Occult coin perforation of the esophagus

Esophageal Bougienage for Management of Lodged Esophageal Coins: Safe, Effective, Efficient, and Underused

OBJECTIVES

The aims of the study are to evaluate outcomes of esophageal bougienage for management of lodged esophageal coins and to assess the extent of bougienage usage and barriers among emergency providers.

METHODS

We performed a retrospective chart review of pediatric patients with single lodged esophageal coins presenting to our single academic pediatric emergency department between November 2012 and December 2018. We compared procedural outcomes, complications, length of stay (LOS), and cost between those managed with bougienage and with endoscopy. We further surveyed emergency physicians to assess the extent of bougienage usage and barriers to utilization across different institutions.

RESULTS

We identified 205 patients with single lodged esophageal coins presenting during our study window. One hundred forty-seven patients ultimately underwent bougienage with 97% success and no major complications. Fifty-six patients were managed by endoscopy with 100% success and one major complication. Bougienage had significantly lower LOS (median 2.18 vs 11.92 hours, P < 0.001) and hospital charges (median $3533 vs $12,679, P < 0.001) compared with endoscopy. We received 242 completed surveys representing 38 states from primarily academic pediatric emergency physicians. The majority of respondents (90%) used specialist consult with only 4.5% performing bougienage. A total of 36.4% of respondents had never heard of the procedure and only 16.1% had ever performed it. Barriers to usage included lack of provider training (95.6%), perceived risk of complications (94.4%), and perceived lack of success (80.5%).

CONCLUSIONS

Bougienage is safe and effective with significant LOS and cost benefits compared with endoscopy. Despite these advantages, the procedure is underused, because of lack of provider education and concerns regarding safety, efficacy, and both family and specialist preference, which are not supported by current literature. These data support the need for broader education regarding the bougienage technique, as well as larger prospective studies of its safety and outcomes.

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.

An ingested foreign body: two sides of the same coin?

A 2-year-old child presented to the emergency department with an acute onset of dysphagia and stertor. A plain anteroposterior chest X-ray revealed a single circular opacity in the middle third of the oesophagus consistent with an ingested coin. The child was taken to the theatre for rigid pharyngo-oesophagoscopy and removal of the coin. After the first coin was removed subsequent endoscopic examination revealed a second coin at the same location. This extremely rare case of two ingested coins becoming impacted with perfect radiological alignment emphasises the importance of thorough examination on endoscopy and the potential limitations of an X-ray in initial assessment of an ingested foreign body.

Predictive factors for successful balloon catheter extraction of esophageal foreign bodies

INTRODUCTION

Foreign bodies in the esophagus are common in children. Time from ingestion to presentation is variable, and may not be known. Our center usually performs Foley catheter balloon extraction under fluoroscopy as the first step to attempt removal to prevent all patients from going to the operating room. The efficacy of this procedure has been reported. However, information is lacking about the relationship between presentation variables and the likelihood of success.

METHODS

After IRB approval, we performed a retrospective single-center review from January 1988 to August 2011 of children with an esophageal foreign body. Pearson's correlation was used to evaluate the relationship between variables and successful balloon extraction for P < 0.05. A logistic regression was done to evaluate for independence.

RESULTS

819 patients presented with esophageal foreign bodies, with a mean age of 3.3 years. 572 patients underwent balloon extraction, 83 % successful. Mean ingestion duration was 16.6 h with fluoroscopy time of 2.3 min and mean number of attempts was 1.5. Successful balloon extraction had a negative correlation with refusal to eat, respiratory distress, cough, wheeze, upper respiratory infection symptoms, stridor, fever, duration of ingestion >1 day, unwitnessed ingestion, fluoroscopy time and number of balloon catheter attempts. There was a positive correlation between success and both age and duration of ingestion <1 day. Independent predictive factors were number of balloon catheter attempts.

CONCLUSIONS

Patients with longer duration of ingestion, symptoms from the foreign body and increased number of removal attempts have a decreased likelihood of success with balloon catheter extraction and should not undergo prolonged efforts of removal.

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.

Migratory foreign body of neck in a battered baby: a case report

Only a small number of ingested foreign bodies perforate the esophagus and even smaller fraction migrate extramucosally with no symptoms. Both of these events are even rarer after marble ingestion. We report here a case of battered baby with homicidal marble ingestion which perforated the esophagus and migrated into the soft tissue of neck. It was diagnosed after 21 days asymptomatic period. The foreign body migrated into the tracheo-esophageal groove, lying deep to strap muscles, which was removed by neck exploration.

Esophageal foreign bodies in the pediatric population: our first 500 cases

BACKGROUND

Children with esophageal foreign bodies are frequently seen by pediatric surgeons. Choking and dysphagia are common presentations; however, esophageal perforation has been reported. Historically, rigid esophagoscopy with extraction of the foreign body has been the recommended treatment. Alternatively, Foley balloon extraction is a safe and effective approach.

METHODS

Over a 16-year period, 555 children presented with an esophageal foreign body. Retrospective analysis of the medical record was undertaken. Statistics were by univariate analysis.

RESULTS

Two hundred ninety-eight boys and 257 girls presented with a mean age of 3.24 years. Dysphagia (37%) and drooling (31%) were the most common symptoms. Foreign bodies were lodged in the superior esophagus in 73%, and 88% of the objects were coins. Balloon extraction with fluoroscopy was performed in 468 children. Eighty percent of the objects were successfully removed with a mean fluoroscopy time of 2.2 min, and 8% were advanced into the stomach. The overall success rate was 88%, with failures necessitating rigid esophagoscopy under general anesthesia. Children younger than 1 year were the most likely to fail (25% failure rate). Airway aspiration never occurred. Significant savings in patient charges were observed with this approach.

CONCLUSIONS

Balloon extraction of pediatric esophageal foreign bodies is a safe and cost-effective procedure. This technique is applicable for infants, children, and adolescents. Experienced practitioners should be able to achieve greater than 80% success rate.

Case of the missing penny: thoracoscopic removal of a mediastinal coin

Complications of coin ingestion in children, although rare, include esophageal perforation, tracheoesophageal fistula, esophago-aortic fistula, and death. The authors describe thoracoscopic removal of a mediastinal coin that migrated extraluminally from the esophagus in a 23-month-old girl. Right-sided thoracoscopic exploration using a 3-trocar technique in a modified prone position was used. Coin location was assisted by manipulation of a transorally placed Foley catheter and intraoperative fluoroscopy. The coin was retrieved successfully with no intraoperative or postoperative complications and minimal postoperative pain. This is the first report of successful thoracoscopic removal of a mediastinal coin. Thoracoscopy may be a valuable approach for mediastinal foreign body removal in children.

Magill forceps extraction of upper esophageal coins

BACKGROUND/PURPOSE

This study demonstrates a minimally invasive technique for upper esophageal coin extraction.

METHODS

A retrospective review was conducted of 36 children who had upper esophageal coins extracted using a Magill forceps.

RESULTS

All coins were removed without complication in approximately 45 seconds (33 on the first attempt, 3 on the second attempt).

CONCLUSIONS

This technique minimizes instrumentation of the esophagus and is highly successful at removing coins lodged at or immediately below the level of the cricipharyngeus muscle.

Management of sharp esophageal foreign bodies in young children: a cause for worry

The most common foreign bodies in children are coins, particularly in the age group of 2-5 years. Sharp esophageal foreign bodies in children are not commonly encountered. We present a report of two sharp foreign bodies in young children. Both of them required cervical esophagotomy for removal of the foreign body after an unsuccessful endoscopic attempt. The principles of evaluation and management of sharp and penetrating foreign bodies of the esophagus are described.

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.

Ingested ring-pull causing bronchoesophageal fistula and transection of the left main bronchus: successful salvage of the left lung and esophagus five years after injury

A 6-year-old girl with a history of ingestion of a ring-pull of a can and a transient episode of stridor had been asymptomatic 3 years before admission when left lung atelectasis with severe respiratory distress developed. Fluoroscopy and 3-dimensional computed tomography scan showed bronchoesophageal fistula and the ring-pull around the left main bronchus. At operation, the ring-pull, which transected the left main bronchus, was extracted. The left main bronchus was reconstructed by end-to-end anastomosis in spite of insufficient inflation of the collapsed left lung. The esophageal defect was repaired. The patient's respiratory distress gradually disappeared, and the x-ray films 3 months after operation showed complete expansion of the left lung. This case shows the risk of the long-term retained esophageal foreign body and the possibility of pulmonary salvage after long-term total atelectasis of the lung.

Home observation for asymptomatic coin ingestion: acceptance and outcomes. The New York State Poison Control Center Coin Ingestion Study Group

OBJECTIVES

To obtain preliminary estimates of the acceptance rate and the frequency of adverse outcomes, and to identify issues related to acceptance, associated with management of asymptomatic pediatric coin ingestion by home observation, in preparation for a large-scale prospective study.

METHODS

Scripted telephone follow-up of callers who had reported asymptomatic pediatric coin ingestions to one of five poison control centers six to 36 months previously, which had been managed by home observation.

RESULTS

Of the 67 callers enrolled, 41 (67%) reported contacting a physician regarding the coin ingestion, despite home observation instruction by poison control center personnel. Those who did not recall being instructed in home observation were more likely to have contacted a physician than those who did. Nearly all, however, were satisfied with the advice they had been given. One child developed subsequent symptoms; as per the instructions that had been given by poison control center personnel, his parent sought physician evaluation, revealing an esophageal coin, which was removed uneventfully. No other child developed complications.

CONCLUSIONS

Although all of the 67 children managed by home observation did well, most of their caretakers had not accepted this management strategy. Acceptance, while unrelated to satisfaction, may be related to comprehension of the instructions caregivers are given. A prospective study of home observation for asymptomatic pediatric coin ingestion would be safe and would allow further examination of factors affecting acceptance.

Efficacy of esophageal bougienage by emergency physicians in pediatric coin ingestion

STUDY OBJECTIVE

To determine the efficacy and safety of bougienage performed by properly trained pediatric emergency medicine physicians to advance a recently ingested coin lodged in the esophagus into the stomach.

METHODS

We carried out a prospective study of consecutive cases at two university-affiliated pediatric hospitals. Our subjects were 31 children, each with an ingested coin lodged in the esophagus, who met criteria for bougienage: a single coin ingested in the preceding 24 hours, radiographically localized in the esophagus; no history of esophageal disease, esophageal surgery, or foreign body removal; and no sign of respiratory compromise. The bougienage procedure involved a single pass of a Hurst bougie dilator from the mouth to the stomach with the unsedated patient sitting upright.

RESULTS

In all cases, the coin was successfully advanced into the stomach with a single pass of the bougie dilator. No patient experienced an acute complication or delayed surgical complication related to the procedure. In one case the coin was vomited after the procedure and recovered without complications. Mild abdominal pain developed in two patients, who were reevaluated 2 weeks after the procedure. In each case the coin was present in the stomach and was removed endoscopically without subsequent complications.

CONCLUSION

When used by trained emergency physicians, esophageal bougienage is a safe, effective, cost-containing treatment for dislodging and advancing ingested coins from the esophagus into the stomach that requires no sedation or general anesthesia.

Pediatric coin ingestion: a home-based survey

To improve understanding of the natural history of pediatric coin ingestions, an anonymous, home-based mail survey of parents followed by a five-physician private pediatric practice in suburban Maryland was conducted. Of 2,263 families surveyed, 798 (35.3%) responded, representing 1,510 children. Sixty-one (4.0%, 95% confidence interval: 3.1% to 5.1%) children had swallowed a coin, at a mean age of 2.8 years. Fifty-two (85%) coin ingestions were managed at home, usually without calling a physician or poison control center. Only 9 (15%) children were examined by a physician. No child (95% confidence interval: 0% to 4.9%) underwent a removal procedure or had an adverse outcome. Most coin ingestions were found to have been managed at home, often without calling a physician or poison control center. Hospital- or poison control center-based studies underestimate coin ingestion incidence and overestimate the frequency of complications.

A safe and cost-effective protocol for the management of esophageal coins in children

Foreign bodies of the esophagus are a common problem in children, with the majority of these foreign bodies being coins. Because there are various methods for managing esophageal coins, we retrospectively reviewed our experience of the past 4 years to establish a safe and cost-effective protocol for their management. From January 1987 to December 1990, 57 children were managed for esophageal coins in our institution. Nineteen children were managed endoscopically under general anesthesia, with a mean patient cost of $1,982 (excluding the surgeon and anesthesiologist charge). Thirty-eight children were managed with Foley balloon extraction or esophageal bougienage in the emergency department with a mean patient cost of $149 (excluding surgeon charge). Both methods were 100% effective, and there were no complications in either group. Rigid criteria were used in selecting patients for balloon extraction and bougienage. These were: (1) duration less than 24 hours; (2) no respiratory distress; and (3) no history of esophageal disease or surgery. Using these criteria, 16 of the 19 patients managed endoscopically could have safely and effectively been managed in the emergency department with a net savings of $1,833 per patient. We conclude that Foley balloon extraction and bougienage of esophageal coins in selected children is both safe and cost-effective. A protocol for managing children with esophageal coins is presented, and the techniques of Foley balloon extraction and esophageal bougienage are reviewed.

Extraluminal esophageal coin erosion in children. Case report and review

Coins are often reported as the most commonly ingested foreign body (FB) in children. They are felt to be benign FBs since they usually pass through the gastrointestinal tract without incident. However, when these objects become impacted within the esophageal lumen, they can perforate the esophagus and migrate extraluminally. Symptoms of the perforation itself are frequently absent, but the potential vascular and suppurative complications may be devastating. We present the 10th reported case of complete extraluminal migration of an esophageal coin, and the only case which was treated without an open surgical procedure. Because of the potential complications, we recommend aggressive surgical intervention as soon as the diagnosis is made.

Esophageal foreign bodies in children. 15-year review of 484 cases

The findings of a retrospective analysis of the charts of 426 children admitted on 484 occasions with diagnoses of esophageal foreign bodies that were managed at the Hospital for Sick Children for 15 years to the end of 1989 are reported. In the majority of cases, ingestion of the foreign body was either witnessed or suspected. Removal was completed with the use of general anesthesia with endotracheal intubation in 90% of cases. The postcricoid area was the commonest site for impaction. Coins were the commonest foreign body. Approximately 5% of children had more than one foreign body. Fifty-nine children had esophageal anomalies. Thoracotomy or laparotomy for the retrieval of foreign bodies was necessary in less than 1% of patients. Complications occurred in 13% of patients; there were no deaths.

Sudden and unexpected death--a late effect of occult intraesophageal foreign body

Acute upper airway obstruction in a 4-month-old male infant who presented as sudden infant death syndrome is described. At autopsy external tracheal compression and tracheobronchitis with plugging of the trachea and bronchi by an abundant mucopurulent exudate were found. The source of the inflammation was the adjacent esophagus where previous impaction of a coin had caused pressure necrosis with mucosal erosion and transmural granulation tissue formation. This case is reported to demonstrate that foreign bodies that remain in the esophagus, having by-passed the larynx, may still result in upper airway obstruction and death in early infancy by this unusual mechanism.

Mediastinal mass and radiolucent esophageal foreign body

The diagnosis of radiolucent esophageal foreign bodies can be difficult, particularly in patients with predominant respiratory symptoms. The consequences of the impaction of a foreign body in the esophagus are serious, and esophageal stenosis, perforation, acquired tracheoesophageal fistulas are among the complications already reported. An unusual complication of a nondiagnosed radiolucent plastic coin that remained impacted for 11 months on the posterior esophageal wall of a 20-month-old child, who presented only with respiratory symptoms, is reported. The foreign body eroded through the esophageal wall, causing an intramural abscess that was initially interpreted as a mediastinal mass, and the patient was operated on with the diagnosis of a foregut duplication. Literature on this situation was reviewed, and the problems associated with the diagnosis and treatment of children with radiolucent esophageal foreign bodies are discussed.

Esophageal bougienage technique for coin ingestion in children

An analysis was performed of 46 consecutive children who received esophageal bougienage for an ingested coin lodged in the esophagus. All patients met the following clinical criteria necessary for performance of this procedure: an acutely ingested single coin, radiographically localized in the esophagus; no previous history of an esophageal disease process, surgical procedure performed or foreign body removed; and no respiratory compromise upon physical examination. All coins were successfully advanced distally into the stomach after one pass of the bougie dilator. No complications were noted during or after performance of any procedure. Esophageal bougienage is a safe and effective method used to dislodge and pass an ingested coin from the esophagus when criteria for its performance are adhered to rigidly.

The contraindications for blind esophageal bouginage for coin ingestion in children

Per oral bouginage of the esophagus for coin lodgement in children is a safe and simple mode of therapy. However, our experience with chronically ingested coins, multiple coins ingestion, and ingestion with preexisting esophageal pathology illustrate the potential hazards of such a practice. Intramural perforation, subacute mediastinitis, tracheoesophageal fistula, and long-term residual injury to the esophagus hallmark such cases. We believe that only acutely ingested coins, and only a single coin, can be treated safely by means of "blind" bouginage, provided that no preexisting esophageal disease is present.