Cervical esophageal perforation with severe mediastinitis due to an impacted dental prosthesis

An unusual sharp magnetic foreign body in the oesophagus and its removal: A case report

Ingestion of foreign bodies is a common pediatric problem. The majority of ingested foreign bodies pass spontaneously. Oesophageal foreign bodies should be urgently removed because of their potential to cause complications. Ingested batteries that lodge in the oesophagus, sharp or pointed foreign bodies in the oesophageal or gastric tract, and ingestion of multiple magnets all require urgent endoscopic removal. A 4-year-old boy ingested a sharp magnetic foreign body, which was removed via rigid oesophagoscopy without complication. To the best of our knowledge, this is the only sharp magnetic foreign body ingested by a young child ever reported in the English-language literature. We describe the presentation and therapeutic procedure adopted in this case.

Designing for Safety: Implications of a Fifteen Year Review of Swallowed and Aspirated Dentures

Objectives

Dentures are worn by around 20% of the population, yet if they become displaced they may enter the gastrointestinal or respiratory system, sometimes with grave consequences. The aim of this study was to review recent published literature in order to identify the epidemiology of patients and characteristics of swallowed and aspirated dental prostheses, and propose strategies to minimise these risks.

Material and Methods

A fifteen year retrospective of published case series and case reports was carried out. Photographs, radiographs and descriptions of the dental prostheses were gathered, as well as the patient’s presenting complaint, the anatomical site where the denture was caught and the procedure required to remove the denture.

Results

Ninety one separate events of swallowed or aspirated dentures were identified from 83 case reports and series from 28 countries. Average age was 55 years, and these were 74% male. Photographs were retrieved for 49 of these dentures. Clasps were present in 25 of the dentures. There was no significant difference between clasped and unclasped dentures for perforation rates, need for open surgery and spontaneously passed dentures.

Conclusions

We discuss the implications of this study regarding denture designs, specifically the importance of using a radiopaque acrylic, using clasps when required even if there is a risk of aspiration, advising patients to return if a denture is loose or damaged, and finally that all patients who wear a denture are at risk of aspiration and swallowing events, and associated morbidity and mortality.

Cervical esophagotomy for foreign body extraction - Case report and comprehensive review of the literature

INTRODUCTION

Esophageal foreign bodies are an important and serious cause of morbidity and mortality in both children and adults. Due to the possibility of serious complications, i.e. perforation, necrosis, mediastinitis, and fistulation, rapid and accurate diagnostic measures with subsequent therapy are necessary.

CASE REPORT

We are reporting a case of a 55-year-old, mentally impaired patient that has swallowed a foreign body, which subsequently became lodged in his esophagus. Due to the fact that endoscopic removal was not possible and there was a high risk of complications such as esophageal perforation or mediastinitis in this case, we performed cervical esophagotomy and successfully extracted the foreign body. The patient showed an uneventful postoperative process and could be discharged on Day 11 after the operation.

COMPREHENSIVE REVIEW

Furthermore, we performed a systematic review of the literature to identify all studies that described a surgical approach through esophagotomy in cases of foreign body ingestion and found 11 publications describing the cases of 29 patients. These studies reported an overall complication rate of 17.2% and a mortality rate of 0%.

CONCLUSION

Our findings suggest that esophagotomy could be a viable approach for the extraction of foreign bodies especially in some cases when endoscopic removal was not successful and the risk of esophageal perforation is high.

Thoracoscopic removal of dental prosthesis impacted in the upper thoracic esophagus

Dental appliances are the most common cause of accidental foreign body esophageal impaction, especially in the elderly population with decreased oral sensory perception. A 47-year-old man with history of oligophrenia and recurrent epileptic seizures was referred to our hospital following dislocation and ingestion of his upper dental prosthesis. Endoscopic removal and clipping of an esophageal tear had been unsuccessfully attempted. A chest CT scan confirmed entrapment of the dental prosthesis in the upper thoracic esophagus, the presence of pneumomediastinum, and the close proximity of one of the metal clasps of the prosthesis to the left subclavian artery. A video-assisted right thoracoscopy in the left lateral decubitus position was performed and the foreign body was successfully removed. The patient was then allowed to wear the retrieved prosthesis after dentistry consultation and repair of the wire clasps by a dental technician. At the 6-month follow-up visit the patient was doing very well without any trouble in swallowing.

Mussel shell impaction in the esophagus

Mussels are commonly used in cooking around the world. The mussel shell breaks more easily than other shells, and the edge of the broken mussel shell is sharp. Impaction can ultimately cause erosion, perforation and fistula. Aside from these complications, the pain can be very intense. Therefore, it is essential to verify and remove the shell as soon as possible. In this report we describe the process of diagnosing and treating mussel shell impaction in the esophagus. Physicians can overlook this unusual foreign body impaction due to lack of experience. When physicians encounter a patient with severe chest pain after a meal with mussels, mussel shell impaction should be considered when diagnosing and treating the patient.

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.

Acute neck swelling: a diagnostic dilemma in a regional hospital

This case study describes an incident of acute neck swelling in a patient presenting to the ED of a regional hospital after hours. Maintaining and securing her airway proved to be challenging, as did arriving at the correct cause of her airway obstruction and neck swelling.

Flexible versus rigid endoscopy for treatment of foreign body impaction in the esophagus

BACKGROUND

The use of either flexible endoscopy (FE) or rigid endoscopy (RE) for removal of ingested foreign bodies (FBs) impacted in the esophagus is still discussed controversially.

METHODS

We report a consecutive series of 139 patients with FB impaction in the esophagus. During a 6-year period, 69 men and 70 women (median age, 64 [0.7-97] years) requiring removal of an impacted FB underwent either RE (n = 63) in the Otolaryngology Department of our hospital or FE (n = 76) in the Surgical Endoscopy Unit.

RESULTS

Foreign body removal was equally effective with FE (success rate 93.4%) and RE (95.2%, p = n.s.). The cases in which foreign body removal failed (5 FE cases [6.6%] and 3 RE cases [4.8%]) were all subsequently successfully managed with "conversion" and use of the other technique. No severe complications occurred when FB removal was attempted with FE (0 of 76 cases; 0.0%), whereas RE was associated with esophageal rupture requiring immediate surgical intervention in 2 of 63 cases (3.2%; p < 0.002). Patient comfort differed significantly between the two procedures (p < 0.0001); RE was always performed under general anesthesia (100.0%), whereas only a minority of patients undergoing FE required general anesthesia (13.0%; p < 0.0001) or mild analgosedation (20.0%). The better patient comfort with FE was also reflected in a significantly lower rate of dysphagia (15%) compared to RE (48%; p < 0.0001). Rigid endoscopy was more frequently used in removal of FBs of the upper esophagus (p < 0.0001), whereas FE was the predominate approach to FBs in the lower esophagus (p < 0.0001).

CONCLUSIONS

A tailored approach to treatment of FB impaction is recommended. Because of the lower rate of severe complications, better patient comfort with a lower rate of dysphagia, and lack of requirement for general anesthesia, FE should be the "first line" approach to FBs, although RE has its place as the "second line" therapy.

Descending mediastinitis: a review

CONTEXT

Mediastinitis is an inflammation of connective tissue that involves mediastinal structures. When the condition has an infectious origin located in the cervical or oral region, it is termed "descending mediastinitis" (DM).

DATA SOURCES

The subject was examined in the light of the authors' own experiences and by reviewing the literature available on the subject. The Medline, Lilacs and Cochrane databases were searched for articles, without time limits, screening for the term "descending mediastinitis". The languages used were English and Spanish.

DATA SYNTHESIS

There are three main fascial pathways by which oral or cervical infections can reach the mediastinum: pretracheal, lateropharyngeal and retropharyngeal. About 70% of DM cases occur via the retropharyngeal pathway. The mortality rate is about 50%. According to infection extent, as seen using computed tomography, DM can be classified as focal (type I) or diffuse (type II). The clinical manifestations are nonspecific and resemble other systemic infections or septic conditions. The primary treatment for DM consists of antibiotics and surgical drainage. There are several approaches to treating DM; the choice of approach depends on the DM type and the surgeon's experience. In spite of all the improvements in knowledge of the microbiology and physiopathology of the disease, controversies still exist regarding the ideal duration of antibiotic therapy and whether tracheostomy is really a necessary procedure.

CONCLUSION

Since DM is a lethal condition if not promptly treated, it must always be considered to represent an emergency situation.

Late hypopharyngo-esophageal perforation after cervical spine surgery: proposal of a therapeutic strategy

BACKGROUND

Hypopharynx and esophagus are occasionally at risk of perforation after cervical spine surgery. Although relatively rare--compared to the frequency of anterior instrumentation--hypopharyngo-esophageal perforation has to be considered as a late complication. An interdisciplinary surgical strategy is required for treatment.

MATERIALS AND METHODS

We herein propose a flow sheet for an interdisciplinary treatment strategy. The concept is based on the authors' personal experiences with this rare complication in a high-volume center for esophageal surgery.

RESULTS

Our interdisciplinary surgical strategy is based on three central parameters that determine the course of treatment: (1) The patient's general condition and signs of systemic infection determine the requirement for critical care management. (2) The stability of the spine (to be addressed by the orthopedic surgeon) determines the requirement for dorsal stabilization, prior to the mandatory removal of the anterior osteosynthesis material that is damaging the hypopharyngo-esophageal structures. (3) The surgical strategy for treatment of the gastrointestinal perforation--the decision to undertake either primary repair or resection--is based on its morphological characteristics; whether it is covered or free, whether it is associated with severe local infection or not, whether the defect is small or large.

CONCLUSIONS

Hypopharyngo-esophageal perforations after spine surgery are an interdisciplinary challenge, best treated by a concert of specialists (ICU, orthopedic surgeon, and gastrointestinal surgeon).