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ASYMPTOMATIC FOREIGN BODY OESOPHAGUS - AN ACCIDENTAL FINDING
Nishit J Shah*, Vimal S Hemani**, Priyadarshini P Naik**
*Hon ENT Surgeon, **Sen Resident in ENT, Department of ENT, Bombay Hospital and Medical Research Centre, New Marine Lines, Mumbai 400 020.
Foreign body ingestion is common in children and most foreign bodies will pass without any problem. Usually, patients present immediately following foreign body ingestion, but in a small percentage of patients foreign bodies may remain undetected for weeks to months. Here, radiology and clinical suspicion play an important role in diagnosing and treating foreign bodies. We present two patients in whom long-term asymptomatic foreign bodies were discovered accidentally while being investigated for other problems. Even in the absence of symptoms, if there is a history of foreign body ingestion, the patient should be completed evaluated. Diagnosis of foreign bodies is imperative to prevent serious and life threatening complications.
Oesophagoscopy remains a safe technique for extraction of foreign bodies in experienced hands.
INTRODUCTION
Foreign body ingestion is common in children and most foreign bodies will pass without any problem. Amongst impacted foreign bodies, coins are the commonest. Whilst foreign bodies may get impacted at any site in the oesophagus, the post cricoid area and cricopharynx are the most frequent locations. Usually, patients present immediately following foreign body ingestion, but in a small percentage of patients foreign bodies may remain undetected for weeks to months. Here, radiology and clinical suspicion play an important role in diagnosing and treating foreign bodies and in prevention of complications. We present two patients in whom long term asymptomatic foreign bodies were discovered accidentally while being investigated for other problems.
CASE REPORT
Case I
A four year old female patient was brought to the neurosurgery department in our hospital by her parents for proptosis of the right eye since 11/2 months, for which she was advised an MRI of the orbit. Whilst doing the MR scan there was difficulty in getting the image due to disturbances caused by a metallic foreign body present in the field. A tomography was done to detect the possible cause and site of the metallic disturbance, and the presence of a circular opaque foreign body was detected in the chest. The patient was then referred to the ENT department for removal of the foreign body from the oesophagus.
Initially, the patient gave no history of any foreign body ingestion. However, on further probing, the parents remembered that the patient had swallowed a coin four months earlier, at which time the x-ray neck was done, but the foreign body not detected. Since the patient remained asymptomatic after that, no further investigations were done and the coin was forgotten. The patient had no complaints of dysphagia, pain, dyspnoea, change of voice, cough or any other symptoms.
Repeat x-ray of the chest was done in antero-posterior and lateral views which documented the presence of a coin in the upper mid oesophagus (Fig. 1). The patient was taken up for rigid oesophagoscopy under general anaesthesia and the coin (Rupee 1) removed without any difficulty. There was no significant granulation tissue or swelling and the foreign body could be removed easily. Recovery was uneventful and patient was sent back to the neurosurgery department.
Fig 1. Plain X-ray chest PA view shwoing foreign body (coin) in the oesophagus
Case II
A 1 year seven old male child was brought to the Urosurgery Department in our hospital by his patents for excessive straining during micturition and was advised surgery after investigations. The pre-operative chest x-ray PA view revealed a small round radio opaque shadow in the lower neck and the patient was referred to the ENT department. There was no definite history of foreign body or coin ingestion. However, the child had vomiting 2 weeks ago, for which a paediatrician was consulted, and the child was admitted and given domperidone. The child stopped vomiting and was discharged the next day. Incidentally, the child had been given coins to play with prior to the incident, but the paediatrician had not been informed about it. At that time no x-ray was taken since the child has responded to the medical treatment and remained asymptomatic after that.
A lateral x-ray neck/chest confirmed the foreign body (coin) lying in the cricopharynx (Figs. 2 and 3). The child was taken up for rigid oesophagoscopy under general anaesthesia and the coin (rupee 5 was removed from the cricopharynx. There was minimal oedema in the posterior wall of cricopharynx. Recovery was uneventful.
Fig 2. Plain x-ray neck PA view showing foreign body (coin) in the cricopharynx
Fig 3. Plain x-ray neck lateral view showing foreign body (coin) in the cricopharnx
DISCUSSION
Whilst it is quite common to find foreign bodies in children, it is rare that they remain asymptomatic and undetected for a long period of time. Since only one of our patients had initial symptoms, and neither had a definite history of foreign body ingestion, they were not investigated thoroughly, especially since they continued to remain asymptomatic.
A plain x-ray neck/chest postero-anterior and lateral view are usually enough to diagnose a foreign body, but occasionally a CT scan may be required.[1] A CT scan will also visualise radiolucent foreign bodes, as well as secondarily induced inflammatory changes in neighbouring structures.
Following ingestion, most foerign bodies will be confirmed on radiology. Occasionally, if there is strong clinical suspicion, even in the absence of radiological confirmation, one may proceed for oesophagoscopy, to detect a possible foreign body.[2-4]
Long term foreign bodies may be found in psychotic patients as they can conceal history and symptoms.[5] Most foreign bodies are ingested accidentally, or while eating and are reported promptly. Sometimes they may not be reported such as in young children or in psychotic patients. In these patients if the foreign body is relatively smooth and inert such as coin, they may remain asymptomatic and therefore remain unnoticed for a long time, until they cause a complication or are discovered accidentally, such as in our patients.[5-10]
Therefore a high index of suspicion is often necessary in diagnosing or detecting foreign bodies in children or in patients with symptoms such as stridor, dyspnoea, dysphagia, vomiting or having a mass in the neck. There should be thorough questioning, examination and investigations so as not to miss any foreign bodies or pathology. Some patients may present with complications of neglected foreign bodies, such as respiratory distress, broncho oesophageal fistula, aorta-oesophageal fistula, oesophageal diverticulum (Zenkar type), anterior-oesophageal fistula, etc.
Foreign bodies can be removed either by rigid oesophagoscopy,[11] flexible oesophagoscopy, Foley’s catheter under fluoroscopic control [12] or bougienage technique.[13] With long term foreign bodies in children, we prefer rigid oesophagoscopy under general anaesthesia, as the removal may occasionally be difficult due to impaction and surrounding oedema or granulations. Where as, in adults, flexible oesophagoscopy may be done under local anaesthesia to confirm and to remove foreign bodies.
Following removal of neglected foreign bodies, the oesophageal mucosa may show no abnormalities, minimal erythema, or minimal abrasion. Our first patient had normal mucosa, and the second patient had minimal oedema.
ACKNOWLEDGEMENT
We would like to thank the radiology department, the neurosurgery department and the Urosurgery department for their help and co-operation.
REFERENCES
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11.Kramer TA, Riding KH, SalKeld LJ. Trachea bronchial and oesophageal foreign bodies in the paediatric population. Journal of Otolaryngology 1986; 15 (6) 355-8.
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