The Case of a Disappearing Knife

Abstract

Purpose: A 32 year old female with a history of psychiatric illness and compulsive foreign body ingestion presented after swallowing a butter knife 10 hours earlier. The patient had 57 upper endoscopies, six exploratory laporatomies and multiple small bowel resections in the past six years, all related to ingested foreign bodies. At presentation, she complained of chest and neck pain, odynophagia and inability to rotate her neck. She was afebrile, normotensive, but tachycardic. She was in no acute distress. Examination of her oropharynx revealed no gross lesions or signs of trauma, no crepitus and no palpable mass in the neck. Her abdominal exam showed some recent surgical scars but was otherwise normal. A radiograph revealed a knife in the hypopharynx and esophagus, terminating below the level the carina. Her laboratory tests showed no leukocytosis. An upper endoscopy with endotracheal intubation was performed in the operating room. No foreign body was found in her esophagus. No esophageal perforation or signs of trauma were noted. The stomach and duodenum were also normal. A lateral x-ray was repeated and showed the knife to be posterior to her esophagus. Surgery was consulted. An exploratory neck surgery was performed emergently and the knife removed from the posterior mediastinum. Postoperative endoscopy excluded injury to the esophagus No free air or pneumothorax was seen on abdominal or chest radiographs. Barium swallow performed two days later showed no evidence of contrast extravasation. The patient progressed well in the postoperative period and was discharged after a short hospital course. Foreign body impaction in the esophagus is a very common clinical problem faced by endoscopists. However, only rarely do foreign bodies penetrate the wall of the upper aerodigestive tract and even more rarely do they migrate into the soft tissue, neck or mediastinum. If perforation occurs it is facilitated by strong contraction of the hypopharyngeal and cricopharyngeal muscles which explains the higher rate of penetration through the hypopharynx and cervical esophagus. Certain findings on endoscopy may suggest the site of penetration such as esophageal ulceration, edema and laceration. However, in many cases of migratory foreign bodies, such as this one, no definitive site of perforation in the hypopharynx is found. The greatest danger with foreign body perforation is the risk of infection. The foreign body can introduce bacteria and if left untreated, carries a high mortality rate. Therefore, if no foreign body is identified on initial endoscopy, the patient should have a CT scan and/or immediate neck exploration for removal.