Clear Plastic Shard Showed Up on CT Scans but Hid from Surgeons Through Two Neck Operations

Surgeons repeatedly missed a 30-millimeter transparent plastic fragment lodged in the prevertebral space of a 77-year-old woman’s neck, despite three rounds of investigation. A case report published July 9 in the Journal of Personalized Medicine describes how her symptoms began with trouble swallowing after taking an ACE inhibitor, leading doctors to suspect medication-linked angioedema. Because inflammatory markers were elevated, she was treated with antibiotics; after instability and multiple organ failure, CT imaging revealed a left-sided prevertebral abscess with gas and later showed the foreign body near her fifth cervical vertebra. Two operations—one drained the abscess through the mouth and another through the neck—found nothing until the third attempt identified the fragment by touch.