|Year : 2015 | Volume
| Issue : 3 | Page : 376-379
Unusual presentation of foreign bodies in esophagus-our experience
Neha A Suman1, Pooja S Nagare2, Shubhalakshmi A Jaiswal2, Arati Mitra2
1 Department of ENT, Dr. DY Patil Medical College, Hospital and Research Centre, Dr. DY Patil Vidyapeeth, Pune, India
2 Department of ENT, Dr. VM Government Medical College, Solapur, Maharashtra, India
|Date of Web Publication||15-May-2015|
Neha A Suman
w/o Major Ansha Kumar, Department of Pathology, Military Hospital, Range Hills, Kirkee, Pune - 411 020, Maharashtra
Source of Support: None, Conflict of Interest: None
Foreign body (FB) in esophagus is not a very rare entity. The main risks are to the children under 3 years of age. In this age group, the second molars have not yet developed, the child's grinding and swallowing mechanisms are poor, and glottis closure is immature. Some patients at risk for FB ingestion may not be able to give an accurate medical history of ingestion, either due to age or mental illness. Coins are the most commonly ingested FBs, with button batteries, fish bone, marble, stone, and pieces of meat, etc., being other forms of ingested FB. In the majority of cases, it is accidental in nature, but can be occasionally homicidal, as was probably in one of our patients. Patient can be asymptomatic or can present with dysphagia, drooling of saliva, FB sensation, vomiting or pain. Patients with long-standing esophageal FBs may present with weight loss, aspiration pneumonia, fever, or signs and symptoms of esophageal perforation including crepitus, pneumomediastinum, or gastrointestinal bleeding. Here, we present four case reports of unusual presentation of FB in esophagus that were successfully removed by rigid esophagoscopy without any complication
Keywords: Crepitus, dysphagia, esophagoscopy, homicidal, pneumomediastinum
|How to cite this article:|
Suman NA, Nagare PS, Jaiswal SA, Mitra A. Unusual presentation of foreign bodies in esophagus-our experience. Med J DY Patil Univ 2015;8:376-9
| Introduction|| |
Foreign body (FB) in esophagus is not uncommon especially in pediatric age group. Nonspherical objects equal to or <1.5 inches and particularly spherical objects equal to or <1.75 inches in diameter are especially dangerous for impaction in pharynx and esophagus.  Diagnosis can be made by positive history of FB ingestion and a plain radiograph. Lateral view to determine if the object is in the pharynx or the airway. Antero-posterior view is of great help specially if the FB is orthogonal to the plane of view. Computed tomography scans are indicated in suspected migrated FBs. Early removal is important as edema and mucosal swelling will make the retrieval more difficult. The rapid and accurate diagnosis, together with subsequent treatment is necessary. In 20% of cases, endoscopic or surgical removal is promptly required.  Major complications include esophageal perforation (0.2-2.0% cases) (from either the FB or endoscopic procedure), mediastinal abscess, retropharyngeal abscess, migration of FB into deep structures, luminal stenosis, perforation of large arteries of neck.  Long-standing esophageal FBs may cause failure to thrive or recurrent aspiration pneumonia.
| Case Reports|| |
An 8-year-old, mentally retarded male child brought by parents to the ENT OPD with complaints of difficulty in swallowing for both solids and liquids. There was a history of ingestion of FB while playing. There was a similar history in the past also when the complaints got relieved on its own. However, this time the problem was severe and more persistent that made them come to the hospital. On examination, there was increased salivation, but no respiratory distress. Rest of ENT examination was within normal limits. X-ray neck and chest [Figure 1] was done, which showed an irregular radio opaque FB in cricopharynx. Esophagoscopic removal of FB was planned under general anesthesia. On the introduction of esophagoscope an irregular black FB was identified at the level of cricopharynx, which was removed with the help of FB removing forcep and was found to be a stone. Check scopy done. The whole process was uneventful.
A 2-year-old female child brought by mother to the pediatric OPD with history of the fall from height 12 days back. She was first taken to some private hospital where she was diagnosed as fracture left forearm bones, fracture both femur and FB in esophagus [Figure 2]. From there, she was referred to our hospital. There was also a history of regurgitation of food from the day of fall. Patient was admitted in Pediatric Department and was posted for esophagoscopy in ENT OT. Under general anesthesia (GA) esophagoscopy was done and FB found in upper esophagus. It was found to be multiple stones and removed meticulously. Check scopy done. Perioperative period was uneventful. It was a case of battered baby, and the mother left this hospital with the baby without informing 2 days after the surgery.
|Figure 2: X-ray showing foreign body in esophagus (multiple stones) with fracture of forearm bones|
Click here to view
A 32-year-old male patient came to ENT OPD with history of accidental ingestion of FB. Patient was having sudden onset of difficulty in swallowing both liquids and noticed. Later he noticed missing denture in his oral cavity and came to the hospital. There were no other complaints. X-ray neck [Figure 3]a was done, which showed FB in cricopharynx. Esophagoscopy under GA was done. A pink colored FB [Figure 3]b was identified in cricopharynx, which was removed with the help of FB removing forcep. Check scopy done. No perioperative complications.
A 3-year-old male child brought to the emergency department with complaints of difficulty in swallowing to liquids and solids since 1-day. There was a sudden history of blood mixed vomiting 1-day back for which some private practitioner was consulted. Patient developed fever and black stool the next morning and brought to our hospital. X-ray neck [Figure 4]a was done in which a radiopaque FB was identified at level C5-C6 vertebra in digestive tract. Patient was posted for emergency esophagoscopy under GA. A sharp metallic FB of size 1 cm (ear ring) [Figure 4]b was identified and removed by rigid esophagoscopy. Check scopy done and nasogastric tube of number 10 inserted into esophagus under direct vision. No perioperative complications.
| Discussion|| |
Plain radiographs generally are used in the initial investigation of patients with suspected FB ingestion, but in one study  of 325 children, only 64% of the ingested objects were radiopaque. In all of our cases, FB was radiopaque, and the diagnosis was made on plain X-ray. Most FBs pass through the gastrointestinal tract spontaneously. In the preendoscopy era, 93-99% of blunt objects passed without intervention, and approximately 1% required surgical removal. Today, 10-20% of children who ingest FBs are managed with endoscopy.  X-rays are also useful for identifying the type of FB ingested and complications of FB ingestion, including mediastinitis and perforation of the esophagus. For esophageal FB the choice between flexible and rigid endoscopy remains controversial. Rigid endoscopy gives a much better view of the hypopharynx, cricopharynx and the first few centimeters of cervical esophagus where as a flexible endoscope gives an excellent view in the thoracic esophagus and esophagogastric junction. Many sharp-pointed objects, wooden, plastic, and glass objects, as well as fish and chicken bones, may not be seen on radiographs, so endoscopy should still follow a radiologic examination with negative findings. The risk of a complication caused by a sharp-pointed object passing through the gastrointestinal tract is as high as 35%.  Devices used include forceps, which come in varying shapes, sizes and grips, snares, and oval loops that can be retracted from outside the gastroscopy to lasso objects, as well as Roth baskets (mesh nets that can be closed to trap small objects), and magnets placed at the end of the scope or at the end of orogastric tubes. In 1966, Bigler  reported a method of extracting smooth esophageal FBs using a Foley balloon catheter. The Foley catheter technique was used predominantly in children with proximally located blunt objects. Magill forceps is a well-studied technique for the extraction of FBs from the upper and medium part of the esophagus. After stabilizing the FB with forceps, scope is then gently advanced forward over the FB enveloping it in the lumen of the rigid scope. A similar technique, to avoid esophageal injury while removing sharp objects, includes grasping the object with its sharp end pointing downwards into the lumen and pulling FB out without contact with the esophageal wall during removal.  Another method for the removal of irregular or sharp objects is the use of overtube.  Overtube is a plastic tube of varying length, through which the scope and retrieved objects are passed. Due to the risk of esophageal injury during insertion, overtube use is less common in pediatric patients, although newer, softer tubes may help to mitigate this risk in older children. In 2003, Van As et al. analyzed injuries due to FB ingestion among the 88,822 patients treated in their trauma unit from 1991 to 2000. Among those injuries, 753 were FBs wedged in the esophagus.  The most frequent lodgment site described in the literature is the cricopharyngeus muscle, which was also seen in all of our cases. Keeping in mind the chances of injury due to sharp esophageal FB a nasogastric tube was inserted under vision in one of our case although there was no obvious injury seen. In 2005, Waltzman et al. performed a randomized trial in children with coins lodged in the esophagus after their ingestion, comparing relatively immediate endoscopic removal to the choice of observation for a definite period of time and retrieved a high frequency of spontaneous passages within 16 h of observation. Although in all of our cases the FB was not coin, this period of observation was over because of the delay in arrival of the patient to our hospital.
| Conclusion|| |
Prevention of FB ingestion is not addressed adequately in families in terms of stressing the need of active supervision of children when playing, eating or interacting with objects inadequate to their age. An expectant management for a period of 12-24 h can be chosen when dealing with low-risk patients. Rigid esophagoscopy remains the mainstay management of impacted esophageal FBs. However, the technique of removal must be tailored to the type, location and possible complications imposed by individual FB.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]