Extraluminal esophageal coin erosion in children. Case report and review

A 3-year-old boy with rapid obstructive symptoms secondary to coin ingestion and gastric impaction

Foreign body ingestion is a common problem in children; blunt objects occur most frequently, and coins are the most common culprit. Rarely does coin ingestion lead to serious consequences other than esophageal impaction. In this report, we present the case of a healthy 3-year-old boy who developed rapid obstructive symptoms after the ingestion of a coin that required endoscopic retrieval from the stomach. Obstruction attributed to an ingested coin once post-esophageal is a rare complication of a relatively common presenting complaint.

Retained dental needle migration across the skull base to the cochlea presenting as hearing loss

OBJECTIVES

Long-term retained foreign bodies in the human body have been reported across many specialties, but relatively few exist in the ENT literature.

PATIENTS

We present a case report of a patient with a broken dental needle fragment in the posterior oral cavity with subsequent migration to the cochlea over the course of 4 years, eventually leading to hearing loss. CT scan and middle ear exploration demonstrated a 4-cm metallic fragment abutting the base of the cochlea, immediately adjacent to the internal carotid artery.

INTERVENTIONS

The needle segment was removed through an endaural approach without complication.

RESULTS

Postoperatively, the patient had improvements in PTA and speech discrimination, as well as the resolution of chronic otalgia and jaw pain. Imaging, audiologic results, and surgical details and pictures are presented herein.

CONCLUSION

To our knowledge, based on a thorough PubMed and Google Scholar search, there are no reports of such a foreign body migration from the oral cavity to the skull base.

Yield of chest radiography after removal of esophageal foreign bodies

OBJECTIVES

The aim of this study was to determine the benefit of routine postoperative chest radiography after removal of esophageal foreign bodies in children.

METHODS

Medical records were reviewed of all patients evaluated with an esophageal foreign body at a single children's hospital over 10 years. Operative records and imaging reports were reviewed for evidence of esophageal injury.

RESULTS

Of 803 records identified, 690 were included. All underwent rigid esophagoscopy and foreign body removal. The most common items removed were coins (94%), food boluses (3%), and batteries (2%). The rate of esophageal injury was 1.3% (9 patients). No injuries were identified on chest radiographs done as routine or for concern of injury. Patients with operative findings suggestive of an esophageal injury (n = 105) were significantly more likely to have an injury (8.6% vs 0%, P = .0001). Of the 585 children who did not have physical evidence of injury, 40% (n = 235) received a routine chest radiograph. Regardless of the indication, no injuries were identified on chest films.

CONCLUSIONS

We conclude that intraoperative findings during rigid esophagoscopy suggestive of an injury are predictive of esophageal perforation. Routine chest radiography is not warranted in children who do not meet this criterion. In patients with a concern for injury, we suggest that chest radiography should be deferred in favor of esophagram.

Mediastinitis associated with foreign body erosion of the esophagus in children

OBJECTIVE

Timely and experienced intervention for esophageal foreign bodies generally allows for removal with minimal morbidity. However, esophageal foreign bodies present a risk for esophageal perforation and subsequent mediastinitis, especially if the diagnosis of the foreign body is delayed. Although much has been written about the management of esophageal foreign bodies and their complications, little has been mentioned in recent literature about the specific complication of mediastinitis. This review was performed to examine our experience with this uncommon complication of esophageal foreign bodies.

METHODS

A retrospective review of the esophageal foreign body database at Children's Hospital of Wisconsin from 1987 to 1997 was performed to identify patients with esophageal foreign bodies and subsequent mediastinitis.

RESULTS

Four patients with esophageal perforation with associated mediastinitis secondary to retained esophageal foreign bodies were identified. Three of the four patients were treated with conservative measures consisting of foreign body removal, intravenous antibiotics and discontinuing of oral nutrition. These patients all achieved resolution of their mediastinitis and esophageal perforation with subsequent return to normal diets and no significant morbidity. One patient, with vascular erosion, required aggressive, invasive therapy.

CONCLUSION

From review of this limited number of patients, in the absence of major vascular erosion, conservative methods of treating children with foreign body esophageal perforation and subsequent mediastinitis appears to be effective.

Use of mediastinoscopy for foreign body removal

Foreign body removal from the aerodigestive tract can be a challenging endeavor despite improvements in technology. Rigid bronchoscopy has been demonstrated to be a safe and effective means of airway foreign body removal with appropriate training and expertise. However, potential complications exist and include extraluminal impaction of a penetrating foreign body during removal. This report details such a complication and the first known use of mediastinoscopy to remove the impacted foreign body to avoid the need for thoracotomy.

Localizing ingested coins with a metal detector

This study was conducted to determine the utility of metal detection in coin localization by inexperienced operators, and determine the rate of spontaneous passage of asymptomatic esophageal coins. All children who presented to the emergency department of an urban children's hospital with a suspected coin ingestion were eligible. Coin location was predicted from metal detector results, while radiographs confirmed location. Asymptomatic patients with esophageal coins were observed for spontaneous passage. Ninety-one children (ages 9 months to 17 years) were prospectively enrolled. The metal detector had a sensitivity of 98% (53/54) in coin detection and 98% (81/83) in determining coin location as esophageal. Symptoms were poor predictors of coin location. Six of eight asymptomatic patients with esophageal coins spontaneously passed their coins. These results show that metal detection is a good screening test for coin presence and to determine coin location as esophageal. Spontaneous passage of asymptomatic esophageal coins warrants further study.

Esophagoaortic perforation by foreign body (coin) causing sudden death in a 3-year-old child

We report an extremely unusual consequence to foreign body ingestion in a case of a 3-year-old boy who died suddenly and at autopsy was found to have an esophagoaortic fistula. This fistula was caused by a coin which lodged posteriorly and eroded through the esophagus into the aorta. Serious complications following foreign body ingestion are rare and include stricture formation, intramural abscess, and the formation of fistula tracts. This case illustrates the potentially unpredictable behavior of impacted foreign bodies. The child's parents were initially suspected of child abuse based on the terminal hemoptysis.

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.