8/13/2019 919.ful.ks

http://slidepdf.com/reader/full/919fulks 1/6

919

Esophagea l Fo re ign Bod ies in

Chi ldren: D iagnos is , T rea tm en t, a nd

Comp l i ca t i ons

.,-. : { 1 49 } 

:

R od e m ick I. M ac p h e m so n i

J e a n n e G . H ill ’

H . B ie m a n n O th e rse n 2

E d w a rd P . T a g g e 2

C h a rle s D . S m ith 2

R ec e iv ed S ep tem be r 2 8 , 1 99 5 : ac cep te d a fte r

rev is ion N o ve m b er 1 3, 19 95 .

  S ect ion o f P e d ia tric R ad io logy , T h e M e d ic a l

U n ive rs ity o f S ou th C aro lin a , 1 71 A s h le y A v e .,

C h arles ton . S C 2 94 25 . A dd res s co rre spo nd en ce to

R . I . M a c ph e rs on .

2S ec tio n o f P e d ia tric S u rg e ry , T he M e d ica l U n i-

ve rs ity o f S o u th C aro lin a , C ha rle s to n , S C 29 42 5 .

0 36 1 - 80 3X 1 96 /1 6 64 -9 19

© A m er ica n R oe n tge n R a y S o c ie ty

OBJEC T IVE . W e perfo rm ed th is s tudy to id en tify th e ro le o f rad io lo g y in th e d iagno -

s is , trea tm en t , and com p lica tio n s o f esophagea l fo re ig n bod ie s in ch ild ren .

M A TER IALS AND METHODS . W e re tro spec tiv e ly rev iew ed th e cha rts and rad io -

g raphs o f 123 esophagea l fo re ig n bod ies seen In 118 ch ild ren a t th e M ed ic a l U n ive r-

s ity o f Sou th C aro lin a from M ay 1980 th rough M ay I 9 95 .

RE SU LTS . M ost fo re ig n bod ie s w e re co in s in th e upper e sophagus (69 ) In In fan tsles s th an 2 yea rs o ld (65 ) fo r few er th an 24 h r (6 0 ). T h e p resen t in g sym p tom s va r-

ied , w ith 20 o f p a tien ts asym p tom a tic . R esp ira to ry s ym p tom s th a t m im ic ked upper

re sp ira to ry tra c t in fec tio n s o r c roup p ro ved m is lead ing w ith lo ng -s tand ing fo re ig n

body re ten tio n . P reex is tin g esophagea l d ise ase w as p re sen t in 1 7 o f p a t ie n ts . T h e

Fo le y ca th e te r m e thod o f fo re ig n body extrac tio n w as a ttem p ted in 53 cases (4 3 )

and w as successfu l w ithou t com p lica tio n s In 46 (8 7 ). E sophagoscopy w as

a tte m p te d in 72 cases (58 ) and w as successfu l w ith ou t com p lica tio n s in 66 (9 2 ).

T h ree pa tien ts h ad m ajo r com p lic a tio n s : a fa ta l a o rtlc o esophagea l fis tu la , an ex tra lu -

m in a l m ig ra tio n o f a co in , and a la rg e esophagea l d ive rtic u lum . S ign ifican t m ucosa l

e ro s ion s w e re show n in s ix pa tien ts on rad io lo g ic s tud ies a fte r ex tra c tion .

CO NC LUS IO N . E a rly re cogn itio n and trea tm en t o f e sophagea l fo re ig n bod ie s is

im pera tive b ec ause the com p lic a tion s are s eriou s an d can be life -th rea te n in g . R ad io l-

ogy p la ys an im po rtan t ro le in th e in itia l d iagnos is , in recogn Itio n o f com p lica tio n s ,

and in tre a tm en t. T he Fo le y ca th e te r m e thod o f fo re ig n body ex trac tio n can be used

on som e pa tie n ts , b u t e sophagoscopy rem ain s th e sa fe s t m ethod o f e sophagea l fo r -e ig n bo dy ex tra c tio n.

AJ R 1 99 6;1 66 :9 1 9 -9 24

E s o p h a g e a l fo re ig n b o d ie s a re a co m m o n a n d p o ten tia lly se rio u s c a u se o f m o m -

b id ity a n d m o rta lity in c h ild re n . T h e re co g n itio n a n d m a n a g em e n t o f fo re ig n b o d y

in g e s tio ns th a t a re w itn e ss e d a re g e n e ra lly n o t a p ro b le m . T h e c lin ic a l d ia g n o s is

o f occ u lt eso p ha ge a l fo re ig n bo d ie s , h ow ev er, ca n b e d iff ic u lt a n d th e c om p lic a-

tio n s se r io u s [1 -3 ]. T ra d itio n a lly , th e d ia g n o s is o f a re ta in e d e so p h a g e a l fo re ig n

b o dy is e s ta b lish e d ra d io log ica lly , a n d m o st a re re m o v e d b y e so p h a g o sco p y . In

th e la te ‘196 0 5 , th e F o le y ca th e te r te ch n iq u e o f fo re ig n b o d y e x tra c tio n w a s in tro -

d u ce d [4 , 5 ], a n d p e d ia tr ic ra d io lo g is ts b e ca m e in vo lv e d in th e tre a tm e nt a s w e ll

a s the d ia g n o s is o f e so p h a g e a l fo re ig n b o d ie s [6 , 7 ]. A lth o u g h th is te ch n iq u e

o ffe rs a fa s t, e ffe c tiv e , a n d in e xp e n s ive a lte rn a tive to e so p h a g o sco p y , s o m e co n -tro v e m sy e x is ts a b o u t its s a fe ty [8 ].

In th is p a pe r, w e d iscu ss th e c lin ic a l, m ad io lo g ic , a nd s u rg ic a l fe a tu re s o fthe 1 23

e p iso d e s o f re ta in e d e so p h a g e a l fo re ig n b o d ie s th a t o c cu rre d in 1 1 8 c h ild re n a t

th e M e d ica l U n ive rs ity o f S o u th C aro lin a fro m M ay 1 980 th ro u g h M a y i 9 9 5 . T h is

‘15 -ye a r e x p e rie n c e id e n tifie s m a n y o f th e d ia g n os tic d ifficu ltie s , co m p lica tio n s ,

a n d th e ra p e utic p itfa lls in tre a tin g e s o p h a g ea l fo re ign b o d ie s . T h e m o le o f th e F o le y

ca th e te r te c h n iq u e in m a n a g in g e so p h a g e a l fo re ig n b o d ie s w ill a lso b e d is cu ss e d .

8/13/2019 919.ful.ks

http://slidepdf.com/reader/full/919fulks 2/6

36

- Gast ro in tes t ina l

u: : : :Respiratory

# {1 4 9 }P a in

ElAs y m pt om at i c

I _ 1oo  <2 4h rs I day to I w k I w k to 4 m os unknown

92 0 M A C P H E R S O N E T A L . A JR :1 66 , A pril 19 96

N ote -S ev e ra l p a t ien ts h ad m o re th an one pre se n tin g s ym pto m .

M ate r ia ls and M e thods

W e rev ie w e d the pa tie n t re co rds a nd rad io g rap h s o f ii8 ch ild re n

w h o e xp erien ce d i 2 3 ep is od es o f re ta in e d es op ha g ea l fo re ig n bo d -

ies b e tw ee n M ay 1 98 0 a nd M a y i 9 9 5 . W e tab u la te d an d a na lyz ed

th e ag e s a nd se xe s o f the p a tie n ts , the p res en tin g sy m p to m s a nd

p re d isp os ing fac to rs , th e n a tu re o f the fo re ign b od ie s , s ites in th e

e so ph a gu s , d u ra tio n s o f re te n tion , trea tm en ts , a n d c om plica tio ns .

S e ve n cas es w e re se lec te d to illus tra te ce rta in d ia gn os tic a n d th e ra -

p eu tic d ile m m a s w e en co un te re d in th e se rie s .

Resu l t s

A t th e tim e o ffo m e ig n b o d y re te n tio n , th e c h ild re n ra n g e d fro m

6 m o n th s to 1 7 y e a rs o ld . E ig h ty (6 5 % ) w e re in fa n ts b e tw e e n 6

m o n th s a n d 2 y e a rs o ld , 2 4 (2 0 % ) w e re b e tw e e n 2 a n d 5 ye a rs

o ld , a n d 1 9 (1 5 % ) w e re m o re tha n 5 ye a rs o ld . S ix ty -s e ve n

(5 4 % ) p a tie n ts w e re m a le . A t p re s e n ta tio n , th e fo re ig n b o d ies

h a d b e e n in th e e so p h a g u s fe w e r th a n 2 4 h r in 7 4 p a tie n ts

(6 0 % ), b e tw e e n ‘1 d ay a n d 1 w e e k in 2 5 p a tie n ts (2 0 % ), a n d

fro m 1 w e e k to 4 m o n th s in iO p a tie n ts (8 % ). In 1 4 p a tie n ts

(1 1 % ), th e d u ra tio n w a s u n kn o w n . T w e n ty -o n e (1 7 % ) e p is o d es

h a d p m e d isp o s in g e s o p h a ge a l d is e a se : p o s to p e ra tive e s o p h -

a g e a l a tm es ia (1 5 e p is o d e s in 1 2 p a tie n ts ), ca u s tic s tr ic tu re (fo u r

e p is o d e s in th re e p a tie n ts ), a n d p o s to p e ra tive fu n d o p lica tio n

(tw o e p iso d es in tw o p a tien ts ). E ig h ty -five (69 % ) o f th e fo re ign

b o d ie s w e re lo d ge d in th e u p p e r es o p h a g u s fro m th e crico p h a -

ryn ge u s to the le ve l o f th e th ird tho m a c ic ve rteb ra , 26 (2 1% ) in

th e m id e s op h a g u s , a n d 1 2 (‘1 0 % ) in th e d is ta l e so p h a g u s. O f

th e fo re ig n b o d ie s , 1 0 3 (8 4 % ) w e re no t fo o d : 8 5 (6 9 % ) w e re

co in s , 1 4 (1 1 % ) w e re o th e r m e ta llic fo re ig n b o d ie s , a n d 4 (3 % )

w e re n o n o p a q u e fo re ig n b o d ie s . T w e n ty (1 6 % ) o f th e fo re ig n

bodies were food, 15 12 ) nonopaque and 5 4 ) opaque.

T a b le 1 su m m a rize s th e p res e n tin g sy m p to m s a nd th e ir

in c id e nc e s fo r a ll pa tie n ts . W h e n th e m a jo r s ym p to m s a re

co m p a re d w ith the in te rva l b e tw e e n in g e s tio n a n d c lin ica l

p re s e n ta tio n (F ig . 1 ), w e n o te d th a t g a s tro in te s tin a l sy m p -

TABLE 1 . P resen tin g Sym p tom s in 123 Cases o f E sophagea l

Fo re ig n B od ies

S ym p tom N o. o f P a tie n ts P e rce n ta g e o f P a tie n ts

A sy m pto m a tic 2 5 20

Gas tro in tes t ina l 5 7 46

D y s p h a g ia 31 26

Droo l ing i9 i6

Vomi t ing i7 i4

G ag g in g 4 3

Anorex ia i i

R es p ira to ry 4 0 33

C o u g h 25 2i

St r ido r i2 iO

Fe v e r 8 7

Conges t ion 4 3

W he e z in g 4 3

A p ne a 2 2

P n e um on ia 2 2

C h es t o r n eck pa in i3 i i

Le tha rgy 2 2

I r r i tabi l i ty 2 2

W e igh t los s 1 i

F ig . i .-In c idence o f fo u r m ajo r s ym ptom s com pa red w ith du ra tio n o f

f or ei gn o dy r et en ti on

to m s pre d o m in a te in fo re ig n b o d y re te n tio n s fo r s ho rt d u ra -

tio n s , b u t re s p ira to ry sym p to m s a re m o re p re v a le n t in lo n g e r

re te n tio n s . F o r m os t as ym p tom a tic pa tie n ts , th e fo re ig n b o d y

in g e s tio n s h a d b e e n w itn e ss e d a n d w e re sh o rt.

E s o p h ag o s co p y w a s p e rfo rm e d in 7 2 ca se s : a s th e p r i-m a ry tre a tm e n t in 6 5 ca s e s a n d th e s e co n d a ry tre a tm e n t,

fo llo w in g u n s u cce s s fu l F o le y e x tra c tio n , in a n o th e r se v e n .

E s o p h ag o s co p y re trie ve d th e fo re ig n b o d y w itho u t c o m p lic a -

tio n in 6 6 o f th e 7 2 p ro c e d ure s . In th e re m a in in g s ix , th e for-

e ig n b o d y p a sse d s p o n ta ne o u s ly in th re e p a tie n ts , tw o

p a tie n ts re q u ire d s u rg e ry , a n d o n e w h o u n d e rw e n t u n su c

c e ss fu l e so p h a g o sc o p y a t a re fe rr in g h o sp ita l h a d a co in

re m o ve d b y F o le y ca th e te r in o u r ins titu tio n .

F o le y c a th e te r e x tra c tio n , a tte m p te d in 5 3 e p is o d e s , w a s th e

p rim a ry tre a tm e n t in 5 2 an d se co n d a ry tre a tm e n t in th e ca se

ju s t m e n tio n e d . F o re ig n b o d ie s w e re re tr ie ve d w ith o u t c lin ic a l

c om p lica tio n in 4 6 o f the 53 p roc ed ures , w ith th e se ve n fa ilu re s

u n d e rg o in g e s o p h a g o sco p y fo r su c ce ss fu l e x tra c tio n .

S ix e so p h a g o sc op ie s re p o rte d m u co s a l in ju r ie s , b u t o n lytw o w e re fa ile d F o le y ex tra c tio n s . A n e so p h a g o g ra rn a fte r

th e p ro c e d ure w a s p a rt o f th e p ro to co l in th e F o le y ca th e te r

re tr ie v a ls b u t n o t in th e e so p h a g o sco p ie s . F o r th re e p a tie n ts

w h o h a d F o le y c ath e te r e x tra c tio n s a n d fo r o n e w h o h a d

e so p h a g o s co p y a fte r fa ile d F o le y re tr ie va l, p e rs is te n t e s o p h -

a g e a l d e fe c ts w e re id e n tifie d a t th e s ite s of th e fo re ig n b o d -

e s . R e te n tio n in th e se ca s e s w e re 3 d a ys , 5 d a y s , a n d

un kn ow n in the re m a in in g tw o ca se s .

E ig h t (7 % ) o f th e fo re ig n b o d ie s p a ss e d sp o n ta n e o u s ly . In

fiv e p a tie n ts w ith d o cu m e n te d co in re te n tio n s w h o w e re

tra n s fe rre d fro m refe rr in g h o s p ita ls , tw o sh o w e d th e co in in

th e s to m a ch o n c he s t m a d io g m a p h s m a d e a fte r a rr iva l a t o u r

in s titu tion ; in th re e , th e e sop h ag us w as e m p ty a t eso p ha -

g o sco p y ; a n d in th e re m a in in g th re e p a tie n ts , th e p a s sa g e ofa d is ta l e so p h a g e a l fo re ig n b o d y in to th e s to m a ch a fte r

in g e s tion o f p e an u t b u tte r w a s w itn e sse d a t flu o m o sc o p y .

T h re e p a tie n ts w h o in g e s te d fo re ig n b o d ie s in th e se rie s

h a d m a jor c o m p lic a tio n s . O n e ch ild d ie d fro m a sa fe ty p in

th a t in d u ce d a n a o rtico e s o p ha g e a l fis tu la ; a se c o n d h a d tru e

a n d fa lse e so p h a g e a l d ive rticu la ca u se d b y a re ta in e d tid d ly -

w in k ; a n d th e th ird h a d a re ta in e d c o in th a t m ig ra te d th ro u g h

th e e so p h a g e a l w a ll to lo d g e b etw e e n th e tra ch e a a nd

e s o p h a g u s .

8/13/2019 919.ful.ks

http://slidepdf.com/reader/full/919fulks 3/6

A JR :1 66 , A pr il 19 96 E S O P H A G E A L F O R E IG N B O D IE S IN C H IL D R E N 92i

Dis cuss ion

A lth o u g h re ta in e d e so p h a g e a l fo re ig n b o d ie s a re fo un d

th ro u g h o u t c h ild h o o d , th e y a re m o re co m m o n in in fa n ts (> 2

ye a rs o ld ). In o u r s e rie s , la te ra l v ie w s o f th e ch e s t co n firm e d

th at th e u p p e r e s op h a g u s , p a rticu la rly a t th e th o m a c ic in le t, w a s

th e m o s t co m m on s ite o f re te n tion . T h is d iffe rs fro m o th e r

s e rie s o f e so p h a g e a l fo re ig n b o d ie s in w h ich th e ce rv ic a l

e s o p h ag u s a t th e le v e l o f th e cr ico p h a ryn g e u s w a s th e m o st

c o m m o n lo c a tio n [9 , iO ]. O u r se rie s a lso co n firm e d th a t the

m o s t co m m o n ly re ta in ed e s o p ha g e a l fo re ig n b o d y in th e s e

in fa n ts a n d c h ild re n w e re c o in s [9 , 1 0 ] a n d th a t e so p h a g e a l

s tric tu re s , p a rticu la r ly th o s e re la te d to e so p h a g e a l a tm es ia afte r

su rg e ry , w e re a c o m m o n p re d is p o s in g fa c to r to re c u rre n t

e so p h a g e a l fo re ig n b o d y re te n tio n in in fa n ts a n d c h ild re n [ii].

M o s t o f th e fo re ig n b o d ie s w e re in th e e so p h a g u s le s s

th a n 2 4 h r b e fo re c lin ica l p re se n ta tio n (F ig . 1 ). V ir tu a lly a ll o f

th e se e p is od e s w e re w itn e s se d b y o th e rs . M a n y o f th e s e

p a tie n ts w e re a s ym p to m a tic a t p re se n ta tio n . M o st h a d g a s-

tro in te s tin a l sy m p to m s ; re sp ira to ry sym p to m s a n d ch e s t

p a in w e re fre q u e n t b u t le ss co m m o n .

In as ym p tom a tic p a tien ts , d ia gn os is a nd tre a tm en t a re u su -

a lly s tra ig h tfo rw a rd . B e ca u s e fo re ig n b o d ie s im p a cte d in th e

u p pe r o r m id e s o p h a g us h a ve little p ros p e c t o f p a ss in g sp o n ta -

n e ou s ly , in s tru m e n ta tio n sh o u ld b e p u rsu e d im m e d ia te ly [1 2 ].

T h ere fo re , a ll pa tie n ts w ith sus pe c ted fo re ign bo d y ing es tio ns

sh o u ld u n d e rg o im m e d ia te c h e s t ra d io g ra p h y o r e s o p h a g o gm a -

ph y to ex c lu de re te n tion , e ve n ifthe ch ild is as ym p tom a tic .

A s th e tim e o f re te n tio n o f th e fo re ig n b o d y in cre a s e s , its

re la tio n sh ip to sym p to m s c a n b e co m e o b s cu re , m a k in g

d ia g n o s is m ore d ifficu lt. F re q u e n tly , th e h is to ry o f fo re ig n

bo d y in g es tion is do cu m e n te d o n ly in re tros pe c t. T h e lon ge r

th e fo re ig n b o d y re m a in s in th e e so p h a g u s, th e g re a te r th e

in c id e n ce o f re sp ira to ry s ym p to m s. C ou g h , fe ve r, a n d c o n -

ge s tio n a re o fte n in te rp re te d as up pe r res p ira to ry in fec tion s ,

a n d strid o m m im ics cm o u p . A n e so p h a g e a l fo re ig n b o d y ca n

c a u se th e s e re sp ira to ry sy m pto m s b y th re e m e ch a n ism s.

C o u g h or s tm id o m o cc u rr in g so o n a fte r in ge s tio n o f a n e so p h -

a g e a l fo re ig n b o d y p ro b a b ly re su lts fro m d ire c t p re ssu re on

th e tra ch e a b y th e fo re ig n b od y itse lf o r by se c o n d ary e so p h -

a g e a l d ila ta tion (F ig . 2 ). W ith p ro lo n g e d re te n tion o f th e fo r-

e ig n b o d y , a s so c ia te d p a m a e so p h a g e a l so ft tis su e ca n

co m p ro m ise th e a d ja c e n t tra ch e a a nd p ro d u ce sy m p to m s .

A n o ccu lt e so p h a g e a l fo re ig n b o d y m a y n o t b e s u sp e c te d as

th e ca u se o f th e se sy m p to m s u n til it is sh o w n o n ch e s t m a d i-

o g m a p h y o r e so p h a g o g m a p h y [1 , 3] .

C o m p lica tion s o f re ta in e d es o p h a g e a l fo re ig n b o d ie s th a t a re

p r im a rily re la te d to p e rfo ra tio n o f th e e so p h a g u s b y th e fo re ig n

b o d y inc lu d e m e d ia s tin itis w ith o r w itho u t a b sc e ss [2 , 9 ], e so p h -

ag us -to -a irw a y fis tu la s [1 , 1 3 ], e so p h a g u s-to -v a scu la r fis tu la s

[2 , 9 ], e x tm a lu rn in a l m ig ra tion o f th e fo re ig n b o d y [1 3 -1 7 ], a n d

fa ls e e so p h a g e a l d ive rticu la [1 8 ]. P ro lo n g e d re te n tio n w ith

o b s tru c tio n is th e c a u se o ftru e e so p h a g e a l d ive rtic u la [1 9 , 2 0 ].

T h e o n ly fa ta lity in o u r se rie s o cc u rre d in a n in fa n t w h o

e xs an g u in a te d th ro u g h a n a o rtico e s o ph a g e a l fis tu la (F ig . 3 ) th a t

w a s ca u se d b y a n o p e n sa fe ty p in fa ilin g to p a ss th ro u g h th e

es op ha g us . A orticoe so ph a ge a l fis tu la s a re u nc om m o n ye t w e ll-

d o cu m e n te d co m p lic a tio n s th a t u su a lly re su lt fro m in g e s tio n o f

sh a rp o b je c ts b u t th a t ca n a ls o o ccu r fro m e ro s io n o f th e e so p h -

a g e a l w a ll b y b lu n t fo re ig n b o d ie s a fte r p ro lo n g e d re ten tio n [2 ].

M ig ra tio n o f a fo re ign b od y ou ts id e th e e so ph ag u s in to th e

m ed ia s tin u m o r th e s o ft tissu e s o f th e n e ck is a ls o a n u n co rn -

m o n b u t w e ll-d o cu m e n te d co m p lica tio n [1 3 - i 7 ]. In th is s ce -

n a rio , w h ich co u ld b e c a lle d “th e b u rie d tre a su re sy n dro m e ,” a

c o in h as a p ro lo n g e d im p a ctio n in th e e so p h a g u s, th e n p e n e -

tra te s th e e so p h a g e a l w a ll a nd m ig ra te s e x tra lu m in a lly , o fte n

b e tw e e n th e e s o p h a g u s a n d tra ch e a . A lth o u g h o n e o f o u r

p a tie n ts w h o e x p e rie n ce d th is sy n d ro m e h a d d ysp h a g ia a n d

w e ig h t lo s s , th e u s u a l p re s e n ta tio n is o n e o f un re le n tin g m e s p i-

m a to ry s ym p to m s th a t m im ic an u p p e r re s p ira to ry tra c t in fe c tio n

F ig . 2 .-N o nopaqu e , esop hagea l fo re ig n b od y In 9 -

m on th -o ld g ir l w ith esop hagea l a tre s la re pa ir a t b irth

w ho p resen ted w ith ac u te s tr id o r. L a te ra l e so p ha g o-

g ram show s re ta ined , n on op aq ue fo re ig n b od y (p ru ne

p it) in s tric tu re a t s ite o f esop hagea l a tres la r epa i r an d

t ra ch ea l c om p re ss io n   a r r owhead) b y d ila te d p ro xl-

m al e so ph ag us . (R ep rin ted w ith perm iss ion from [23 ])

F ig . 3 .-A orticoe so ph a ge a l fis tu la In i-ye a r-o ld

boy w ith hem atem es is . R ad iog raph o f ch es t and ab -

dom en show s m ass ive le ft p leu ra l flu id co lle c tion

an d open safe ty p in In low e r ab dom en  a r rowhead .

Au topsy revea led ao rt ic o esophagea l fis tu la and

m ass ive le ft h em o tho ra x from pe rfo ra tio n o f a o rta b y

s afe ty p in .

8/13/2019 919.ful.ks

http://slidepdf.com/reader/full/919fulks 4/6

F ig . 5 .-E so ph ag ea l d iv ert icu la s eco nd ary to re ta ined fo re ig n bo dy in 4 -ye ar -o ld g irl w ith 4 -m on th

h is to ry o f d ysph ag ia an d re cu rre n t resp ira to ry tra c t In fec tio ns .

A, La te ra l e sophagog ram show s larg e tru e d iv er ticu lum p ro je c tin g poste rio r ly from prox im al

esop hagu s . Co n tras t m ed ia leak s from esoph ag us in to so ft-tiss ue m ass b etw een trache a  wh i t e

arrowhead a nd e so ph ag us . T id dly win k  b la ck a rro wh ea d Is s ee n w ith in fa lse d iver t i cu lum.

B, A xia l C T s ca n o f up per m ed las tin um s ho ws true d iv er tic ulu m   wh i t eanowhead) p ro je ct in g p os te rio r

a nd t o rig ht. T ldd ly w lnk b iac k a r r owhead) I s s ee n in f als e d iv er ti cu lu m , w h ic h e xte nd s a nte rio ra nd to le ft.

F ig . 6 .-Fo ley ca the te r techn iqu e fo r co in cx -

t ra c tio n . U sing seda tio n and gu ld ew ire , F o ley

ca the te r Is p assed beyond Im pacted co in . B al-

lo on is in fla te d w ith w ater -s o lu ble co ntras t an d

cathe te r is w ith draw n. A s co in is w ith draw n in to

o ro pha ryn x, p atie n t is p la c ed fa ce d ow n In T ren -

d elen be rg ’s p os itio n to p ro te c t a irw ay , an d co inI s r ap id ly e xt ra ct ed from m outh .

922 M A C P H E R S O N E T A L. A JR :1 66 , A pril 19 96

or c ro u p . T h e bu rie d co in is ide n tified b y ch es t ra d iog ra ph y

(F ig . 4 A ) b u t ca n n o t b e fo u n d a t e so p h a g o sc o p y . E s o p h a g og -

m a p h y (F ig . 4 B ) co n firm s the e x tra lu m in a l lo ca tio n o f a fo re ig n

b o d y , a n d su rg ica l e x tra c tio n is c u ra tive .

E so p h a g e a l d ive rticu la a re le ss co m m o n co m p lic a tio n s o f

p ro lo n g e d re te n tio n of e so p h a g e a l fo re ig n b o d ie s [1 8 -2 0 ].

A n o th e r o f o u r p a tien ts re ta in e d a tid d lyw in k in th e e s o ph a g u s ,

p o s s ib ly fo r ye a rs , a n d de v e lo p e d a la rg e tru e d ive rtic u lu m

p ro x im a l to th e ob s tru c tio n tha t w as se e n o n e so ph ag o gm a p hy

(F ig . 5A ) a nd C T (F ig . S B ). T w o str ik in g ly s im ila r ca se s h a ve

b e e n re p o rte d [1 8 , 1 9 ] in w h ich im p ac te d tid d lyw in ks w e re a s so -

c ia te d w ith tru e e so ph a ge a l d ive rticu la p ro x im a l to the ob s tru c -

tio n . In a fo u rth p a tie n t, a re ta in e d tid d lyw in k w a s a sso c ia te d

w ith m ark e d sym me tr ic e so p h a g e a l d ila ta tio n , n o tru e d ive rticu -

lu m , a n d a p ro b a b le fa lse d ive rtic u lu m [2 0 ]. In th is s itu a tio n , tru e

d iv ertic u la h a ve b e e n a ttrib u te d to a sy m m etr ic d ila ta tio n o f th e

es op ha g us p rox im a l to a lo n g -s ta n d ing o b s truc tion [1 8 , i 9 ].

C o nv e rs e ly , fa lse d ive rtic u la oc cu r a fte r a fo re ig n b o d y p e m fo -

m ate s th e e so p h a g u s a n d a p e rs is te n t c o m m u nica tio n d e v e lo p s

b e tw e e n th e e s o ph a g u s a n d a n a sso c ia te d e n c a p su la te d

pa ra eso p ha ge a l in fla m m a to ry p roce ss (F ig . 5 ) . B ec au se t idd ly -

w in ks a re th in , co in -s ize , p la s tic d isk s w ith re la tive ly sh a rp

F ig . 4 .-E x tra lum in a l m ig ra tio n o f co in in 2 -

y ea r -o ld g ir l w ith 7 -m on th h is to ry o f d ysp hag la

an d w eig ht los s .A , La te ra l ch es t rad io grap h sh ow s co in p oe -

ten o r to tra ch ea , b u t so ft-t iss ue sw ellin g s ep a-

ra tin g co in from tra chea   a r r owhead) w as

con tra ind ica tio n to F o le y ca th e te r ex tra c tion .

C o in cou ld n o t b e s e e n w i th e s op h a go s c op y .B, La te ra l e sophagog ram show s co in be -

tw een esophagus and trachea w ith ex trav asa -

tio n o f con tra s t   a r rowhead a round co in . A t

surgery , co in w as found be tw een tra chea and

esophagus .

8/13/2019 919.ful.ks

http://slidepdf.com/reader/full/919fulks 5/6

A JR :1 66 , A pr il 1 99 6 E S O P H A G E A L F O R E IG N B O D IE S IN CH IL D R E N 9 2 3

F ig . 7 .-Sh a llow esophagea l e ros ion In i-

y ea r-o ld bo y w ith cou gh and congestio n w ho

h ad co in in esop hagu s fo r un cer ta in t im e .

E so ph agogram fo llow ing su cces sfu l Fo le y

c ath ete r ex tra ctio n s ho ws Irre gu la r m uc osa l d o-

fec ts   a r rowheads w he re re ta in ed co in e ro ded

e so ph ag ea l w all.

F ig . 8 .-D e ep esophagea l e ros io n in 9 -m on th -

o ld b oy w ith 3 -da y h is to ry o f Ir ritab ility fo l low in g

wf tnes s ed co in in g es tio n . E sophagog ram , te l-

low ing success fu l F o ley ca th e te r e x tra c tIo n ,

s ho ws d ee p, ro un de d de fec t in p rox im al esoph-

ag us co nfo rm in g to impac ted co in .

ed g e s , th e y ca n cu t th ro u g h th e e so p h a g e a l w a ll fa s te r th a n a nac tu a l co in ca n a nd , be in g n on o pa qu e , re m a in un de tec te d by

p la in ch e s t rad io g rap hy . P aren ts sh ou ld be ad v ised o f th e ha z -

a rd o f th ese to ys .

U se o f a F o le y ca the te r to tre a t e so ph a ge a l fo re ig n bo d ie s

(F ig . 6 ) ap p ea re d in th e su rg ica l lite ra tu re in th e i9 6 0 s . In i-

tia lly , the se ca th e te rs pu sh ed co ins in to the s to m a ch [4 ]. La te r ,

th e c a th ete r w a s u se d to e x tra c t th e m fro m th e e so p h a g u s [5 -

7 ]. O ne a u th o r su gg es te d b lind e x tra c tio n w ith ou t flu o ros cop ic

g u ida n ce [2 1 ], a te chn iq u e s til l p rac tice d in e m e rge n cy ro o m s

[2 2 ]. A re ce n t s u rv e y o f N o rth A m e ric a n p e d ia tric ra d io lo g is ts

sh o w e d th a t s in ce th e ea rly 1 9 70 s , the y ha ve co lle c tiv e ly

e x tra c te d o ve r 2 5 0 0 b lu n t e so p h a g e a l fo re ig n b o d ie s u n d e r

fluo m o sco p ic g u ida n ce w ith a 9 5 % s ucc ess m a te a nd o n ly o ne

s e rio u s co m p lica tio n [2 2 ]. C o n v erse ly , in a su rv e y to w h ich1 52 p e d ia tr ic o to la ry n g o lo g is ts re sp o n d e d , 4 5 co m plica tio n s

w e re a s crib e d to th e p roc e d u re u s in g F o le y c a th e te rs a n d flu -

o m o sco py [8 ]. T h e m o s t s e riou s co m p lica tion is d isp la cem en t

o f th e fo re ign b od y in to the a irw ay . A lth o ug h no t e nc ou n te red

in th e pe d ia tric ra d io log y su rve y [2 2 ] a nd m e n tio n ed on ly o nce

in th e o to la ryn g o log y q u es tion na ire [8 ], it rem a ins a po ten tia l

h a za rd th a t ra d io lo g is ts m u s t a vo id w h e n u s in g th is m e th o d o f

tre a tm e n t. In o u r m e d ica l ce n te r, w e e m p lo y th is p ro c e du re

o n ly in p a tien ts w ith re ta ine d b lu n t fo re ig n bo d ie s , suc h as

co ins , in th e eso p ha gu s fo r a sh o rt p e rio d o f tim e . W e re ly o n

th e la te ra l c h e s t ra d io g ra p h ic fin d in g o f a th ick e n e d tm a ch e o e -

so ph a ge a l in te rfa ce (F ig . 4 A ) a s a p re d ic to r th a t the fo re ig n

b o d y h a s b ee n re ta in e d a re la tive ly lo n g tim e a n d F o le y ca th -

e te m retr ie v a l w ill b e u n s u cce s s fu l [1 0 ]. N o n e o f o u r p a tie n tsh a d s ig n ifica n t c lin ica l c o m p lica tio n s fro m th e p ro c e d u re .

H o w eve r, w e ob se rve d as ym p tom atic m u ra l d e fe c ts o n

e s o ph a g o g m a m s m a d e a fte r th e p ro c ed u re (F ig s . 7 a n d 8 ) th a t

p ro ba b ly rep re se n t e ro s io n o f the eso p ha ge a l w a ll b y the fo r-

e ig n bo d y , ra the r th an a co m p lic a tion o f the p ro ce du re its e lf.

In a cas e o f an e x tm a lu m in a l co in (F ig . 4 ) , the se le c tio n p ro -

ce ss e lim in a te d th e p o te n tia l d isa s ter th a t co u ld h a v e a cco m -

p a n ied a tte m pte d F o ley ca th e te r e x tra c tio n .

C o n n e m s e t a l. [i2 ] n o te d th a t re ta in e d fo re ig n b o d ie s inthe u p p e r a n d m id e s o p ha g u s u su a lly re q u ire so m e fo rm o f

ins tru m e n ta tio n , w he re as th o se in the d is ta l eso p ha gu s c an

p a s s sp o n ta n e o u s ly . In d is ta l e so p h a g e a l re te n tio n s , w e

h a v e u s e d a F o le y ca th e te r to p u sh th e fo re ig n b o d y in to th e

s to m a ch o r h a v e fe d th e p a tie n t p e a n u t b u tte r a n d w a tch e d it

carry th e fo re ig n bo d y in to th e s to m a ch w ith flu o ro s co p y .

D u rin g o u r s tud y , a ch ild w a s re fe rre d to u s w ith a m etm o p ha -

ryn g ea l a bs ces s th a t co m p lic a te d an eso p ha go sco p y fo r co in

re tr ie v a l. H o w e ve r, in o u r m e d ica l ce n te r, n o n e o f th e e so p h a -

g o s co p ie s to rem o v e fo re ig n b o d ie s h a d a n y co m p lica tio n s

re la te d to th e p ro ce d u re . A lth o u g h th e a d v o ca te s o f th e F o ley

ca th e te r te ch n iqu e c la im tha t it is fa s te r a nd le ss exp e ns ive

[2 2 ], su p p o rte rs o f e so p h a g o sc o p y a rg u e th a t w ith m o d e rn

tec h n iq u e s fo r o u tp a tie n t s u rg e ry , e so p h a g o sc op y fo r fo re ig nb o dy rem ova l ca n be pe rfo rm e d sa fe ly u nd e r g en e ra l a n es -

the s ia , a n d th e p a tie n t c a n b e d isc h a rg e d th e sa m e d a y [8 ],

su g g e s tin g th a t a sp e e d a n d e c o n o m y g a p n o lo n g e r e x is ts

b e tw e e n th e tw o p ro ce d u re s . In o u r m e d ic a l c e n te r, h o w e ve r,

the a v e ra g e co s t o f a n e s op h a g o s co p y fo r fo re ig n b o d y

r e m o v a l is a lm o st fo u r tim e s th a t o f F o le y ca th e te r e x tra c tio n .

D e sp ite a n x ie ty o ve r c o s t co n ta in m e n t in m e d ic in e , ce rta in

p rin c ip les in the m a na g em e n t o f a p a tien t w ith a p os s ib le

re ta in e d e so p h a g e a l fo re ig n b o d y s h o u ld n o t b e c o m p ro m is e d .

In fa n ts o r ch ild ren w ith fo re ig n b od y in ge s tion s th a t a re w it-

n e ss e d o r a re o n ly su s p e c te d , e ve n a s yrn p to m a tic p a tie n ts ,

s h o u ld h a v e th e a p p ro p r ia te ra d io lo g ic in ve s tig a tio n s to e xc lu d e

im p a ctio n in th e e so p h a g u s. W h e n a fo re ig n b o d y is re ta in ed in

the u p p e r o r m id e s o p ha g u s , it s h o u ld b e re m o v e d im m e d ia te ly .In fa n ts a n d ch ild re n w ith c h ro n ic o r re cu rre n t u p p e r re sp ira to ry

tra c t in fe c tio n s , pe rs is te n t c rou p , o r e v e n va g u e s ym p to m s,

s u ch a s le th a rg y an d w e ig h t lo ss , sh o u ld b e in ve s tig a te d to

e x c lu d e a n e so p h a g e a l fo re ig n b o d y . A lth o u g h F o le y ca th e te r

e x tra c tio n re pre se n ts a fa s t a n d in e xp e n s ive a lte rn a tiv e to

e s o p h a g o s c o p y , i t s h ou ld b e e m plo ye d o n ly in c a re fu lly se lec ted

p a tie n ts . E so p h a g o sco p y re m a in s th e sa fe s t m e th o d o f e s o p h-

a g e a l fo re ig n b od y re m ova l in in fa n ts a n d ch ild re n .

8/13/2019 919.ful.ks

http://slidepdf.com/reader/full/919fulks 6/6

92 4 M A C P H E R S O N E T A L . A JR :1 66 , A pril 19 96

R E F E R E N C E S

1 . N ew man D E. R ad io lu ce n t eso p ha ge a l fo re ig n b od y : an o ften fo rg o tten

c au se o f re sp ira to ry s ym pto ms . J P e di at r i978 ;92 :60 -63

2 . R em sen K , Law son W , B ille r H F , e t a l. U n usua l p res en ta tio ns o f pen etra t -

ing fo re ig n b od ies o f th e u pp er a e ro d ig es tive s ys tem . A n n O to l R h in o l

La r y ngo l 1983 ;92 :32 -44

3 . Sm ith C P , Sw isch uk LE , Fagan C J . A n e lu s iv e , o fte n u nsuspecte d cause o f

s trid or o r p ne um on ia (th e e so ph ag ea l fo re ig n b od y) . AJ R i974 ;122 :80 -89

4 . A iken 0 w . C oin s in the e so ph a gu s : a de p artu re from con ve n tion a l th e r -a py . M i M ed i 965 ;130 : i82 - 183

5 . B ig le r F C . T he u se o f a F o le y ca the te r fo r re m ova l o f b lun t fo re ign b o d ies

fr om t he e so ph ag us . J T ho ra c C ard iov as c S urg i9 66 ;5 1 :7 59 -7 60

6 . S ha cke ifo rd G D, M cA lis te r w H , R obe rtso n C L . T h e use o f a F o le y ca th e -

te r fo r re mo va l o f b lu nt e so pha ge al fo re ig n bo dies fro m ch ild re n. Rad io -

og y i9 72 ;105 :455 -456

7 . C am pbe ll JB , D av is W S. C ath e te r te ch n iqu e fo r ex trac tion o f b lu n t e sop h -

a ge ai f or eig n b od ie s. Rad io logy i 973 ;108 :438 - 440

8 . M yer CM . Po ten tia l ha zards o f e so ph ag ea l fo re ig n bo dy extrac tio n . Ped i -

a tr R ad io i 99 i ; 2i : 97 -9 8

9 . N a nd i P , O n g G B . F ore ign b od y in th e e sop h ag us : re v ie w o f 2 39 4 ca se s .

B rJ S urg i9 78 ;65 :5 -9

10 . To w b in R , L e de rm a n H M , D u nb a r JS , e t a l. E s op ha g ea l e de m a a s a p re -

dic tor o f u n suc ces s fu l ba lloo n e x trac tion o f eso p ha ge a l fo re ig n b od ie s .

P ed ia tr R ad io i 989 ;19 :359 - 360

11 . H olin ge r P H , Jo h ns to n K C , G ree ng a rd J . C o n ge n ita l a no m alies o f the

eso pha gu s re la ted to eso pha ge al fo re ign b od ies . A m J D is C h ild i949 ;78 :467 -476

12. C on n ers G P , C h a m b erla in JM , O ch se ns ch lag e r O W . S ym pto m s an d

s po n ta ne ou s pa ss age o f es oph ag ea l co ins . A rc h P ed ia tr A d o le sc M ed

i995;149:36-39

13 . Y ee K F, S ch ild JA , H olling e r P H. E xtram ura l fo re ign b od ie s (co ins ) in th e

fo od a nd a ir p as sa ge s. A n n O t o l R h i n o L a r yn g o 1 9 7 5 ;8 4 :6 1 9 -6 2 3

14. lian ko va n V . R eta in ed fo re ign b od y in a c h ild . A nn E me rg M ed 1 9 8 7 ;

i6 : i i7 i -1173

1 5. J an ik J5 , Ba ile y W C, Bu rring ton JO . O ccu lt c o in pe rfo ra tio n o fthe e so ph -

ag u s . J P e d ia tr S urg i 98 6;2 1 :7 94 -7 97

i6 . N ah m an B J, M ue lle r C F. A sym ptom atic e sop h ag ea l p e rfo ra tion by a co inin a c hild . A nn E m e rg M ed i 984 ;13 :627 - 629

i 7 . B u rton D M , 5 tith JA . E x tram ura l e so ph a ge a l c o in e ros ion in ch ild re n :

c as e re po rt an d rev ie w.  n tJ P e d ia t r O t or h in o la r yn g o il 99 2 ;2 3 :i 87 - 19 4

18 . K a tz K R , Em m en s RW , W oods B P . Esophagea l o bs tru c tion a nd a bsc ess

fo rm atio n se co nd a ry to im pac te d e ro d ing tid d lyw in k : ra d io log ic c ase o f

t he m o nt h. A m JD is C hild 1989 ;143 :96 i - 962

19 . H erm an T E, M cA lis te r W H. E so p ha ge a l d ive rticu la i n c h il d ho o d assoc i -

a ted w ith s tric tu res from un su sp ec ted fo re ign bo d ie s o f the esop hagu s .

P ed ia tr R ad io 19 9i 2 1 : 4 i0 - 4i 2

20 . Ram adan MF , R o g e rs JH . A n a cq u ire d e sop h ag ea l p ou ch in ch ild h oo d : a

p ro ble m o f d ia gn os is . J La ryn go l O to l 1 9 81 9 5 :1 0 1- 10 8

21 . B ro w n L P . B lin d e so ph ag e a l c o in rem ova l us in g a F o le y c a th e te r. Ar c h

S u rg i 968 ; 96 : 931 - 932

22 . C am pbe ll JB , C on d on yR . C ath e te r re m ova l o f b lu n t e so ph a ge a l fo re ig n

b od ies in c h ild re n : s u rv ey o f th e S oc ie ty fo r P ed ia tric R ad io lo gy . Pedia tr

Rad io i9 89 ;19 :361 -365

23 . M acp he rso n R I, Le ith ise r R E. A irw ay o bs tru c tion in ch ild ren . R ad ioG r aph -ics i9 85 ;5 :339 -376