Size, shape, type of foreign body	Treatment	Intraoperative and Postoperative complications	Follow-Up
1	Hung 2009 (1)	F/68	Sensation of a lump in throat, slight dysphagia, hoarseness, choking, weight loss	Right paraglottic space and right pyriform sinus	Immobility, medial bulging, swelling of right vocal cord; swollen mucosa of right pyriform sinus	Right vocal cord immobility	2.4 cm, pin-like, inearly, fishbone	Operation under direct laryngoscopy	No	All back to normal, 1 month
2	Megwalu 2016 (2)	M/68	Odynophagia	Right paraglottic space	NA	NA	2.5 cm, linear, fishbone	Transcervical exploration via posterolateral approach (twice)	No	All back to normal, 1 month
3	Wong 2017 (3)	M/62	Voice changes, odynophagia, dysphagia, a foreign body sensation	Right paraglottic space	Edematous rigtht arytenoid and false cord	Reduced right vocal cord mobility	4 cm, linear, fishbone	Transcervical exploration via lateral thyroid cartilage window	No	NA
4	Alkhudher 2018 (4)	M/45	Throat pain, hoarseness	Left paraglottic space	Edematous left aryepiglottic fold, left pyriform fossa with secretions	Left vocal cord immobility	3 cm, linear, fishbone	Transcervical exploration via thyroid cartilage window approach	No	All back to normal, 2 weeks
5	Present case	F/51	Pharyngodynia	Left paraglottic space	Edematous left false cord, aryepiglottic fold and pyriform fossa	Normal	3.6 cm, linear, fishbone	Transcervical exploration via posterolateral approach	No	All back to normal, 45 months

Most laryngeal foreign bodies can be removed using endoscopic techniques. Hung et al ¹ used the endoscopic approach to remove an ingested fishbone embedded in the paraglottic space; in that patient, the fishbone was impacted in the lateral wall of the pyriform sinus and could be seen via direct laryngoscopy. However, completely embedded foreign bodies may not be visualized by endoscopy and should be removed using the transcervical approach. Transcervical exploration techniques for the paraglottic space include thyrotomy of the lateral thyroid cartilage, thyroid cartilage window, and anterior laryngofissure, and posterolateral approaches.^2-5 Unlike the other approaches, the posterolateral approach does not damage the laryngeal frame or mucosa of the larynx and pharynx, so there is less trauma and fewer complications. In 2016, Megwalu et al ² first reported the posterolateral approach for removal of a foreign body from the paraglottic space; however, the first removal attempt failed and the patient required reoperation. In comparison, we successfully removed the foreign body during a single operation using the aforementioned technique, which allowed precise preoperative and intraoperative localization of the fishbone.

Conclusions

Foreign bodies are rarely embedded in the paraglottic space. In completely embedded foreign bodies, an external transcervical approach is almost always required. The posterolateral approach is a safe and effective option for foreign bodies that are completely embedded in the paraglottic space.