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| CASE REPORT |
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| Year : 2015 | Volume
: 8
| Issue : 3 | Page : 380-382 |
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Chronic retained esophageal foreign body masquerading as a mediastinal mass
Bhagya Sannananja, Hardik Uresh Shah, Padma V Badhe
Department of Radiology, Seth GS Medical College and KEM Hospital, Parel, Mumbai, Maharashtra, India
| Date of Web Publication | 15-May-2015 |
Correspondence Address:
Bhagya Sannananja
Department of Radiology, Seth G. S. Medical College and K. E. M. Hospital, Parel, Mumbai - 400 002, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0975-2870.157093
Foreign body ingestion is a common problem in children, coin being the usual offender in most of the cases. In the majority of the times, they pass through the esophagus without any complication. It is rare to have complications such as perioesphagitis, peri esophageal abscess, vascular fistula or carotid rupture and still rare to have the condition silent for 20 long years and presenting with acute symptoms. We report a case of retained esophageal foreign body presenting as recent onset dysphagia and mediastinal widening. Keywords: Aluminum, foreign body, mediastinal mass, esophagus
How to cite this article:
Sannananja B, Shah HU, Badhe PV. Chronic retained esophageal foreign body masquerading as a mediastinal mass. Med J DY Patil Univ 2015;8:380-2 |
| Introduction | |  |
Foreign body ingestion is very common in children with coin being the offender in majority of the cases. Most of the times, these are asymptomatic without any consequences or may present with symptoms such as drooling, vomiting, dysphagia, pain or a foreign body sensation. [1] Because coins lack sharp edges they usually pass through the esophagus without any complication. It is very rare for a coin to perforate the esophagus and even rarer for it be asymptomatic for 20 long years. We report a case of retained esophageal foreign body presenting as recent onset dysphagia and mediastinal widening.
| Case Report | | |
A 29-year-old female presented with progressive dysphagia since 2 months. Initially, she had a sensation of solid food getting stuck at the level of the throat that then gradually progressed to involve even liquids. There was no h/o heartburns, fever, ingestion of the caustic substance, and trauma. A weight loss of 7 kg over 2 months was present. There were no other significant past illnesses except for h/o tonsillectomy at 10 years of age.
The patient came to us for barium swallow study as a part of the evaluation of dysphagia. Chest radiograph showed mediastinal widening [Figure 1]a. A faint well defined radio-opacity was seen proximal to tracheal the bifurcation that on the lateral view [Figure 1]b was situated posterior to the trachea. On barium swallow, upper esophageal luminal narrowing was seen with barium suspension seen passing through a nondistensible and rigid upper esophagus with widening of tracheo-esophageal stripe. The radio-opacity seen on screening seemed to be extra luminal. A small diverticulum was seen in the anterior wall of narrowed esophagus proximal to this radio-opacity [Figure 2]. | Figure 1: (a and b) Frontal and lateral radiograph of chest. There is widening of paratracheal stripe bilaterally. Thickening of tracheoesophageal stripe seen on the lateral view. Faint well defi ned radio opaque structure (arrow) is seen in the tracheo-esophageal stripe
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 | Figure 2: Barium swallow spot fi lms in the same patient showing narrowing of upper esophageal lumen with thickening of tracheoesophageal stripe. The well-defined radio opaque structure (arrow), which later proved to be a coin seemed extra luminal. A small diverticulum is seen in the anterior wall of narrowed esophagus proximal to this radio-opacity
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On further probing the female gave history of swallowing a 10 paisa coin at 7 years of age, being treated then by a general practitioner. We went ahead with noncontrast computed tomography upper thorax which showed metallic density foreign body in the region of upper esophagus with an inflammatory soft tissue mass surrounding the foreign body [Figure 3]. The final diagnosis was long standing retained esophageal body presenting with mediastinal widening and short duration dysphagia. The patient was managed with endoscopic removal of the coin [Figure 4]. Under general anesthesia rigid endoscope was passed down the esophagus to retrieve a foreign body. The fibrous and inflammatory soft tissues surrounding the coin are dissected out using forceps, and the coin was retrieved. Postoperatively the patient is under follow up and is recovering well. | Figure 3: Noncontrast computed tomography of upper thorax in mediastinal window setting shows metallic density structure in the mediastinum posterior to trachea
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| Discussion | | |
Foreign body ingestion is common in children. A variety of foreign bodies are swallowed by children, but coins constitute majority among them. Most of the ingested foreign bodies pass spontaneously and in many cases the parents of the child may not even be aware of such an event.
Retention of foreign body in esophagus is a rare entity, and if retained, it is usually below the level of cricopharyngeus. [2] Literature search done says, retained esophageal foreign bodies in children may be associated with a preexisting stricture, which are mostly congenital. [3] This could explain our case as the patient had no acquired risk factor which can cause retention of the foreign body in the upper thoracic esophagus much below the level of cricopharyngeus, which otherwise is the most common site for such an event. Because coins lack sharp edges they don't perforate the esophagus acutely, it is the pressure and foreign body reaction that causes erosion of the esophageal wall hence takes longer time for presentation.
In our case, the ingested foreign body was an aluminum coin. Aluminum is a low molecular weight compound, relatively radiolucent, unlike most other common metals. Therefore ingested aluminum objects are difficult to appreciate on radiographs. [4],[5],[6] It has a property to induce delayed type of hypersensitivity reaction forming foreign body granulomas, [7] which justifies the inflammatory soft tissue reaction around the coin causing mediastinal widening that led to initial misdiagnosis of mediastinal mass.
In general, the complications of penetrating foreign bodies within the esophagus include perioesphagitis, peri esophageal abscess, vascular fistula or carotid rupture. The finding in the present case was that of perioesphagitis and a blind ending diverticulum. Fortunately, there were no other major complications such as esophago-tracheal or esophago-aortic fistula, even though the coin was there for more than 20 years.
Though retained foreign body has been reported previously, to our knowledge, this is the first case, which manifested after an unusually long time of 20 years; presenting atypically with a short duration of symptoms and masquerading as a mediastinal mass. Through this case we also want to emphasize the radiographic and chemical property of aluminum which can be easily missed on a radiograph and can produce a granulomatous reaction mimicking a mass lesion.
| References | | |
| 1. | Webb WA. Management of foreign bodies of the upper gastrointestinal tract: Update. Gastrointest Endosc 1995;41:39-51.  |
| 2. | Ekim H. Management of esophageal foreign bodies: A report on 26 patients and literature review. East J Med 2010;15:21-5. |
| 3. | Ravi Shankar B, Yachha SK, Sharma BC, Singh B, Mahant TS, Kapoor VK. Retained esophageal foreign bodies in children. Pediatr Surg Int 1996;11:544-6. |
| 4. | Heller RM, Reichelderfer TE, Dorst JP, Oh KS. The problem with the replacement of copper pennies by aluminum pennies. Pediatrics 1974;54:684-8. [ PUBMED] |
| 5. | Dorst JP, Reichelderfer TE, Sanders RC. Radiodensity of the proposed new penny. Pediatrics 1982;69:224-5. [ PUBMED] |
| 6. | Eggli KD, Potter BM, Garcia V, Altman RP, Breckbill DL. Delayed diagnosis of esophageal perforation by aluminum foreign bodies. Pediatr Radiol 1986;16:511-3. [ PUBMED] |
| 7. | Vogelbruch M, Nuss B, Körner M, Kapp A, Kiehl P, Bohm W. Aluminium-induced granulomas after inaccurate intradermal hyposensitization injections of aluminium-adsorbed depot preparations. Allergy 2000;55:883-7. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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