Volume 4, Issue 4 , Pages 169-172, December 2009
Migrating foreign body of the neck as a cause of recurrent febrile lymphadenopathy
Article Outline
Summary
A 15-year-old girl was referred to our Pediatric Emergency Unit because of recurrent fever associated with a painful right laterocervical mass over the previous four months, which was unresponsive to various antimicrobial therapies. During surgery, performed to obtain a biopsy, an unexpected vegetable thin fibre, about 1.2
cm long, was found among the laterocervical lymph nodes. The patient subsequently experienced complete clinical remission and told us that about one month before the development of symptoms she had felt a punctory sensation in the floor of her mouth after she had been playing with a blade of grass between her lips.
Keywords: Foreign body, Migration, Cervical lymphadenopathy
1. Introduction
Foreign-body ingestion is a frequent event in children and adolescents. According to Wai Pak et al., who recently described 311 cases of foreign body ingestion in children, fish bones are the most common [1] but there are substantial differences between Oriental and Western populations as a result of their different cultural and eating habits [2], and other frequently observed foreign bodies include chicken and beef bones, coins, plastic toys and glass pieces [1]. It is well known that sharp foreign bodies like wires, pins or tacks can perforate the oral mucosa, and lead to acute symptomatic manifestation, but the migration of a foreign body through the muscles and soft tissues of the neck is rare in children and adolescents. There have been reports of various fish bones migrating to the neck [3], [4], [5], to the thyroid gland [6], in the throat through the common carotid artery [7] or in the pharynx through the internal jugular vein [8] in adults. To date only few cases of migrating foreign bodies in the neck have been described in children: a fish bone [9], a marker pen [10], a grass blade [11], and a nail [12]. In this last case, its spontaneous expulsion from the cutaneous tissue of the neck was described in an asymptomatic 11-month-old girl eight months after its ingestion.
We here describe a very unusual case of a patient with a recurrent laterocervical swelling associated with fever, caused by a vegetable foreign body migrated from the floor of mouth to the neck.
2. Case report
A 15-year-old girl was referred to the Pediatric Emergency Unit of the Policlinico Hospital in Milan because of recurrent fever associated with right painful laterocervical mass (10cm×8cm) in the previous four months. Her parents reported that she had been hospitalised three times during this period and had always been intravenously treated with broad-spectrum antibiotics, which were initially beneficial but the symptoms reappeared in the week after the treatment was discontinued. During the previous 10 days, she had received antimicrobial therapy with intramuscular ceftriaxone without any clinical benefit. The patient lived in a gipsy community, in poor socio-economic conditions.
Upon the admission to the Pediatric Unit, blood tests showed a WBC count of 17,300mmc−1 (78.9% neutrophils) and CRP levels of 6.3mg/L. Suspecting an infectious disease, a search was made for the most common antimicrobial antibodies (anti-HIV, anti-Toxoplasma, anti-CMV, anti-EBV; anti-Coxsackie, anti-Parvovirus, anti-ECHO virus) but the results were negative. An ultrasonographic examination (Hitachi H21 7.5MHz) revealed a dishomogeneous, hypovascularised oval cervical mass anteriorly to the sternocleidomastoid muscle measuring 6cm×3cm, and some reactive lymph nodes near the right parotid gland. Axial and coronal CT (Fig. 1) showed a dishomogeneous mass extending to the right laterocervical region of the neck that also involved the parotid and submandibular glands, and the masseter and sternocleidomastoid muscles, with areas of colliquation and multiple pathologic lymph nodes. The right pyriform sinus was partially obliterated and created an asymmetric image of the larynx, which seemed to be dislocated to the left. There were no pathological pulmonary images and no foreign bodies were suspected. As the Mantoux test was positive, gastric and bronchial aspiration was performed in a search for BK or atypical mycobacteria, but no pathogen was revealed by bacterioscopic, polymerase chain reaction (PCR) and culture analyses.
Fig. 1.
Axial CT scan showing a dishomogeneous mass extending to the right laterocervical region of the neck with areas of colliquation and multiple pathologic lymph nodes.
Systemic antimicrobial therapy (vancomycin 40mg/kg/day and imipenem 60mg/kg/day) was started and led to the partial remission of symptoms in 14 days. The patient underwent ultrasound-guided fine needle cytological aspiration of the mass with a G14 needle under local anaesthesia, but the cytological material was negative upon standard cultural examination and a PCR search for BK, atypical mycobacteria and Mycoplasma pneumoniae. Because of the partial symptomatic remission induced by prolonged systemic antimicrobial therapy, the patient underwent surgery to obtain an excisional biopsy using a traditional right cervicotomy to approach the second and third level of the laterocervical lymph nodes and a major fibrotic reaction of the muscles and facial planes in the region seemed to justify a biopsy of the sternocleidomastoid muscle.
During the surgical procedure, an unexpected foreign body was found among the laterocervical lymph nodes (Fig. 2), which was like a thin vegetable fibre about 1.2cm long (Fig. 3), and the II and III levels of the right laterocervical lymph nodes were dissected. The postoperative histopathological examination showed that the isolated lymph nodes had a policlonal aspect, and the foreign body was confirmed to be a vegetable fibre. The biopsy of the sternocleidomastoid muscle revealed a fibrotic reaction. Bacterioscopic examination, PCR and culture for BK and atypical mycobacteria were negative, as was PCR for M. pneumoniae.
Fig. 2.
Detection of a foreign body during surgery in the right laterocervical space.
Fig. 3.
Measurement of the thin vegetable fibre (1.2
cm in length).
After the surgical treatment, the patient experienced complete clinical remission. During the last follow-up evaluation, she told us that about one month before the development of the cervical swelling and fever she had felt a punctory sensation in the floor of her mouth after she had been playing with a blade of grass between her lips.
3. Discussion
Although the ingestion of foreign bodies is frequent during childhood and adolescence, their migration through the soft tissues of the neck is a rare event. Two mechanisms may be involved: small foreign bodies such as particles can migrate to the local lymph nodes through the lymphatic drainage system or as a result of macrophage phagocytosis [13], whereas large foreign bodies such as fish bones, wires, pins and vegetable fibres are assisted in their migration after oral mucosal penetration by movement of neck muscles and viscera in an attempt to induce their spontaneous expulsion [12].
We here describe a case in which a vegetable fibre migrated from the mucosa of the oral floor to the soft tissues of the neck and could not be detected by means of traditional radiographic and ultrasonographic examinations of the upper airway and neck structures. Only one other case of a grass blade migrating to the neck and causing swelling has so far been described: in this case, a four-year-old girl experienced odynophagia and neck swelling for two months that partially remitted after antibiotic treatment, and the foreign body was only found during the surgical drainage of the cervical abscess [11].
Our patient showed recurrent fever associated with a laterocervical mass that partially responded to different systemic antibiotic therapies. As she lived in a gipsy community in poor social conditions, her positive Mantoux test reaction induced a strong suspicion of a mycobacterial disease. Although persistent cervicofacial lymphadenitis is the most common manifestation of non-tubercular mycobacterial infections in children [14], [15], differential diagnosis requires the consideration of other disorders, such as neck abscesses due to methicillin-resistant Staphylococcus aureus [16], toxoplasmosis, cat scratch disease and chronic systemic diseases (Kawasaki disease, collagen vascular diseases, Kikuchi-Fujimoto disease) [17]. As our patient had no systemic symptoms other than fever, the indication for surgery was to obtain a diagnostic bioptic sample because the bronchial and gastric aspiration samples were negative for BK and atypical mycobacteria; furthermore, surgery is considered to be more effective than antibiotic treatment in children with non-tuberculous mycobacterial cervical lymphadenitis [18]. The finding of the foreign body during the surgical procedure was unexpected as the positive Mantoux reaction in the presence of negative gastric and bronchial aspirates, and negative lymph node tissue, seemed to be related to a previous vaccination unreported by the parents or previous contact with BK or atypical mycobacteria.
In conclusion, although rare, migrating foreign bodies in the neck represent, a real emergency in children and adolescents not only because of their atypical clinical presentation, but also because of the high risk of possibly life-threatening complications such as retropharyngeal abscess [19] and mediastinitis [20]. In this regard, foreign body ingestion and migration should be considered as an etiological cause in the differential diagnosis of any persistent phlogistic cervical mass observed in pediatric or adolescent patients. Finally, our case underlines the importance of taking a meticolous case and family history, and the choice of surgery as the best option for both diagnostic and therapeutic purposes in patients with persistent inflammatory neck masses that fail to respond to antibiotics.
References
- . A prospective study of foreign-body ingestion in 311 children. Int. J. Pediatr. Otorhinolaryngol. 2001;58:37–45
- . Foreign bodies in the upper digestive tract. Singapore Med. J. 1987;28:162–165
- . Migrating pharyngeal foreign bodies: a series of four cases of saw-toothed fish bones. Eur. Arch. Otorhinolaryngol. 2008;265:1125–1129
- . Migratory foreign body in the neck. Asian. J. Surg. 2005;28:136–138
- . Unusual migratory foreign body in the neck. Singapore Med. J. 2004;45:487–488
- . Thyroid lobectomy for removal of a fish bone. J. Laryngol. Otol. 1990;104:511–512
- . Foreign body in the throat migrating through the common carotid artery. J. Laryngol. Otol. 1996;110:793–795
- . A foreign body in the pharynx migrating through the internal jugular vein. Am. J. Otolaryngol. 2003;24:89–91
- . An unusual neck lump. J. Ped. Surg. 2000;35:1132–1133
- . Unusual and surprising neck mass: a case report of extraluminal migration of pharyngeal foreign body. Otolaryngol. Head Neck Surg. 1996;115(2):173–174
- . An unusual foreign body migrating through time and tissues. Head Face Med. 2006;2:30
- . Ingested nail penetrating the neck in an infant. Int. J. Pediatr. Otorhinolaryngol. 2002;65:159–162
- Migration of aluminium silicate from the oral cavity to the submandibular region, with foreign body granuloma formation: report of a case. Oral. Surg. Oral. Med. Oral. Pathol. Oral. Radiol. Endod. 2007;104:e45–e49
- . Imaging of granulomatous lesions of the neck in children. Radiol. Clin. North Am. 2000;38:969–977
- . Cervical lymphadeopathy in children—incidence and diagnostic management. Int. J. Pediatr. Otorhinolaryngol. 2007;71:51–56
- . Pediatric neck abscesses—changing organisms and empiric therapies. Laryngoscope. 2008;118:2111–2114
- . Childhood cervical lymphadenopathy. J. Pediatr. Health Care. 2004;18:3–7
- . Surgical excision versus antibiotic treatment for nontuberculous Mycobacterial cervicofacial lymphadenitis in children: a multicenter, randomised, controlled trial. Clin. Infect. Dis. 2007;44:1057–1064
- . Retropharyngeal abscess secondary to penetrating foreign bodies. J. Cranio-Maxillofac Surg. 2000;28:243–246
- . Mediastinitis and retropharyngeal abscess following delayed diagnosis of glass ingestion. Emer. Med. J. 2006;23:e12
PII: S1871-4048(08)00079-8
doi:10.1016/j.pedex.2008.12.003
© 2009 Published by Elsevier Inc.
Volume 4, Issue 4 , Pages 169-172, December 2009
