Perforation of the esophagus is a well-recognized entity with potentially serious morbidity estimated to be 12% [2] and mortality of 2.1% in a pooled analysis [3]. Its causes may be iatrogenic, traumatic, spontaneous, or foreign body ingestion. Foreign body ingestion in the adult population is less frequent than in the pediatric group [4], as majority are accidental and related to food. A slightly higher incidence of foreign body ingestion has been found in individuals with underlying psychiatric diseases or alcohol intoxication [5]. According to current statistics, the most common foreign bodies requiring intervention are meat and fish bones (54% and 39%, respectively) [6], and esophageal perforation due to ingestion of foreign bodies occurs in less than 1% of patients [4].
Perforations usually occur in correlation with esophageal anatomical constrictions, including of the cervical esophagus, which is the most common site of penetration, followed by the upper thoracic esophagus [7].
Although the alimentary tract constitutes a part of the neck, it is an uncommon source of thyroid pathology. The thyroid gland has unique anatomical and physiological characteristics, making it resistant to infection including a rich blood supply and lymphatic drainage, a high glandular content of iodine with bactericidal potential, and segregation of the gland due to total encapsulation from other structures of the neck [8]. Therefore, abscess formation is mainly attributed to suppurative thyroiditis [9]. Direct trauma from foreign bodies and extension from neighboring anatomical structures accounts for a minority of cases [10].
Laryngoscopy can play an essential role in the presence of acute symptoms of airway compromise secondary to impacted foreign bodies early in the disease course, or secondary to compression by infected swelling or established abscess later. In asymptomatic patients, laryngoscopy can be used as an adjunct tool to diagnose, localize, and evaluate the epiglottis and vocal cord preoperatively.
Esophagoscopy remains the mainstay diagnostic tool for esophageal perforation, with a sensitivity of 100% and specificity of 83% [11]; however, caution should be exercised in selected cases (e.g., an acute history of hours to days and poor patient general condition) as air insufflation can enlarge the perforation.
The latest guidelines for the management of esophageal perforation recommend emergent flexible endoscopy, preferably within 2 h or at latest within 6 h (Grade 1 B), to search for sharp-pointed objects, batteries, magnets, or other foreign bodies [12]. The period between perforation and esophagoscopy can affect the sensitivity and specificity of the test; a finding of grossly normal esophageal mucosa can be encountered after perforation secondary to the migration of the foreign body to the adjacent structures, which may necessitate further diagnostic modalities to reach a diagnosis.
Radiographs are useful for assessing the presence of foreign bodies, their location, or the development of complications. In a prospective single-center study on 358 adult patients with symptomatic fish bone foreign body impaction, the sensitivity of computed tomography (CT) was 90–100% and the specificity was 93.7–100% [13]. Current guidelines recommend CT scans in cases where perforation or other complications may require interventional endoscopy or surgery (Grade 1B) [12]. In this case, CT was the main modality for diagnosing the complication of thyroid abscess formation, along with assessment of the esophagus and evaluation of the presence of perforation. Additionally, CT scans are accurate in diagnosing other esophageal perforation complications such as mediastinitis or aortic/tracheal fistulas [14].
Management is guided toward the acute presentation or sequelae of the perforation, such as the formation of a thyroid abscess. Delays in management carry the risk of septicemia, retropharyngeal abscess, tracheal rupture, internal jugular vein thrombosis, vocal fold paralysis, and suppurative mediastinitis [15]. Management of thyroid abscesses in the literature has been recommended through case series and case reports, but no standardized treatment has been established, ranging from conservative management to total thyroidectomy. Source control is performed by draining the abscess through an incision made over the thyroid gland (thyrotomy). The disadvantage of this technique is that it leaves an inflamed thyroid gland near the source of the infection. However, resection of the diseased part of the thyroid gland is needed to prevent the inflamed gland tissue and pus material from extending to the recurrent laryngeal nerve, causing inflammatory neuritis, and subsequently vocal cord paralysis [16]. Aggressive management with total thyroidectomy has been reported as a treatment for thyroid abscess, although it is seldom used due to complications of hormonal deficiency and risk of recurrent laryngeal nerve injury.
