Application of imaging guidelines in patients with foreign body ingestion or inhalation: literature review

Accidental ingestion of a fractured piece of orthodontic aligner: a case report

BACKGROUND

Ingestion and aspiration of orthodontic devices are rare occurrences, typically associated with components such as expansion keys, archwire segments, dislodged fixed appliances (including brackets, buccal tubes, and bands), as well as fractured metal or plastic appliances. This article describes the clinical diagnosis and treatment process of a case of accidental ingestion of a fractured piece of orthodontic aligner.

CASE PRESENTATION

A 31-year-old female under orthodontic treatment by aligners accidentally ingested a fractured piece of the aligner. The special difficulty of this case is that the transparent orthodontic aligner has a low radiopacity. At the beginning, no foreign body was found in the commonly used soft tissue window, causing difficulty in its location until greyscale was adjusted to lung window. The 2-centimeter fractured piece was taken out under anesthesia and endoscopic surgery.

CONCLUSION

Materials with low radiopacity should be read with a lower grayscale range. Fractured orthodontic appliances with low retention force should not continue to be worn until consultation with attending doctor.

Ultrasound Imaging of Various Ingested Foreign Bodies in an Ex Vivo Intestinal Model

OBJECTIVE

Foreign body ingestion is an increasingly prevalent issue for children who are in the preverbal to early verbal stages of life. Foreign bodies lodged in the gastrointestinal tract can cause issues such as obstruction, perforation, and fistulae. Radiographic imaging can often locate most foreign bodies; however, radiolucent objects may be missed. Ultrasound is an alternative imaging modality that can be used to locate and track foreign objects as they pass through the bowel. The objective of this study was to characterize the sonographic appearance of various ingested foreign bodies of varying characteristics in an ex vivo gastrointestinal tract segment.

METHODS

A GE Logiq 9 ultrasound machine with a linear transducer at a frequency of 15 MHz was used to examine various ingested foreign bodies placed in a segment of pig intestinal tract.

RESULTS

Imaged objects varied in visual appearance from echogenicity, texture, size, and shape; acoustic shadows and reverberation artifacts cast were particularly distinguishing characteristics.

CONCLUSIONS

Ultrasound evaluation to assess foreign body ingestion in the pediatric population may provide a useful alternative or supportive imaging modality in confirming the location and real-time tracking of the ingested item. This may be especially useful for objects of varying radiodensities that cannot always be reliably seen in traditional radiographs.

Clinical practice guidelines in the management of pediatric foreign body aspiration and ingestion: a systematic evaluation using the AGREE II instrument

PURPOSE

Several clinical practice guidelines (CPGs) have been produced to optimize the diagnosis and management of pediatric foreign body aspiration and ingestion. However, to date there have been no critical evaluations of their methodological rigor or quality. Herein, we address this need via the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument.

METHODS

A literature search of Embase, MEDLINE via PubMed, and Scopus was performed up until February 25, 2021. Identified CPGs were then assessed by four independent reviewers trained in AGREE II. A scaled domain score of >60% was indicated as satisfactory quality. Intraclass correlation coefficients (ICC) were calculated to assess inter-reviewer agreement.

RESULTS

11 guidelines were assessed with only one being classified as high quality and others being either average (two) or low quality (eight). Domain 4 (clarity of presentation) achieved the highest mean score (66.41 ± 13.33%), while domain 5 (applicability) achieved the lowest score (10.80 ± 10.37%). ICC analysis revealed generally strong agreement between reviewers with a range of 0.60-0.98.

CONCLUSION

Quality appraisal using the AGREE II instrument suggests that the methodologic rigor and quality of current guidelines for the diagnosis and management of pediatric foreign body aspiration and ingestion need significant improvement.

Surgical Management of an Intentionally Ingested Vape Device Chronically Impacted within the Duodenum of an Adult Male

Most foreign body ingestion cases are accidental in the adult population. Intentional ingestion of foreign bodies in adults is typically associated with psychiatric disorders or developmental delay. In most cases, foreign bodies pass spontaneously through the gastrointestinal tract or can be managed endoscopically. Rarely, surgical intervention is indicated. We present a unique case of surgical management of an intentionally ingested vape device that was chronically impacted within the duodenum of an adult male present for six weeks before intervention without associated perforation. The foreign object was removed via exploratory laparotomy with duodenotomy and primary duodenorrhaphy with an uncomplicated postoperative course. There are only two previously reported cases of an ingested vape device. One was managed by observation, and the other was removed endoscopically. There are no previously reported cases of an ingested vape device that required surgical management.

Pediatric Multiple High-Powered Magnetic Buckyballs Ingestion—Experience From Six Tertiary Medical Centers

Multiple high-powered magnetic Buckyball ingestions may lead to a high risk of severe complications. Great concerns have been raised by public health workers, and it remains challenging for clinicians to solve this troublesome problem. We report a large case series of children with Buckyball ingestion from six tertiary medical centers. The clinical data, including demographics, medical history, diagnosis tools, management options, intraoperative or endoscopic findings, and outcomes, were retrospectively analyzed. Seventy-one children aged 1–13 years ingested 2–41 Buckyballs. Among them, Buckyballs passed spontaneously on 2–10 days post-ingestion in seven cases; gastroscopic removal was performed in 14 cases; laparoscopic removal in 13 cases; laparoscopic-assisted surgical removal in 6 cases; and open surgical removal in 31 cases. Surgical indications included small bowel obstruction, perforation, peritonitis, acute abdominal pain, or along with ingestion of other metallic foreign bodies. Among those who underwent a surgical procedure, primary intestinal repair was performed in 44 cases, enterectomy with primary anastomosis in 6 cases. The postoperative hospital stay ranged from 5 to 28 days. No major complications occurred. In unwitnessed cases, a vague medical history and nonspecific symptoms usually make the diagnosis difficult. The treatment options should include the watch-and-wait approach, endoscopic, laparoscopic-assisted, or open surgical removal of Buckyballs, with primary intestinal repair or anastomosis. Preventive measures, including children's not having access to Buckyballs, are essential to protect children from this kind of unintentional injury.

Diagnosis of Nonmigrating Metallic Foreign Bodies in the Abdomen Using Ultrasound: An Alternative Approach Using a Traditional Method

Ingestion of foreign bodies (FBs) is a common phenomenon among young children. Plain radiography is the first step diagnostic modality to detect the radio-opaque FBs. And computed tomography has been recommended by several guidelines as useful modalities for diagnosing ingested FBs. However, there is a risk of radiation exposure, making it burdensome to use in asymptomatic patients. Ultrasound (US) is not a commonly used technique for diagnosing ingested foreign bodies. However, US can provide real-time imaging with good resolutions without radiation exposure in pediatric patients. Herein, we report two pediatric cases of metallic foreign body ingestion that were successfully diagnosed using US for localizing foreign bodies. This study indicates that US may be used as an alternative method for detecting the localization of metallic foreign bodies in the gastrointestinal tract without exposure of radiation, particularly in pediatric patients.

Foreign Body Aspiration in Egyptian Children Clinical, Radiological and Bronchoscopic Findings

Purpose

Foreign body aspiration (FBA) is a frequent cause of childhood morbidity and mortality. Diagnosis of FBA is challenging in the absence of a witnessed aspiration event. The aim of this study was to determine the accuracy of presenting symptoms as well as physical and radiologic findings as predictors of FBA in children. Thus, indications for bronchoscopy could be determined in such cases.

Methods

This retrospective cohort study was conducted in the ENT department, Kafr-elsheikh University Hospital. The medical records of patients younger than 16 years old who underwent rigid bronchoscopy for suspected FBA were included. Data including age, gender, symptoms, physical examination findings, radiological features, nature and location of foreign body, and outcome of the bronchoscopy were collected.

Results

This study included 130 patients, 105 (80.8%) patients were positive for the presence of a foreign body in their airways. Foreign bodies were most frequently (43.8%) lodged in the right main bronchus, and nuts (66.7%), were the most commonly retrieved. Multivariate regression analysis identified the presence of suggestive signs or symptoms as independent predictors of FBA on rigid bronchoscopy.

Conclusion

Objective finding of clinical signs eg unilateral wheezes on chest examination in the presence of symptoms such as a sudden cough, dyspnea, and hoarseness could predict FBA and help physicians in deciding bronchoscopy.

Diagnosis of a missed bronchial foreign body in an 8-year-old girl: a rare case report

Tracheobronchial foreign body aspiration (TB-FBA) with subsequent airway obstruction typically occurs in children younger than 4 years. TB-FBA results in significant morbidity and mortality in children requiring urgent recognition and prompt management. Some cases remain more indolent and cause unusual respiratory insults ranging from chronic respiratory symptoms such as persistent cough, wheezing, and recurrent pneumonia to life-threatening airway obstruction. This case report presents a rare case of TB-FBA in an 8-year-old girl with a prolonged history of cough and dyspnea for 15 months despite many medical treatments and a rigid bronchoscopy examination performed by a board-certified pediatric surgeon. The patient was referred to Namazi Hospital's Pediatric Interventional Pulmonology Division where fiberoptic bronchoscopic exploration was conducted to remove a foreign body (a 6-cm wheat cluster) from the right lower lobe bronchus. This case report demonstrates the importance of clinical history in the diagnosis of aspirated foreign bodies despite unusual age and normal radiological findings.

Perianorectal abscesses and fistula due to ingested jujube pit in infant: Two case reports

BACKGROUND

About 90% of perianal infection is caused by cryptoglandular infection. Only a few cases of peritonitis or intra-abdominal abscesses secondary to perforation of the digestive tract by an ingested foreign body have been reported. The most common sites of impaction and perforation include the appendix, cecum and the terminal ileum. The rectum is an unusual site of foreign body impaction. This report intends to highlight that ingested foreign body impacted in the rectum is an extremely rare cause of perianal abscess and subsequent fistula in infants.

CASE SUMMARY

Two cases of perianal abscess and fistula due to ingested jujube pit impacted in the rectum are reported. Both cases are infants with free previous medical history suffered from recurrent perianal infection. The caregivers of the two patients denied ingestion of a foreign body or any history of trauma. Physical examination combined with ultrasound or computed tomography scan established the diagnosis. Both of the patients underwent operation under general anesthesia. In case 1, a jujube pit with sharp ends was discovered embedded within a subcutaneous fistula. The jujube pit was then removed intact along with fistula resection. The wound was successfully laid open to allow healing by secondary intention. In case 2, a jujube pit was found with its sharp end puncturing the rectum, surrounded by pus and necrotic tissue. Subsequent incision and adequate drainage were performed. The whole jujube pit was then removed from the abscess cavity at the same time. Both patients received colonoscopy to rule out inflammatory bowel disease or other potential damages by the ingested jujube pit. The postoperative period was uneventful. At 1.5 year follow-up, no recurrent abscess or fistula were found in either patient.

CONCLUSION

An impacted foreign body must not be overlooked as an unusual cause of perianal abscess and fistula, especially in young children.

A Child With a Gastrocolic Fistula After Ingesting Magnets: An Unusual Complication

Foreign body ingestion is frequently the cause of emergency visits in the pediatric population, and these cases are challenging to diagnose and manage. In particular, the ingestion of magnets is dangerous and can lead to serious complications and even death. Urgent endoscopic intervention or surgical exploration remains the best approach for removing multiple ingested magnets and preventing further injury to the gastrointestinal (GI) tract. We report a nine-year-old child with an adjustment disorder who developed a gastrocolic fistula following the deliberate ingestion of multiple magnets. The magnets were successfully retrieved after an emergency laparotomy, and the fistula was subsequently repaired.

Internal Jugular Vein Injury by Fishbone Ingestion

Fishbone ingestion is a common occurrence in the Middle East countries. We present a patient with a unique complication of fishbone ingestion. A 65-year-old woman presented with left-sided neck pain and swelling since 5 days before admission. A linear foreign body with horizontal orientation was seen in CT scan at the superior part of the pharynx along with a collection around it which caused a laceration on the medial aspect of internal jugular vein and thrombosis inside the internal jugular vein.

Management of Sharp-Pointed Esophageal Foreign-Body Impaction With Rigid Endoscopy: A Retrospective Study of 130 Adult Patients

OBJECTIVES

To propose a management algorithm for adult patients with sharp-pointed esophageal foreign-body impaction (EFBI) who have rigid endoscopy (RE) indications and to conduct a retrospective analysis of their data.

METHODS

All adult patients who received RE at the Department of Otorhinolaryngology in Beijing Shijitan Hospital between January 2017 and May 2019 were enrolled. The demographics, clinical characteristics, and management data were collected and analyzed.

RESULTS

A total of 130 patients were identified, 56.9% were female with median age 60 years. More than half (56.9%) of patients had foreign-body (FB) ingestion on holidays. The most frequent FBs were jujube pits (66.9%) and bones (23.8%). There is a significant female predominance in ingestion of jujube pits (65.5%, P = .005). The most common symptoms were odynophagia (49.2%) and sore throat (47.7%). The majority (96.8%) of FB founded were lodged at upper esophagus. In all, 74 patients were categorized as having mild complications and 54 having significant complications. Time interval from ingestion to presentation longer than 15 hours was an independent risk factor for significant complications, while esophagogram with barium as a protective factor.

CONCLUSIONS

Long-time interval from ingestion to presentation will lead to high risk of significant complications. Computed tomography should be a prioritized imaging method for all patients suspected with EFBI, and multidisciplinary collaboration is recommended. Besides, mass education on eating habits is necessary.

Role of Sonography for Evaluation of Gastrointestinal Foreign Bodies

Foreign body ingestion is frequently encountered in children. The locations of the foreign bodies and the period during which they have been present in the thorax and abdomen are important for determining the method and timing of treatment. Although plain radiography and computed tomography are primarily used for assessment of foreign bodies, sonography without radiation is also useful for diagnosis of foreign bodies. This report describes 5 cases of foreign bodies in the digestive tract and the usefulness of sonography for real-time evaluation of foreign bodies with high spatial resolution. Physicians can use sonography along with radiography and computed tomography in cases involving foreign bodies.

The Management of Voluntary Ingestion of Razor Blades by Inmates

Ingestion of sharp objects is a rare event. We report our experience in the care of prisoners who ingested razor blades and the in-time evolution of our management. This is a descriptive study including all detainees ingesting a razor blade, transferred from the prison to Farhat Hached University Hospital of Sousse, from January 1, 2014 to December 31, 2015. Thus, we counted 19 cases of swallowed razor blades in 16 prisoners; indeed, 1 prisoner ingested a razor blade three times and another had ingested a blade twice. Our study includes 19 episodes of swallowed razor blades. In 2 cases, these events were secondary to suicide attempts. In the other cases, it was an expression of discontent and rejection of the situation in the prison. Three patients had a psychiatric history. The mean age of the patients is 24 years. The initial clinical examination had not objectified signs of gastrointestinal perforation. Thoraco-abdomino-pelvic computed tomography scans allowed specifying the blade location in all cases. It also objectified a pneumo-mediastinum in 2 cases. The blade location was esophageal in 1 case, gastric in 6 cases, and in the small bowel in the other cases. The first 4 patients had surgical removal of the blade. In subsequent cases, surgical abstention was the rule, and spontaneous blade expulsion was observed. The average time of expulsion was 4 days. In our experience, surgical removal of sharp foreign bodies should not be performed systematically without complications.

Bronchial Leech Infestation in a 15-Year-Old Female

Foreign body aspiration (FBA) is a common incidence in young children. Leeches are rarely reported as FBA at any age. This study describes a 15-year-old female who presented with hemoptysis, hematemesis, coughs, melena, and anemia seven months prior to admission. Chest X-ray showed a round hyperdensity in the right lower lobe. A chest computed tomography (CT) demonstrated an area of consolidation and surrounding ground glass opacities in the right lower lobe. Hematological investigations revealed anemia. Finally, bronchoscopy was performed and a 5 cm leech was found within the right B_7-8 bronchus and removed by forceps and a Dormia basket.

Do Times until Treatment for Foreign Body Aspiration Relate to Complications?

Introduction. Foreign body aspiration is an emergency condition and may be fatal. Delayed diagnosis and treatment may be associated with complications. This study evaluated the association between time until treatment and complications due to foreign body aspiration. Methods. This study was a retrospective study conducted at Khon Kaen University Hospital, Thailand. We enrolled patients diagnosed with foreign body aspiration with evidence of foreign body detected using direct laryngobronchoscopy at any area from the larynx to the bronchus. Descriptive statistics were used to analyze the association of times of treatment with complications of foreign body aspiration. Results. During the study period, there were 43 patients that met the study criteria. The most common age group was 0-2 years. Plant seeds were the most common foreign bodies (41.9%), and the right main bronchus was the most common site (16 patients, 37.2%). There were 30 patients (69.8%) that experienced complications from foreign body aspiration. Pneumonia was the most common complication (14 patients, 32.6%). The retention time was not significantly associated with the presence of complications (p value: 0.366). Two patients (4.7%) died due to complete airway obstruction and prolonged hypoxia. Conclusion. Times until treatment were not significantly associated with complications from foreign body aspiration.

A computed tomography phantom study of foam earplugs: Uncommon but potentially hazardous foreign body ingestion in children

Ingestion of a foreign body is common among children. However, ingestion of foam earplugs (FEPs) has not been reported previously. A 7-month-old female infant presented with small bowel obstruction, which was finally proved to be a case of FEP ingestion.Computed tomography (CT) phantom study was performed to examine the imaging features of FEPs. We studied the following dry and fully wet FEPs, FEPs squeezed in pure water to varying degrees, and FEPs with different degrees of compression in the dry and wet states from day 0 to 6 and all scanned with a CT scanner.The density of a dry FEP is -843.5 ± 4.5 Hounsfield units (HU) and it increases to 0.76 ± 9.3 HU when fully wet. The densities of FEPs ranged from -844.2 to 1.0 HU with different water/air ratios, and some showed a heterogeneous geographic pattern. The densities of FEPs increase due to compression and gradual water absorption.FEPs can be potentially hazardous objects to children. Owing to the special foam structure of the FEP, it can mimic a fatty lesion if the density ranges from -100 to -50 HU; moreover, it can hide in the water if fully wet. However, it should not be mistaken as air, as the density of a dry FEP is -843.5 HU, and the contour can be observed if the window level is set appropriately. Because of its soft texture, the surgeon should be careful not to miss an FEP during the operation. Moreover, radiologists should be familiar with the CT features of FEPs so that they can be identified before surgery.

Imaging Patients With Alimentary Tract Perforation: Literature Review

Alimentary tract perforation is a frequent emergency condition. Imaging plays an important role to make an accurate diagnosis, defining the presence, the level, and the cause of the perforation, essential information to enable the most correct therapeutic choice. Plain radiography is generally performed as the first choice. In case of a clinically suspected bowel perforation, not detected on x-ray imaging, the contribution of computed tomography is essential. Magnetic resonance is not yet widely used in diagnostic workup of patients with acute abdominal pain, but it can be useful in the differential diagnosis of acute abdomen in specific patients (pregnancy and pediatric patients).