|Year : 2015 | Volume
| Issue : 1 | Page : 35-37
Impacted Fish Bone Leading to Rapidly Growing Common Carotid Artery Pseudoaneurysm
Habib Md Habib Md Karim1, Manuj Kr Saikia2, Jayanta Kr Mitra1, Jayanta Medhi3
1 Department of Anesthesiology and Critical Care, NEIGRIHMS, Shillong, Meghalaya, India
2 Department of Cardiothoracic and Vascular Surgery, NEIGRIHMS, Shillong, Meghalaya, India
3 Department of ENT and Head and Neck Cancer Surgery, NEIGRIHMS, Shillong, Meghalaya, India
|Date of Web Publication||5-Mar-2015|
Dr. Manuj Kr Saikia
Department of Cardiothoracic and Vascular Surgery, NEIGRIHMS, Shillong, Meghalaya
Source of Support: None, Conflict of Interest: None
Accidental impaction of small fish bone in upper gastro intestinal tract is relatively common. Most of the time people ignore such small fish bone impaction as they become asymptomatic with subsequent swallowing of food. Rarely, it may perforate esophagus and cause serious complications and may even be fatal. A 28-year-old male was referred to us with a 4 day history of painful swallowing, and rapidly enlarging right sided neck swelling for last 3 days. He had a history of a fish bone impaction 2 weeks ago on the same side which he felt had resolved with subsequent dry rice swallow. Radiological investigation showed a pseudoaneurysm of the right common carotid artery (CCA) with impacted fish bone in the neck outside gastro intestinal tract impinging on the wall of CCA. The neck was explored; the CCA repaired, and patient was discharged in good health. This is an unusual complication of fish bone impaction. Urgent surgical intervention, rapid resuscitation and multidisciplinary approach are necessary for a good patient outcome.
Keywords: Common carotid artery, fish bone, pseudoaneurysm, shock
|How to cite this article:|
Karim HH, Saikia MK, Mitra JK, Medhi J. Impacted Fish Bone Leading to Rapidly Growing Common Carotid Artery Pseudoaneurysm. Indian J Vasc Endovasc Surg 2015;2:35-7
|How to cite this URL:|
Karim HH, Saikia MK, Mitra JK, Medhi J. Impacted Fish Bone Leading to Rapidly Growing Common Carotid Artery Pseudoaneurysm. Indian J Vasc Endovasc Surg [serial online] 2015 [cited 2020 Jun 4];2:35-7. Available from: http://www.indjvascsurg.org/text.asp?2015/2/1/35/152835
| Introduction|| |
The neck houses vital structures like trachea, jugular vein, carotid artery in close proximity to esophagus. Accidentally swallowed foreign bodies commonly get impacted in the pharynx and esophagus. Fish bone impaction is relatively common; most do not need medical attention as they get ingested with subsequent swallowing of food. Fish and chicken bones are the most common ingested foreign bodies, both in children and in adults. , They are radiolucent and may be easily missed in the primary center even after physical examination, X-ray, or laryngoscopy. Sharp fish bones may rarely lead to perforation or migrate out of esophagus leading to mediastinal and vascular complications that may be fatal. Pseudoaneurysm of common carotid artery (CCA) otherwise occurs with blunt or penetrating trauma, inflammation and iatrogenic vascular injury.  Though pseudoaneursym of the aorta and external carotid are reported, this is the first report of a pseudoaneurysm of the CCA.
| Case Report|| |
A 28-year-old boy was referred from a secondary level hospital with 4 days history of difficulty in swallowing, followed by pain and swelling of the right side of the neck. The pain was persistent, increasing in intensity over time and was more at the time of swallowing. On the day of presentation, he was unable to swallow even liquids due to pain. The neck swelling was also rapidly increasing in size. No airway related symptom was found. He gave a history of small fish bone impaction on the same side 2 weeks ago, which he felt had resolved with subsequent swallowing of dry rice. He sought medical care at a primary health center where he was examined by indirect laryngoscopy and X-ray - the impacted bone was not detected. There was no history of fever, neck injury, or other complaints on systems review in the intervening 10-day period.
On examination, there was a 7.5 cm × 6 cm soft tender swelling over the right side of the neck, not moving with swallowing or tongue protrusion. Overlying skin colour and temperature was normal. He was hemodynamically stable with BP 120/78 mmHg and heart rate 84/min. Bruit was heard over the mass on auscultation.
Computed tomography (CT) scan of the neck and angiography revealed a 3.6 cm × 2.2 cm × 3 cm pseudoaneurysm arising from medial wall of the right CCA with an impacted foreign body likely to be fish bone [Figure 1] and [Figure 2].
|Figure 1: Axial view of contrast-enhanced computed tomography scan showing pseudoaneurysm arising from the medial side of common carotid artery. Trachea and esophagus seen compressed and displaced laterally toward the opposite side|
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|Figure 2: Sagittal section of contrast-enhanced computed tomography showing impacted foreign body (fish bone) in the wall of common carotid artery and pseudoaneurysm|
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Patient was taken up for urgent exploration under General Anesthesia with endotracheal intubation with 2 units of packed red blood cells (PRBC), fluid pump and fluid warmer in hand. 3 g × 16 g venous free flow cannula was placed. Arterial line inserted under local anesthesia for continuous blood pressure (BP) monitoring before induction of anesthesia.
As soon as pseudoaneurysm was reached, a sudden spurt of blood lead to approximate 1000 ml blood loss before it could be stopped using surgeon's finger to occlude CCA and subsequently repair of CCA done with grafting. Patient's BP came down immediately with a sudden gush of blood loss that was managed with pumping the warm crystalloid followed by 2 units of PRBC. Total blood loss was approximately 1200 ml. Patient was extubated in the deep plane of anesthesia to prevent coughing over the tube and shifted to intensive care unit for observation. No neurological deficit was found in the postoperative period, and he was discharged home in good health on 5 th postoperative day.
| Discussion|| |
Fish bone is the most commonly ingested foreign body in adults constituting 9-45% of cases in some reports.  Most impacted fish bones are found on indirect or direct laryngoscopy, clinical examination and X-ray and can be removed by direct laryngoscopy.  Missed impacted fish bone may perforate the gastro intestinal tract that is, esophagus,  intestine  and may even protrude through neck.  Rarely, it may even cause an aortic pseudoaneurysm. 
Our patient had a missed impacted fish bone which caused a pseudoaneurysm of the CCA. This presentation is rare, and not so far reported. CCA pseudoaneursms usually occur following trauma or inflammatory diseases.  Foreign bodies like wires and needles have been reported to cause pseudoaneurysm of CCA. , This can be accompanied by mediastinitis that may be rapidly progressive and fatal if not identified and treated early.  Broad spectrum antibiotic therapy with anaerobic cover is essential-duration depends on the severity of the presentation. Pain usually in a pseudoaneurysm may arise from pressure effect to surrounding structures, thrombosis or infection. A rapidly enlarging neck mass may compromise vital airway function and endanger the patient's life.
Endovascular management is emerging as a safe alternative to open surgical repair for pseudoaneurysm for CCA  but it may not be always feasible. Surgical repair is required in pseudoaneurysms with local mass effect, complications such as ischemia and neuropathy, infected pseudoaneurysms, and in patients in whom minimally invasive therapeutic techniques have failed.  Though the surgery is an effective treatment method, it requires technically expertise. Complications like cranial nerve palsy, stroke, rupture during surgery, or leakage into the surgical area and even death can occur. The rate of stroke or death during surgery is reported to be between 9% and 15%, and the incidence of cranial nerve injuries is reported to be as high as 15%. 
Our patient presented with a rapidly expanding pseudoaneurysm with significant mass effect. Though there was blood loss intraoperatively, this was anticipated and surgical repair and grafting was completed successfully. Postoperatively the patient did not have any cranial nerve palsy or stroke, recovery was uneventful.
| Conclusion|| |
A pseudoaneurysm is a differential of a nonpulsatile neck swelling; there should be a high index of suspicion to identify and manage this rare condition. Neck pain following a history of fish bone impaction should alert a physician to an impacted foreign body causing complications. Negative preliminary assessment by clinical method and X-ray may need to be supplemented with a CT scan with oral and intravenous contrast if the patient is symptomatic.
Open repair supplemented with a broad spectrum antibiotic cover is a feasible option in such a patient.
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[Figure 1], [Figure 2]