Cyanosis from a foreign body in the esophagus. Respiratory difficulties three months after swallowing a coin

The removal of coins from the upper esophageal tract of children by emergency physicians: a pilot study

Objective:

There are few reports in the medical literature describing removal of a coin from the upper esophageal tract of a child by an emergency physician. However, given the nature of their training and practice, emergency physicians are well suited to perform this common procedure. We describe our experience with this procedure.

Methods:

This was a retrospective review of a continuous quality improvement data set from a university-based tertiary care pediatric emergency department between Nov. 1, 2003, and Mar. 31, 2004.

Results:

Thirteen children, with a median age of 20 months, underwent rapid sequence intubation and had coins successfully removed from their upper esophageal tract by emergency physicians. In 10 cases, the coin was visible at laryngoscopy and removed with Magill forceps. In 3 cases this approach failed and a Foley catheter was used to remove the coin. One child suffered a tonsillar abrasion and two sustained minor lip trauma, but all were extubated and discharged home from the emergency department with no significant complications. Eleven of the 13 patients were successfully followed up, and the parents reported no problems.

Conclusions:

This pilot study suggests that the removal of a coin from the upper esophageal tract by an emergency physician can be both safe and effective. A larger study is needed before this procedure can be generally recommended.

Esophageal foreign body extraction in children: flexible versus rigid endoscopy

BACKGROUND

Esophageal foreign body (FB) impaction is a common emergency in children. The goal of this study was to compare rigid versus flexible endoscopy in esophageal FB extraction in children.

METHODS

In a retrospective cohort study with consecutive data, children with esophageal FB impaction who were admitted between January 2005 and December 2008 to the Stollery Children's Hospital, Edmonton, Canada, were included. Nature of the procedure for FB removal (flexible vs. rigid endoscopy), duration of the procedure, complications, and associated pathology were documented.

RESULTS

A total of 140 children were included (81 boys; mean age, 59.8 ± 48.6 (range, 4-203) months). More than half (54%) of patients were aged 3 years or younger. Coins were the most common foreign body (77.9%). Flexible endoscopy was used in 89 patients, rigid in 49, and both in 2 patients. The mean duration of the endoscopic procedure was 10.50 ± 12.2 minutes for FE (95% confidence interval (CI), 7.94-13.08) and 16.49 ± 21.1 minutes for RE (95% CI, 13.75-22.45; p = 0.04). Biopsies were taken in 19% of patients undergoing FE and in 6% of RE (p = 0.04).

CONCLUSIONS

Both rigid and flexible endoscopy techniques appear to be equally safe and effective in esophageal foreign body extraction. However, performing flexible endoscopy for esophageal foreign body takes a substantial shorter duration compared with rigid endoscopy. Flexible endoscopy would probably allow a better and more thorough examination and, hence, biopsying esophageal mucosa compared with rigid endoscopy.

Atypical presentation of an impacted radiolucent esophageal foreign body

Patients with impacted esophageal foreign bodies usually present with gastrointestinal and rarely with respiratory symptoms. Impacted esophageal foreign bodies may be identified by radiologic studies. Ingested radiolucent foreign bodies may be more difficult to diagnose, especially if the patient presents with minimal symptoms. We report a rare case of a child who presented with stridor and obstructive sleep apnea. The cause of respiratory symptoms was thought to be due to enlarged tonsils and adenoids, and the patient was scheduled for tonsillectomy and adenoidectomy. On re-evaluation by the surgeon on the day of surgery, the procedure was changed to diagnostic microlaryngoscopy and bronchoscopy to rule out any other cause. The patient's respiratory symptoms were resolved when an incidental discovery and retrieval of the radiolucent esophageal foreign body was made. The diagnosis of radiolucent esophageal foreign body can be difficult and can be easily missed without reasonable clinical suspicion.

A randomized clinical trial of the management of esophageal coins in children

CONTEXT

Children frequently ingest coins. When lodged in the esophagus, the coin may cause complications and must either be removed or observed to pass spontaneously.

OBJECTIVES

(1) To compare relatively immediate endoscopic removal to a period of observation followed by removal when necessary and (2) to evaluate the relationship between select clinical features and spontaneous passage.

DESIGN/SETTING

Randomized, prospective study of children <21 years old who presented to an emergency department with esophageal coins in the esophagus. Exclusion criteria were (1) history of tracheal or esophageal surgery, (2) showing symptoms, or (3) swallowing the coin >24 hours earlier. Children were randomized to either endoscopic removal (surgery) or admission for observation, with repeat radiographs approximately 16 hours after the initial image.

OUTCOME MEASURES

Proportion of patients requiring endoscopic removal, length of hospital stay, and the number of complications observed.

RESULTS

Among 168 children who presented with esophageal coins lodged in the esophagus, 81 were eligible. Of those eligible, 60 enrolled, 20 refused consent, and 1 was not approached. In the observation group, 23 of 30 (77%) children required endoscopy compared with 21 of 30 (70%) in the surgical group. Total hospital length of stay was longer in the randomized-to-observation group compared with the randomized-to-surgery group (mean: 19.4 [SD: +/-8.0] hours vs 10.7 [SD: +/-7.1] hours, respectively). There were no complications in either group. Spontaneous passage occurred at similar rates in both groups (23% vs 30%). Spontaneous passage was more likely in older patients (66 vs 46 months) and male patients (odds ratio: 3.7; 95% confidence interval: 0.98-13.99) and more likely to occur when the coin was in the distal one third of the esophagus (56% vs 27% [95% confidence interval: 1.07-5.57]).

CONCLUSIONS

Because 25% to 30% of esophageal coins in children will pass spontaneously without complications, treatment of these patients may reasonably include a period of observation, in the range of 8 to 16 hours, particularly among older children and those with distally located coins.

Vocal cord paralysis secondary to impacted esophageal foreign bodies in young children

Impacted foreign bodies in the esophagus can result in respiratory symptoms including stridor and aphonia. Several mechanisms have been proposed to explain these symptoms, but the possibility of vocal cord paralysis and its cause has not been adequately emphasized. Two cases of young children with esophageal foreign body are described; both presented with respiratory symptoms, 1 with aphonia and the other with stridor. In both cases, the symptoms were secondary to vocal cord paralysis. A possible mechanism of recurrent nerve injury is proposed.

Brain abscess following delayed endoscopic removal of an initially asymptomatic esophageal coin

Brain abscesses are rare occurrences in pediatric patients, and making their diagnosis can be difficult. The two most commonly cited risk factors are otorhinologic infections and cyanotic congenital heart disease (CCHD). We present a 13-month-old child with a brain abscess who, 2 weeks prior, underwent rigid endoscopy for the extraction of a coin from the esophagus. We believe this to be the first such report of a brain abscess after rigid endoscopy for removal of an esophageal foreign body. In this case the esophageal coin was initially asymptomatic and had been present for weeks prior to removal. The potential association between delayed coin extraction and development of an intracranial infection, suggested by this report, may warrant investigation.

Pharyngeal coin removal in children

Two cases of coin extraction from the upper third of the oesophagus are described, using a Foley catheter in the accident and emergency department without complication. Although previously reported, the method is not widely used; indeed many junior doctors appear unaware of it. Coins can be removed from this proximal position provided the operator is confident and swift. This appears to be a safe and useful technique, avoiding the need for hospital admission and anaesthesia. It is worth trying before resorting to endoscopy.

Conservative management of pediatric distal esophageal coins

Management of the child with an esophageal coin has typically included an invasive coin removal procedure, usually endoscopy. Coins in the distal esophagus, however, often pass spontaneously into the stomach in the first 24 h after coin ingestion, suggesting that conservative management alone may be effective. Four children with distal esophageal coins who were successfully managed without an invasive procedure are presented. Recommendations for conservative management are given. Further study of the effectiveness of conservative management of distal esophageal coins in healthy children is warranted.

Oesophageal perforation caused by a coin

An unusual consequence of an initially asymptomatic coin ingestion is described to alert paediatricians that coins are not always innocuous. The case illustrates the need to investigate subtle but persistent symptoms, and also describes the surgical approach to coins that erode through the oesophageal wall.

Successful use of a metal detector in locating coins ingested by children

The purpose of this study was to examine the accuracy of a metal detector in locating coins ingested by children. The metal detector correctly identified the presence or absence of coins in 13 patients (93%), as confirmed by radiologic studies.

Fatal aspiration pneumonia caused by an esophageal foreign body

Esophageal foreign body accompanied by respiratory complications is a rare condition. A few cases have been reported, only two of them in adults. We describe the case of a 34-year-old mentally retarded patient who was hospitalized for aspiration pneumonia and died 48 hours after admission. At autopsy, the prominent finding was a 3 X 3-cm stone impacted into the upper esophagus and compressing the trachea from behind. The possibility of an esophageal foreign body should be included in the differential diagnosis of unexplained respiratory distress or aspiration pneumonia in adults.

Unsuspected esophageal foreign bodies in adults with upper airway obstruction

Esophageal foreign bodies rarely cause respiratory distress in adults. While it is well known that upper airway obstruction can occur with esophageal foreign bodies in children, the otorlaryngologic literature mentions little of this problem in older patients. Two adults with airway obstruction from unsuspected esophageal foreign bodies are described, with emphasis on the problems of diagnosis and management. The possibility of an unsuspected esophageal foreign body should be kept in mind during the evaluation of respiratory distress in an adult, especially in one who is a poor historian or has a history of a psychiatric disorder. Early endoscopic removal in the treatment of choice, although esophagotomy may be required.

Unsuspected foreign bodies of the aerodigestive tract

The well-known tendency for children to place loose objects in their months not infrequently leads to the entrapment of foreign bodies in the aerodigestive tract. With prompt and adequate removal few complications occur. However, when the foreign body goes undetected or is neglected the patient may develop dysphagia, pneumonia, failure to thrive, lung or mediastinal abscesses, bronchopulmonary or bronchoesophageal fistulas, or erosion of major vessels. Fifteen cases of retained foreign bodies were identified in a chart review between 1971 and 1977 at the Children's Hospital of Philadelphia, calling attention to the problems of aerodigestive foreign bodies of prolonged duration. Early and late complications are discussed and early diagnosis and endoscopic removal emphasized.

The radiolucent esophageal foreign body: an often-forgotten cause of respiratory symptoms

Three children under 2 years of age with a history of respiratory symptoms for one to seven months, secondary to a radiolucent esophageal foreign body, are presented. Delay in diagnosis resulted in an acquired tracheosophageal fistula in two patients and a thoracotomy in all three patients. Physicians alert to the clinical presentation and aware of the proper radiographic investigation of radiolucent esophageal foreign bodies can reduce the morbidity and hospital stay for these patients.