Curious case of a calcified food bolus

Curious case of a calcified food bolus Authors present an 80-year-old male attending with obstructive food bolus. Lateral soft tissue neck x-ray demonstrated a suspected calcified foreign body at the level of the larynx. Subsequent senior radiological input reported the findings as inci- dental calcification of carotid arteries. ENT surgeons should demonstrate increased awareness for potentially calcified soft tissues on interpreting such x-rays. visualization of the food bolus was noted. For completeness, a INTRODUCTION lateral soft tissue neck x-ray was performed. Radiographs Patients presenting to ENT services with impacted food bolus in demonstrated the presence of a calcified area within the larynx itself is not an unusual phenomenon, with incidence approaching thought, initially by junior colleagues, to represent a foreign 13 in 100 000 [1]. Management of the condition involves directed body (Fig. 1). The patient was placed upon regular hyoscine butyl- history, endoscopic evaluation. Patients commonly complain of bromide injections, and observed until morning with a plan for dysphagia, excessive salivation and sensation of foreign body in rigid endoscopic evaluation plus removal of calcified piece of throat. meat. Radiographic soft tissue x-rays can provide advantageous During morning ward round review; the senior consultant information for the identification of radio-opaque foreign mate- requested a repeat trial of oral liquids. Doctors were subsequently rials, e.g. fish or chicken bones. This can be invaluable amongst presented with a very pleased patient plus a self-evacuated food patients where primary observation and medical management bolus. The food bolus demonstrated no evidence for the presence has failed and surgical intervention becomes a requirement. of bone, in correlation with the calcification observed on initial x-rays. A complete resolution of the patient’ssymptomswas CASE REPORT observed, being able to eat and drink without restriction. X-rays were reviewed by lead ENT and Radiology consultants. The Authors present an 80-year-old male attending with symptoms ‘unusual foreign body’ is reported to be soft tissue calcification of dysphagia, drooling and globus sensation. Symptoms com- likely within the carotid artery. menced during the patients evening meal. The patient reported eating pork, with no recollection for presence of bones. The patient’s medical history was complicated by previous squa- DISCUSSION mous cell carcinoma of the vocal cords requiring laryngectomy plus neck dissection 8 years previously. Despite multiple attempts Carotid artery arthrosclerosis has several risk factors including to swallow the food bolus, supplemented by assistance from car- increasing age, smoking, dyslipidaemia and cardiovascular dis- bonated drinks, no improvement was observed. Doctors per- ease [2]. Amongst these patients, lateral soft tissue neck x-rays formed naso-endoscopic evaluation of the pharynx, and no being used for identification of foreign bodies, increased Received: December 19, 2017. Accepted: February 17, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/3/rjy035/4935315 by Ed 'DeepDyve' Gillespie user on 16 March 2018 2 A.D. Hart-Pinto et al. Clinicians working up impacted food bolus patients should display vigilance in ensuring clinical history and endoscopic findings establish appropriate correlation with radiological findings. LEARNING POINTS � Soft tissue x-rays are known to be helpful with identifica- tion of radio-opaque foreign bodies. They provide detailed information of the level at which the obstruction lies, per- mitting pre-operative planning in cases requiring surgical intervention. � Increased awareness amongst clinicians of potentially cal- cified soft tissues. In this case calcification present within the carotid artery was assumed to be the foreign body in question. � Importance of correlation of history and clinical findings with radiographic imaging. The most obvious answer is not always the correct one. CONFLICT OF INTEREST STATEMENT None declared. REFERENCES 1. Longstreth GF, Longstreth KJ, Yao JF. Esophageal food impac- tion: epidemiology and therapy. A retrospective, observa- Figure 1: Lateral view soft tissue neck radiograph demonstrating calcified lesion tional study. Gastrointest Endosc 2001;53:193–8. at level of C4–C5. Presence of previous ligation clips noted from previous 2. de Weert TT, Cakir H, Rozie S, Cretier S, Meijering E, Dippel laryngectomy. DWJ, et al. Intracranial internal carotid artery calcifications: association with vascular risk factors and ischemic cerebro- awareness of calcification of surrounding soft tissues may vascular disease. AJNR Am J Neuroradiol 2009;30:177–84. doi: mask the true presentation. Incidental calcification of carotid https://doi.org/10.3174/ajnr.A1301. arteries have been previously reported as high as 5.06% in 3. Sisman Y, Ertas ET, Gokce C, Menku A, Ulker M, Akgunlu F. patients undergoing routine dental x-rays [3], therefore, appro- The prevalence of carotid artery calcification on the pano- priate translation is required on interpretation of lateral soft ramic radiographs in Cappadocia region population. Eur J tissue neck x-rays. Dent 2007;1:132–8. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/3/rjy035/4935315 by Ed 'DeepDyve' Gillespie user on 16 March 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Surgical Case Reports Oxford University Press

Curious case of a calcified food bolus

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Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018.
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Abstract

Authors present an 80-year-old male attending with obstructive food bolus. Lateral soft tissue neck x-ray demonstrated a suspected calcified foreign body at the level of the larynx. Subsequent senior radiological input reported the findings as inci- dental calcification of carotid arteries. ENT surgeons should demonstrate increased awareness for potentially calcified soft tissues on interpreting such x-rays. visualization of the food bolus was noted. For completeness, a INTRODUCTION lateral soft tissue neck x-ray was performed. Radiographs Patients presenting to ENT services with impacted food bolus in demonstrated the presence of a calcified area within the larynx itself is not an unusual phenomenon, with incidence approaching thought, initially by junior colleagues, to represent a foreign 13 in 100 000 [1]. Management of the condition involves directed body (Fig. 1). The patient was placed upon regular hyoscine butyl- history, endoscopic evaluation. Patients commonly complain of bromide injections, and observed until morning with a plan for dysphagia, excessive salivation and sensation of foreign body in rigid endoscopic evaluation plus removal of calcified piece of throat. meat. Radiographic soft tissue x-rays can provide advantageous During morning ward round review; the senior consultant information for the identification of radio-opaque foreign mate- requested a repeat trial of oral liquids. Doctors were subsequently rials, e.g. fish or chicken bones. This can be invaluable amongst presented with a very pleased patient plus a self-evacuated food patients where primary observation and medical management bolus. The food bolus demonstrated no evidence for the presence has failed and surgical intervention becomes a requirement. of bone, in correlation with the calcification observed on initial x-rays. A complete resolution of the patient’ssymptomswas CASE REPORT observed, being able to eat and drink without restriction. X-rays were reviewed by lead ENT and Radiology consultants. The Authors present an 80-year-old male attending with symptoms ‘unusual foreign body’ is reported to be soft tissue calcification of dysphagia, drooling and globus sensation. Symptoms com- likely within the carotid artery. menced during the patients evening meal. The patient reported eating pork, with no recollection for presence of bones. The patient’s medical history was complicated by previous squa- DISCUSSION mous cell carcinoma of the vocal cords requiring laryngectomy plus neck dissection 8 years previously. Despite multiple attempts Carotid artery arthrosclerosis has several risk factors including to swallow the food bolus, supplemented by assistance from car- increasing age, smoking, dyslipidaemia and cardiovascular dis- bonated drinks, no improvement was observed. Doctors per- ease [2]. Amongst these patients, lateral soft tissue neck x-rays formed naso-endoscopic evaluation of the pharynx, and no being used for identification of foreign bodies, increased Received: December 19, 2017. Accepted: February 17, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/3/rjy035/4935315 by Ed 'DeepDyve' Gillespie user on 16 March 2018 2 A.D. Hart-Pinto et al. Clinicians working up impacted food bolus patients should display vigilance in ensuring clinical history and endoscopic findings establish appropriate correlation with radiological findings. LEARNING POINTS � Soft tissue x-rays are known to be helpful with identifica- tion of radio-opaque foreign bodies. They provide detailed information of the level at which the obstruction lies, per- mitting pre-operative planning in cases requiring surgical intervention. � Increased awareness amongst clinicians of potentially cal- cified soft tissues. In this case calcification present within the carotid artery was assumed to be the foreign body in question. � Importance of correlation of history and clinical findings with radiographic imaging. The most obvious answer is not always the correct one. CONFLICT OF INTEREST STATEMENT None declared. REFERENCES 1. Longstreth GF, Longstreth KJ, Yao JF. Esophageal food impac- tion: epidemiology and therapy. A retrospective, observa- Figure 1: Lateral view soft tissue neck radiograph demonstrating calcified lesion tional study. Gastrointest Endosc 2001;53:193–8. at level of C4–C5. Presence of previous ligation clips noted from previous 2. de Weert TT, Cakir H, Rozie S, Cretier S, Meijering E, Dippel laryngectomy. DWJ, et al. Intracranial internal carotid artery calcifications: association with vascular risk factors and ischemic cerebro- awareness of calcification of surrounding soft tissues may vascular disease. AJNR Am J Neuroradiol 2009;30:177–84. doi: mask the true presentation. Incidental calcification of carotid https://doi.org/10.3174/ajnr.A1301. arteries have been previously reported as high as 5.06% in 3. Sisman Y, Ertas ET, Gokce C, Menku A, Ulker M, Akgunlu F. patients undergoing routine dental x-rays [3], therefore, appro- The prevalence of carotid artery calcification on the pano- priate translation is required on interpretation of lateral soft ramic radiographs in Cappadocia region population. Eur J tissue neck x-rays. Dent 2007;1:132–8. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/3/rjy035/4935315 by Ed 'DeepDyve' Gillespie user on 16 March 2018

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Journal of Surgical Case ReportsOxford University Press

Published: Mar 1, 2018

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