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             \author[1]{Dr. Meena Vishwanath  Kale}

             \author[2]{Dr. Ninad Subhash  Gaikwad}

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\date{\small \em Received: 8 December 2019 Accepted: 5 January 2020 Published: 15 January 2020}

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\begin{abstract}
        


Introduction: ENT foreign body (FB) account for around 11% of emergencies. Swallowed FB especially fish, mutton bone or chicken bone are commonly seen in adult and elderly while coin in children. In adult, etiology may be considered due to gluttony, poor mastication or age related neuromuscular, decrease in oral tactile sensation. A traumatic FB of neck passed through the esophageal lumen and lodged into intramuscular plane of neck. Radiological investigations helps in localizing migrated FB from lumen. Neck dissection for extraluminal FB removal is the one of the surgical management. Aim of study: To present extraluminal FB and its management. Case Report: We had a case of a 60 year old female with complaints of 3 weeks continuous throat pricking sensation. She was treated like gastro-esophageal reflux disease (GERD) but was not getting relief, hence along with radiological investigations we have found a radiopaque extraluminal FB in the right trachea-esophageal groove. FB removal was done without any complications. Aim of study:To present extraluminal FB and its management.Case Report: We had a case of a 60 year old female with complaints of 3 weeks continuous throat pricking sensation. She was treated like gastro-esophageal reflux disease (GERD) but was not getting relief, hence along with radiological investigations we have found a radiopaque extraluminal FB in the right trachea-esophageal groove. FB removal was done without any complications.

\end{abstract}


\keywords{esophageal lumen, extraluminal foreign body, GERD, neck dissection, radiopaque.}

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\let\tabcellsep& 	 	 		 
\section[{Introduction}]{Introduction}\par
oreign body in ear, nose and throat are common and around 11\% are responsible for ENT emergencies. \hyperref[b0]{1} Ingestion of foreign body can be spontaneous or accidental. F.B. in throat is more common in adults or elderly patients whereas foreign body in nose and ear are more common in children. \hyperref[b1]{2} Incidence of swallowed FB in children is spontaneous due to their naughtiness while playing, intellectual disabilities, insanity, attention deficit hyperactivity disorder, along with the availability of the objects and absence of watchful caregivers. \hyperref[b2]{3} FB that is found commonly in children are coins; due to the fact that the coins are often handed to younger children and they accidentally swallow because of their tendency to take things into the mouth. Inadequate control of deglutition and shouting or crying while playing or eating. \hyperref[b3]{4} In adults, esophageal FB (EFB) are more with fish, mutton or chicken bone. Heavy consumption of alcohol and eating meat like gluttons, especially during festive events, along with poor mastication may be the cause for meat bone/bolus impaction in adults. \hyperref[b3]{4} While elderly, edentulous patients presented more with artificial dentures which can obliterate tactile sensation in the mouth so that bones and other sharp objects are not detected until they have entered the oropharynx. \hyperref[b4]{5} Defective peristalsis due to age-related neuromuscular incoordination and poor masticating habits are the predisposing factors for the cause of impaction of meat bone/bolus in the esophagus \hyperref[b1]{2,}\hyperref[b3]{4} Esophageal foreign body can be 1) nontraumatic like coins, marbles, peanuts, beads or 2) traumatic like needles, bone (fish, chicken, mutton) fragments, safety pin, piece of glass etc.\par
The most common site of impaction is the cricopharyngeal sphincter due to its narrowing. While the other sites of FB impaction are the cervical esophagus and the oropharynx i.e. tonsil, valeculla, base of the tongue. \hyperref[b1]{2} Clinically patients presenting with doubtful FB ingestion complain of pricking sensation in hypopharynx, dysphagia for solids and odynophagia.\par
Management of FB in throat depends on its location. Most commonly direct laryngoscopy and rigid esophagoscopy is performed. Different modes of intervention for luminal and extraluminal FB of digestive tract are available.\par
Aim of our study to present a case of extraluminal foreign body with its management by using magnet. 
\section[{II.}]{II.} 
\section[{Case Report}]{Case Report}\par
We had a case of a 60 year old female from Uttar Pradesh without any comorbidity; repeatedly complaining of pricking irritating sensation in throat, no If FB visible in oropharynx it can be easily removed with cold instruments in an OPD setup. While sometimes their diagnosis is made on examination with indirect laryngoscopy, flexible or 70 0 Hopkins rigid endoscope. Radiological investigations like X-ray neck with chest (AP and Lateral view). CT scan are indicated where the object is not found during endoscopic examination and has migrated to unusual and difficult to reach areas. \hyperref[b5]{6} MRI is useful in the evaluation of organic foreign bodies. \hyperref[b5]{6} dysphagia or odynophagia. General practitioner treated her like a gastro-esophageal reflux disease (GERD) for 3 weeks but she was not getting relief with her symptoms. She came to our tertiary care hospital to have relief of her symptoms. Initially we treated her like GERD with medical line of management. Her 70 0 degree Hopkins endoscopy revealed no evidence of foreign body or pooling of saliva in the pyriform fossa. Persistant pricking sensation made us to dig further into her history. Then she explained that the pricking sensation started while having food in a marriage ceremony. Furthermore we proceeded with X-ray neck anteroposterior and lateral view. This surprisingly showed a radiopaque sharp traumatic FB in right lateral part of the neck with (Fig: \hyperref[fig_1]{1}) clinically no evidence of neck injury showing entry point of sharp object. Even the in neck, surprisingly patient did not developed any infection due to continuation of antibiotics.\par
X-ray showed traumatic FB with a pointed end towards esophagus in tracheo-esophageal (TE) groove. Computed tomography was suggestive of extraluminal FB seen in right TE Groove abutting the carotid sheath. For management basis we have done flexible esophagoscopy to see if the tip of traumatic FB was visible. There was no esophageal mucosal damage or blood tinged but only normal healthy mucosa was seen. With assistance of a cardio-vascular-thoracic surgeon the patient was posted for right sided neck exploration, where inspite of a meticulous neck dissection we could not detect the FB. Hence we used high power magnets to pinpoint the foreign body and dissected around its magnetic field. Finally we found a rusted iron wire. Neck closed in layers with capillary drain. No evidence of post-operative complications. 
\section[{III.}]{III.} 
\section[{Discussion}]{Discussion}\par
In our study, a 60 year old adult female had an accidental FB ingestion while eating food in a marriage reception. In some study there is male predominance of FB ingestion may be due to physical or psychological stress. \hyperref[b6]{7} The mean age of male: female ratio is 51.5: 50.5 years in adults for ingested foreign body. \hyperref[b1]{2,}\hyperref[b3]{4} One of the study says in a marriage ceremony due to alcohol consumption and poor mastication leads to frequent FB lodgements in the digestive system \hyperref[b2]{3} . Repeated complaints of GERD or throat pricking should be considered for further investigation specially X-ray neck or endoscopy for probable diagnosis.\par
In adult, FB lodgement in upper (cervical) esophagus is 2 nd most common site after cricopharynx due to its narrow orifice. \hyperref[b3]{4,}\hyperref[b7]{8} Most common blunt esophageal FB is coin seen in children while chicken, fish or mutton bone FB is seen in adult stated by study of Adhikari P. \hyperref[b8]{9} We had an extraluminal FB from esophageal lumen into right side intramuscular plane of neck. In Xray neck, we found a sharp radiopaque FB in right lateral side of neck. As per Nixon GW study, sharp foreign bodies of neck like needle, wire etc. may migrate extraluminally as their position changes with the act of deglutition. \hyperref[b9]{10} We had proceeded with CT Scan of neck to rule out exact location of FB. As per Ray R et al, CT Scan of neck is usually adviced when the object was not found during esophagoscopy and had migrated extraluminally where it is present in unusual and difficult to reach areas. \hyperref[b5]{6} Nowadays with advent technology, during removal of these foreign bodies, pre-operative fluoroscopy (C-arm) helps to detect the exact position of foreign body. \hyperref[b9]{10} After investigations, patient was posted for neck exploration and removal of foreign body with the help of a high power magnet.\par
Rigid esophageal endoscopy is currently the most commonly used method for removal of esophageal foreign body. \hyperref[b10]{11} Various other modalities available which have been described in the literature, such as dislodgment or removal by a Foley's catheter, advancement with bougie, balloon extraction during fluoroscopy etc. Fluoroscopically controlled foley's catheter can be used to remove the non-opaque, soft, smooth oesophageal foreign bodies like marble or meat bolus. \hyperref[b9]{10} Extraluminal location of metallic radiopaque FB in neck, surgical neck dissection using a magnet is very effective. \hyperref[b7]{8,}\hyperref[b10]{11} Morbidity rates reported in the literature are lower than 1\% \hyperref[b10]{11}  harmlessly through gastrointestinal tract and only 1\% or less require intervention \hyperref[b11]{12,}\hyperref[b12]{13} .\par
IV. 
\section[{Conclusion}]{Conclusion}\par
In case of prolonged symptoms of GERD with suspicious FB ingestion not getting relief with medical management for more than 2 weeks, then proceed with radiological investigations. Extraluminal radiopaque metallic FB are not uncommon but to treat it, meticulous neck dissection with magnet can be consider for management.\begin{figure}[htbp]
\noindent\textbf{9}\includegraphics[]{image-2.png}
\caption{\label{fig_0}F 9 Year}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{1}\includegraphics[]{image-3.png}
\caption{\label{fig_1}Fig. 1 :}\end{figure}
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\end{bibitemlist}
 			 		 	 
\end{document}
