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A female in her early 20s presented to the emergency department complaining of central chest pain and vomiting following ingestion of multiple foreign bodies, namely a pen and paintbrush, 2 days prior. The patient presented to the hospital on a background of recurrent foreign body ingestion. Significant medical history included depression and anxiety, schizophrenia, schizotypal personality disorder and self-harm. Within the emergency department, the patients’ vital signs were largely unremarkable and blood tests revealed a C reactive protein of 178 and a white cell count of 12.1 × 109/L; blood cultures were negative. Flexible nasoendoscopy examination with direct visualisation of the larynx and pharynx carried out by the otolaryngology team did not reveal any retained foreign bodies or structural defects. A chest X-ray showed four metallic foreign bodies projected over the stomach region with superior mediastinal lucencies suggesting pneumomediastinum.
A CT scan with contrast of the neck and chest was arranged promptly and reported a radiolucent linear structure in the soft tissues of the neck, lateral to the right hypopharynx, presumed to be the retained pen, and another linear structure within the mediastinum: likely the wooden component of the paintbrush, findings appreciated by figures 1–3. Evidence of pneumomediastinum with gas locules extending into the neck and to the mediastinum was observed, in keeping with a developing mediastinal abscess, demonstrated by figure 2. Figure 3 additionally shows displacement of the oesophagus anteriorly and indentation of the posterior aspect of the trachea by a small amount of fluid with further displacement of the azygous vein by the collection. Metallic hyperdensities within the stomach, the likely metal components of the pen and paintbrush, had caused proximal oesophageal perforation. Anatomical illustrations of the neck and thorax highlighting important structural fascial planes and cavities can be appreciated by figures 4–6, respectively.
Axial view of CT scan with contrast of the neck showing a radiolucent structure in the right neck tissues, immediately lateral to hypopharynx (presumed retained pen).
Coronal section of CT scan of the neck and thorax with contrast showing a linear radiolucent structure in right neck tissues (retained pen). Adjacent locules of gas and fluid inferiorly are in keeping with a developing mediastinal abscess.
Sagittal view of CT scan with contrast of the neck, thorax and abdomen showing a linear radiolucent object in the midline within the mediastinal structures; the presumed wooden component of the paintbrush. Evidence of anterior displacement of the oesophagus with indentation of posterior aspect of the trachea by a small amount of fluid.
From Teach Me Anatomy Series: Fascial Layers of the Neck, Oliver Jones, Transverse Section of the Neck. https://teachmeanatomy.info/neck/misc/fascial-layers/, Copyright © 2019.
From Teach Me Anatomy Series: Fascial Layers of the Neck, Oliver Jones, Fascial Layers of the Neck, Carotid Sheath and Prevertebral Fascia. https://teachmeanatomy.info/neck/misc/fascial-layers/, Copyright © 2019.
From Teach Me Anatomy Series: The Superior Mediastinum, Katherine Sanders, Spacial Relationship of Structures. https://teachmeanatomy.info/thorax/areas/superior-mediastinum/, Copyright © 2022.
Management included prompt interdisciplinary communication between surgical specialty teams leading to urgent surgical intervention. This comprised a joint surgical procedure between otolaryngology, cardiothoracic and upper gastrointestinal teams. The otolaryngology team extended the retro-oesophageal space via an open right collar incision, and the pen was identified and safely removed. Blunt dissection into the left retro-oesophageal space revealed a broken wooden paintbrush which was also removed, and the wound cavity thoroughly washed out. Upper gastrointestinal surgeons carried out an oesophagogastroduodenoscopy and placement of nasogastic tube into the stomach. The cardiothoracic surgical team subsequently utilised video-assisted thoracic surgery via the fifth intercostal space to remove the remaining foreign bodies within the chest as well as washout the mediastinal cavity. On day 2 following surgery, the patient was transferred to a specialist upper gastrointestinal surgery unit for monitoring and to commence a feeding regime until safe to feed orally.
It has been reported that 12%–16% of cases of foreign body ingestion require surgical intervention for retrieval,1 2 and that following the paediatric population, adults with psychiatric disorders, developmental delay and intoxication with alcohol are among the most common to present with intentional true foreign body ingestion.3 4 An assessment and management algorithm for upper aerodigestive tract foreign body ingestion has been suggested by the authors of this communication (see figure 7), which takes these important aspects into account that those suggested by existing literature findings.5
Upper aerodigestive tract foreign body ingestion management algorithm.
In such challenging anatomical cases, it is imperative for specialty teams to align their approaches in a multidisciplinary fashion in order to achieve an optimal and safe outcome for the patient. In this particular case, clear communication between specialist surgical teams, the medical doctors as well as psychiatric teams were essential in determining the surgical strategy, guiding perioperative care as well as aiding patient recovery. A treatment algorithm compiled and illustrated by figure 7 demonstrates the important aspects of the suggested management of such cases.
Patient’s perspective
When I came into hospital, I remember having a lot of neck pain and was not particularly scared but I was worried about not being able to eat and drink for a long time after this happened.
Learning points
This case highlights the importance of a multidisciplinary approach in an anatomically challenging procedure requiring surgical exploration into multiple cavities of the upper body.
Communication between the associated surgical teams to discuss management and surgical strategy is imperative for such cases in which exploration of multiple disparate anatomical regions is required; this is equally important in the postoperative period to aid patients’ recovery.
As ingestion of foreign bodies in the adult patient is often prevalent in adults with concomitant psychiatric illness, effective communication liaison with medical and psychiatric services is additionally pertinent in achieving a safe and optimal outcome for patients.
Ethics statements
Patient consent for publication
Footnotes
Contributors The following authors were responsible for drafting of the text, sourcing and editing of clinical images, investigation results, drawing original diagrams and algorithms, and critical revision for important intellectual content: SA, AMAK. The following authors gave final approval of the manuscript: DS.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.