A Case of Migratory Thyroid Foreign Body

Abstract

Foreign bodies in the esophagus and pharynx are common acute emergencies in otolaryngology - head and neck surgery. Most foreign bodies remain lodged in the lumen and can be removed via fiber laryngoscopy, esophagoscopy, or electronic gastroscope. However, a minority of sharp foreign bodies may perforate the wall, leading to wandering neck abscesses. Migratory thyroid foreign bodies are relatively rare, especially when the onset interval exceeds six months. This report presents a case of a 43 - year - old female patient who was admitted due to severe neck pain. After comprehensive examinations, she was diagnosed with a migrated thyroid foreign body and was cured and discharged after open neck surgery.

Case Report

A 43-year-old female patient presented to a local county People’s Hospital with the chief complaint of “right neck pain for one week.” A cervical color Doppler ultrasound revealed abnormal echoes in the right neck (suggesting a fishbone with possible surrounding abscess formation), which was closely related to the right thyroid lobe.

Upon further inquiry, the patient reported a history of accidental fishbone ingestion six months prior, accompanied by a pricking sensation in the throat. At that time, she forcefully swallowed boluses of food, such as a rice ball, to push it down. The pricking sensation subsequently disappeared, so she did not seek further medical evaluation or treatment. Physical examination upon admission revealed a palpable mass approximately 3 x 2 cm in size in the right neck. The mass was mildly tender, with slight erythema of the surrounding skin and palpable fluctuation. Given the suspicion of a cervical foreign body, a non-contrast cervical CT scan with three-dimensional reconstruction was performed. The imaging revealed a space-occupying lesion in the right thyroid lobe and the right parapharyngeal space, suggestive of an abscess. A linear hyperdense shadow was identified within the lesion, highly indicative of a foreign body (Figure 1).

Figure 1.

(A), (B), (C) Image from the preoperative cervical CT scan. Arrow indicates the foreign body; asterisk indicates the abscess

The surgical approach selected was a lateral cervical incision for foreign body removal. Initially, considering the close proximity between the foreign body and the cervical abscess, an incision was made at the site of the abscess on the right neck. Yellow purulent exudate was observed and aspirated. However, upon exploration of the abscess cavity, no distinct foreign body was palpated.

After carefully reviewing the cervical CT scans, which revealed a close relationship between the foreign body and the right lateral thyroid lobe, a transverse incision was made anterior to the right neck, parallel to the thyroid plane. The thyroid isthmus and the right thyroid lobe were exposed. Intraoperatively, significant local induration was palpable in the right thyroid lobe. A longitudinal incision was made into the right lateral thyroid lobe, revealing a fishbone lying horizontally within. A white, fishbone-like foreign body approximately 3 cm in length was successfully retrieved.

Following removal, the thyroid lobe was sutured with meticulous hemostasis. Subsequently, the muscular layer, subcutaneous tissue, and skin were closed in layers.

Postoperative management included anti - inflammatory treatment and wound dressing changes. The patient recovered well postoperatively. At the 6 - month follow - up, the cervical surgical scar had healed well with no palpable masses, and thyroid function remained normal(Figure 2).

Figure 2.

(A) Intraoperative view: complete visualization of foreign body. (B) The removed foreign body

Discussion

Foreign bodies in the esophagus represent a common otolaryngological emergency. Overseas reports indicate that foreign body types in adults include food boluses, fish bones, chicken bones, dentures, crab shells, wires, and needles. Domestically, reports suggest that foreign bodies in the elderly are predominantly animal bones and jujube pits, followed by fish bones and dentures.^1,2

Fish bone ingestion is one of the most frequent occurrences. These objects often lodge in the palatine tonsils, base of the tongue, vallecula, pyriform sinuses, or esophagus. Most cases can be diagnosed and managed via careful oropharyngeal examination, indirect laryngoscopy, or endoscopy.

Extraluminal migration of pharyngoesophageal foreign bodies occurs when sharp, pointed objects penetrate the digestive tract wall under pressure from muscular contractions and swallowing. They then migrate along muscular planes; the distance and depth of migration depend on the shape of the foreign body and the direction of surrounding muscular contractions. In rare instances, these foreign bodies can migrate to distant locations such as the retropharyngeal space, parapharyngeal space, supraclavicular and infraclavicular regions, and submandibular space.^3,4 However, complications involving cervical abscesses that extend to and involve the thyroid gland are uncommon.

Cervical abscess is an infectious disease of the neck that is not frequently encountered in otolaryngology. It is mostly secondary to pharyngeal tissue infections or congenital branchial cleft fistulas. High - risk populations primarily include the elderly and infants with low resistance, as well as patients with immunocompromising conditions such as diabetes or AIDS. ⁵ In clinical practice, cervical abscesses occurring in middle - aged or young adults without obvious predisposing factors or systemic diseases should raise a high suspicion of pharyngeal or esophageal foreign bodies.

Based on the patient’s history, throat pain, and relevant endoscopic examinations, most pharyngeal and esophageal foreign bodies can be diagnosed and removed. For patients in whom endoscopy fails to reveal a foreign body, but who continue to experience throat pain and odynophagia, migration should be highly suspected. In such cases, thin - slice CT scans or three - dimensional reconstruction should be utilized. If a palpable abscess is present in the neck, ultrasound imaging can provide accurate localization and morphological description of the foreign body.^6,7

A detailed patient history is essential before treatment. The type and quantity of the ingested object should be clarified, and the approximate location of the foreign body should be assessed based on physical signs.

Initial Imaging: If an esophageal impaction is suspected, a CT scan should be the initial investigation to confirm the type and precise location of the foreign body.

Endoscopic Caution: Esophagoscopy or gastroscopy should be performed meticulously to trace the path of the foreign body and protect normal mucosal tissue. If no foreign body is found during the procedure but the patient still reports throat discomfort, a follow - up CT scan or 3D reconstruction is recommended to rule out residual or migrated foreign bodies.

Surgical Management: For patients with confirmed free - floating cervical foreign bodies, surgical intervention should be performed as early as possible. Preoperative planning must fully consider the size, nature, location, and potential damage caused by the foreign body. Careful preoperative imaging review and thorough preparation are required. During surgery, vital neck structures must be protected. The goal is not only the complete removal of the foreign body but also the minimization of damage to neck soft tissues.

Conclusion

This article reports a case of thyroid migratory foreign body and shares relevant clinical experience and surgical approaches.