Download “What is known-“ Esophageal foreign bodies (FB) usually present

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“What is known-“
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Esophageal foreign bodies (FB) usually present with dysphagia and odynophagia.
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Metallic radio opaque FBs are usually detected on chest x ray.
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“What is new?”
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Esophageal FBs can present with respiratory distress
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Thin linear radio opaque FBs lying over the spine, can be missed on routine chest x-ray.
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Abstract
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Esophageal foreign bodies (FBs) are common and potentially serious cause of morbidity and mortality in
children. One third of FBs, retained in the gastrointestinal tract are present in the esophagus. Their management
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depends on the anatomic location, shape and size and duration of the impaction. In children, unwitnessed esophageal
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FBs can present with respiratory symptoms such as stridor. Therefore, a high index of suspicion is generally
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required to avoid significant morbidity and mortality. We are reporting a two years old female child presented with
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unusual symptoms with an unusual FB.
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Conclusion: In children, an unwitnessed esophageal FBs can present with respiratory symptoms such as stridor.
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Therefore, a high index of suspicion is generally required to avoid significant morbidity and mortality.
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Keywords--Foreign body, pharynx, esophagus
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Introduction
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The aero digestive foreign bodies are seen most common among children of age 6months to six years [5].
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Impaction of FBs in the upper aero digestive tract is a serious pathological condition and is particularly more
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common in children. The potentially fatal complications include mediastinitis, tracheo esophageal fistula, and
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retropharyngeal abscess, which can lead to septicemia, shock and hence require immediate treatment [5,7]. Diagnosis
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at times becomes difficult because of the non availability of a clear history, lack of characteristic clinical features
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and absence of characteristic radiological findings [6].
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Case report
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An apparently healthy 2 years old female child brought to us with history of noisy breathing since morning with
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no history of cold, cough, choking spell, or difficulty in swallowing or drooling of saliva. On examination baby was
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irritable with audible stridor and no cyanosis. Her pulse rate was 112/min, respiratory rate of 48/min, blood pressure
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84/60mmhg, and spo2 of 76% on room air. On examination trachea was central, suprasternal and sub coastal
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retractions were present. On auscultation baby had bilateral equal air entry with bilateral conducted sounds. Other
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systems were normal. Chest x-ray revealed prominent broncho vascular markings with no direct or indirect evidence
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of FB (Fig 1A). In view of inspiratory stridor and babies worsening clinical parameters; suspicion of FB aspiration
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was raised. Hence baby was subjected to rigid bronchoscopy, which revealed minimal purulent material in the
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trachea with no evidence of FB. But baby persisted to have respiratory symptoms post bronchoscopy and required
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ventilatory support for few days. We noticed drooling of saliva when the baby was kept on ventilator; hence CT
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scan thorax was done which surprisingly revealed radio opaque linear FB posterior to cricopharynx (Fig 2C &D).
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Flexible esophagoscopy revealed tear in the cricopharynx with metallic FB posterior to cricopharynx. Baby was
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subjected to thoracoscopy at the same time, which revealed the sharp metallic FB, the metallic foil posterior to
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cricopharynx with tear in esophageal wall. Thoracoscopic removal of metallic sharp FB was done successfully (Fig
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1B). But unfortunately post operatively patient could not be revived due to widespread sepsis.
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Discussion
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Foreign body (FB) ingestion is a commonly encountered problem in both children and adults in emergency
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departments which requires prompt diagnosis and therapy. The most common ingested FBs in children are coins but
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meat bone, marbles, safety pins, hair clips, batteries and screws are also been reported [5]. Although most FBs in the
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digestive tract are passed spontaneously, 10 to 20 % of these patients need treatment and approximately 1% will
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require surgery as reported by Lee et al (2007). Literature also shows that incidence of impacted FBs is more in 2
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years and older children [4]. The common sites of impaction of FBs in esophagus are post cricoid region, level of
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aortic arch, left main bronchus and diaphragm. Eighty percent of impacted foreign objects are held up at
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cricopharynx (Han et al, 2009). There is one more site of impaction especially in cases of flat objects like coin at the
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level of T1 i.e. thoracic inlet [7]. Sharp FBs, if not retrieved at the earliest may penetrate esophageal wall and can
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cause potentially serious complications [7].
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Most common FBs in upper and mid esophagus are less likely to pass spontaneously hence immediate
instrumentation are required for their retrieval [4,5].
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The common signs and symptoms in a patient with a FB that has been retained for less than 24 hours tend to be
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gastrointestinal and include dysphasia, drooling, vomiting, gagging and anorexia. Major respiratory symptoms are
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more common after weeks or months of ingestion, such as coughing, stridor, fever, chest pain wheezing, chronic
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upper respiratory tract infections, pneumonia and hemoptysis [4]. Esophageal FBs can cause respiratory symptoms
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either by direct pressure on trachea, indirectly by esophageal dilation and para esophageal edema compromising
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tracheal lumen, hence producing the symptoms [4].
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Complications of retained esophageal FBs are primarily related to perforation of esophagus which includes
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mediastinitis with or without abscess, esophagus to airway fistula, esophagus to vascular fistula, extra luminal
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migration of FB, esophageal diverticula [5]. Although the overall incidence of gastrointestinal perforation due to FB
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ingestion is less than 1%, sharp and pointed objects result in perforation rates up to 35 % as reported by Bounds
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(2006)[5]. The mechanism by which these FBs migrate through the soft tissues is due to movement of neck muscles,
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esophageal peristalsis, carotid pulsations, tissue reaction as well as infection and abscess formation [6].
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Postero-anterior, lateral cervical and chest radiographs are basic radiological methods of FB detection.
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Since most FBs are radiolucent, the indirect findings such as larynx and tracheal deviation, hyperinflation with
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widening of intercostal spaces will raise the suspicion.
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CT scanning of the neck and thorax is considered the most accurate imaging modality for diagnosing the
presence of any FB impaction [5, 7].
Many alternative methods for removal of FBs have been described in the literature, such as dislodgment by
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a Foley catheter, advancement with bougie, papain or carbonated fluid treatment, glucagon therapy, balloon
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extraction during fluoroscopy but rigid endoscopy remains the gold standard treatment [5].
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There were two surprising events in this case report. One was, patient presented with respiratory symptoms with
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upper esophageal FB and another is, sharp metallic FB which was not detected in spite of serial chest x-rays, and
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hence diagnosis was delayed.
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Macpherson R et all stated that esophageal FBs can present with respiratory symptoms [4]. Eisen GM and Baron
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et al have stated that the thin object such as a razor blade can be difficult to visualise if it happens to be overlying the
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patient's spine at the time of imaging [2].Similarly in our case, the sharp linear metallic FB, the metallic foil lying in
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and though cricopharynx was almost overlying the spine, hence was missed by initial serial chest x-rays.but when
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the FB migrated posterior to cricopharynx with babies worsening clinical scenario CECT was done, which revealed
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the FB.
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Only few cases of mortality related to complicated esophageal FBs have been reported in the literature [4].
Conclusion Ear
In children, unwitnessed esophageal FBs can present with respiratory symptoms such as stridor. Therefore, a high
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index of suspicion is generally required to avoid significant morbidity and mortality. In case of strong suspicion of
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FB aspiration and if the bronchoscopy is negative for FB, one should also consider esophagoscopy.
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Informed consent was obtained.
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Ethical approval: This article does not contain any studies with animals performed by any of the authors
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Funding source-nil
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Conflicts of interest--authors disclose no conflicts of interest.
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