‘The catcher in the rye’ – a case report of a swallowed grain and a peculiar neck abscess

Abstract Inhalation or swallowing of foreign bodies (FBs) are relatively common in the pediatric population, with a male predominance. Obtaining relevant clinical history, in these situations, may be a challenge, due to the fact that young children cannot give a detailed account of what happened and in some cases an adult caretaker may not have been present. In order to complicate even further, many aspirated or swallowed FBs in children tend to be small and radiolucent, making the radiological diagnosis even more challenging. A 16-year-old healthy male presented to the emergency room with the chief complaint of a swollen mass in the left midjugular area of his neck, off-midline. He recalled, that 3 months prior to the incident, he accidentally swallowed a grain of wheat while picking his teeth. One month later, he started complaining of intermittent dysphagia as well as localized edema and erythema in his neck, without pyrexia. Two months later, a neck ultrasound demonstrated a 7 mm hyper echogenic linear mass in a small fluid collection. A contrast enhanced computed tomographic (CT) scan of the soft tissues of the neck revealed an abscess measuring 0.8*2.36*2.0 cm, superficial to the sternocleidomastoid (SCM) muscle. Due to the fact that a superficial collection was diagnosed, the patient underwent incision and drainage during which a splinter of a grain of wheat, measuring 1 cm in length, was surgically extracted. In cases of localized neck masses, FBs should be considered as a possible cause, especially in children.


Introduction
Aspiration or swallowing of foreign bodies (FB) remain a common cause for pediatric emergency room visits, and may lead to serious complications [1].Comprehensive history taking is crucial, and high level of suspicion is indicated.Presentation may by unusual, as described in this following case report.

Case presentation
A 16-year-old healthy male presented with the chief complaint of a swollen mass in the left midjugular area of his neck, off-midline.No prior history of congenital or acquired neck masses was noted.During medical history taking, the patient recalled that 3 months prior to the incident, he accidentally swallowed a grain of wheat while picking his teeth with it.One month later, he started complaining of intermittent dysphagia as well as localized edema and erythema in his neck, without pyrexia.During the following 2 months, the patient had multiple visits to his general practitioner as well as to other specialists.He was treated with multiple antibiotic therapies without symptom resolution.He was even suspected to have a second branchial cleft cyst.Due to this, the patient was sent to perform a neck ultrasound which demonstrated a 7 mm hyper echogenic linear mass in a small fluid collection.Following these findings the patient was sent to our hospital.
The otolaryngologist who examined the patient upon his arrival, observed a superficial round and tender, fluctuative mass measuring 2 cm × 0.8 mm (Figure 1).Laboratory results including a complete blood count and C reactive protein levels were normal.A contrast enhanced computed tomographic (CT) scan of the soft tissues of the neck (Figure 2) revealed an abscess measuring 0.8*2.36*2.0cm, superficial to the sternocleidomastoid (SCM) muscle, without a communicating path to the esophagus, and without any suspicious findings indicating a FB.
Surgical incision and drainage were conducted under local anesthesia, extracting a small amount of pus with mild bleeding, as well as a small yellow foreign body that resembled a wheat grain splinter, measuring 1 cm in length.A drain was placed and sewn to the margins of the wound, and removed after 24 h.
Following the surgical extraction, an upper gastrointestinal modified barium swallow test was performed, in order to rule out any fistula to the esophagus, the exam revealed a normal esophageal walls and no signs of fistula.

Discussion
Gregori et al. [1] studied FB aspiration cases in children aged 0-14 years in the major hospitals of 19 European countries during 2000-2002.They found a higher incidence (63%) in males, and showed that among the FBs that were most likely to cause complications were seeds and other small organic substances, whereas fish bones were responsible for around 12% of the complicated cases.Petrarolha et al. [2] described a case of a woman who had complaints similar to our patient: left sided dysphagia and localized pain, 9 days following accidentally swallowing a fish bone.She underwent an ultrasound and CT scan, both showing a linear foreign body in her left thyroid lobe, suspected to be the swallowed fish bone.She subsequently underwent fish bone removal via an exploratory cervicotomy.A similar case was described by Watanabe et al. [3], with a woman who presented with right neck swelling 9 months following accidentally ingesting a fish bone.The CT scan revealed a linear radiopaque object, and she underwent a successful removal of a 34 mm fish bone found superficial to her thyroid gland.
It is extremely uncommon for swallowed FBs to penetrate the esophageal walls and migrate extraluminally, however, when they migrate it is usually to the surrounding soft tissues, the mediastinum or the thyroid gland [4].
In case of a FB ingestion, as described by Lai et al. a delayed presentation and radiographic evidence of a FB are both significantly associated with a higher risk of persistent symptoms; fever, hemoptysis, dysphagia and odynophagia, and prolonged hospitalizations, with an overall complication rate of 2.8%.These complications range from retropharyngeal abscesses to pharyngeal wall perforations and mediastinitis [4].Abscess formation following FB ingestion may also occur in the esophagus itself, and should be considered as a possible cause for new symptoms of dysphagia with a concurrent esophageal mass [5].
When treating the pediatric population, it is important to keep in mind that FBs tend to be accidentally swallowed or inhaled, due to the fact that many toddlers and children like to put different objects in their mouths.These objects are often radiolucent and small, making their detection on imaging studies more challenging, especially when treating younger children, as the details of the accident are often lacking [6].Hence, an elaborate history taking is imperative, with parents, siblings and other close contacts to help shed some light on the circumstances.Penetrating FBs can remain asymptomatic for months and even years following the incident [7].As described in our case and in some of the aforementioned FB ingestion cases, a thorough questioning can lead to a possible FB incident that occurred long before the onset of symptoms [3,5].
Another diagnostic challenge in children presenting with neck masses, is the wide differential diagnosis.Pediatric neck masses may be frequently misdiagnosed as  branchial cleft lesions, other congenital lesions, or simply lymphadenopathies.In children, branchial cleft anomalies are the cause behind 30% of all congenital head and neck lesions, with 95% being second branchial cleft lesions.The child will present with cysts, sinuses, or fistulae [8][9][10].

Conclusion
When encountering a patient with a neck mass, FBs should always be considered as a possible cause, especially in the pediatric population, even without radiological confirmation.

Figure 2 .
Figure 2. Axial contrast ct image of soft tissues of neck (abdomen window), revealing a 0.8*2.36*2.0cm liquefied collection superficial to the left scM muscle (arrow).

Figure 1 .
Figure 1. the patient's neck mass, upon his admission to the otolaryngology/head and neck surgery department.