suspected esophageal foreign body — choosing appropriate management

ORIGINAL CONTRIBUTION

Suspected Esophageal Foreign Body Choosing Appropriate Management

Tim Allen, MD Ste-Foy, Qubbec, Canada

Twenty-two cases of probable esophageal or pharyngeal foreign body seen at an emergency service were studied retrospectively, using 15 predetermined factors chosen to detect or anticipate the acute qonsequences of foreign body ingestion. Three findings were particularly predictive: 1) foreign body visualized directly or on plain x-ray films; 2) hypersalivation; 3) obstruction or foreign body image in the esophagus on barium swallow. No patient with none of these three abnormal findings, even in the presence of localized pain increased by swallowing, received further treatment, and no complications developed. All patients with any one of these three findings underwent direct foreign body removal (four cases) or esophagoscopy (11 cases). Five esophageal foreign bodies passed spontaneously into the stomach before esophagoscopy; four foreign bodies were removed, and two esophagi were abnormal (stricture, myasthenia gravis). In two cases no foreign body was found. Hypersalivation was the only finding always associated with an abnormal esophagoscopy. Particular attention m u s t be paid to the interpretation of plain x-ray films, with regard to probable foreign body location at the cricopheryngeal constriction and to indirect signs such as fluid levels, soft tissue swelling, free air, if small foreign bodies are not to be missed. Allen T: Suspected esophageal foreign body - - choosing the appropriate management. JACEP 8:101-105, March, 1979. foreign bodies, esophagus

I N T R O D U C T I O N

While the vast majority of' swallowed objects that reach the stomach do not require any specific treatment, 1,2 those that lodge in the pharynx or esophagus are uncomfortable, potentially dangerous, and need to be removed. It is impor- tant to decide whether, in fact, there is a foreign body lodged above the stomach, and to identify it well enough to predict its subsequent behavior and determine appropriate management . The dangers and economics of routine general anethesia, esophagoscopy and hospitalization complicate this process. Few stan- dard texts t reat the problem of ingested foreign bodies in much detail; Hamilton-Bailey's Emergency Surgery is an exception. 3

The acute consequences of foreign body ingestion are limited in number: local irritation, respiratory obstruction, esophageal obstruction, and esophageal perforation with mediastinitis. Significant hemorrage is extremely rare and need not usually be considered. 1 These consequences give rise to certain signs and symptoms on clinical or radiological examination that form the basis for diagnos- ing the presence of an esophageal foreign body and selecting management.

From the D6partment d'Urgence, Centre Hospitalier de I'Universit6 Laval, Qu(~bec, Canada.

Presented at the University Association for Emergency Medicine Annual Meeting in San Francisco, May, 1978. Address for reprints: Tim Allen, MD, Department d'Urgence, Centre Hospitalier de I'Universit(~ Laval, 2705 Boulevard Laurier, Ste-Foy, Quebec, Canada GlV 4G2.

8:3 (March) 1979 JACEP 101/23

This s tudy eva lua te s the re la t ive ' impor tance of s igns and symptoms in the diagnost ic process in order to t ry and identify the key factors in mak- ing the cl inical decision. In th is way, a s tandard inves t iga t ive and thera- peut ic protocol can begin to be developed.

MATERIALS AND METHODS

For ty consecut ive cases of pre- sumed swallowed foreign body seen a t an emergency service were s tudied retrospect ively. None of the pa t ien ts was in r e sp i r a to ry distress. The. 18 cases in which the foreign body was located in the g a s t r o i n t e s t i n a l (GI) t rac t are not repor ted here. The 22 c a s e s of p r o b a b l e p h a r y n g e a l o r esophageal foreign body were studied in de ta i l , u s i n g 15 p r e d e t e r m i n e d factors chosen to detect or ant ic ipate t h e acu te c o n s e q u e n c e s of fo re ign body ingest ion (Table 1). The diagnosis, m a n a g e m e n t and outcome of the cases were then corre la ted with the 15 factors.

No s t a n d a r d d i a g n o s t i c or the rapeu t i c protocol was in use dur- ing the per iod of s tudy , hence the presence or absence of cer ta in factors was not noted for all cases.

S t anda rd x-ray techniques were used for soft t i s sue e x a m i n a t i o n of the neck, the ches t and the abdomen. I f a foreign body was found, addi- t ional views were used as necessary to locate i t precisely.

The ba r ium swallows were performed using s t a n d a r d ba r ium solu- tion, wi thout any solid medium (eg, co t ton wool). A n t e r o p o s t e r i o r and l a t e ra l views were t a k e n dur ing the s w a l l o w i n g , and r e p e a t e d s e v e r a l minu te s la ter to pe rmi t the empty ing of a normal esophagus. The radiological signs sought were positive imag- ing of a fo re ign body by r e s i d u a l b a r i u m af te r e sophagea l empty ing , negat ive imag ing of a foreign body dur ing the swal lowing, or esophageal obstruct ion. No fluoroscopic s tudies were done.

RESULTS

All cases were of recent inges- t ion, less t h a n four hours , and no case of per fora t ion or medi~s t in i t i s was seen. Sixteen cases involved food ingest ion and al l of these occurred in p a t i e n t s over 7-years-o ld . Ch icken bones accounted for e igh t cases, and fish bones for six others; three of the l a t t e r lodged in the pharynx. The six cases of t rue foreign body ingest ion (money, p ins , etc.) a l l occurred in chi ldren 7-years-old or younger.

The cases were divided into two

Table 1 FACTORS IN THE DIAGNOSIS

OF PHARYNGEAL OR ESOPHAGEAL FOREIGN

BODIES

Age Antecedents (esophagus) T ime since ingest ion Type of foreign body Local ized pain Effect of swa l lowing on the

pain Respiratory symptoms Hypersalivation Neck examinat ion Throat examinat ion Indirect laryngoscopy Fever (if > 24 hours) Chest examinat ion Abdomina l examinat ion X-ray examinat ion

Table 2 (GROUP 1)

FOREIGN BODY SENSATION NO FOREIGN BODY

IDENTIFIED

n = 7* Local pain 5 Increased on swa l low ing 5 Hype rsalivation 0 Direct examinat ion 1 erosion X-ray f i lm studies

Plain no foreign body Bar ium no obstruct ion

*Some patients had local pain not increased by swallowing, some had no pain except on swallowing.

Table 3 (GROUP 2)

ESOPHAGEAL FOREIGN BODY FOUND

n = 1 1

Case No. 1 2 3 4 5 6 ' 7. 8 9 10 11

Age(yrs) 42 21 28 2 2 , 9 73 21 1 4 6 3 Object B B B B BE B B T C C C

Local pain + + + ? + + + + + + + Swal lowing ? + + + + + ? ? ? ? ?

Salivation + + + + + ? ? ? - ? ?

X-ray Plain - + + + + + + + + Barium

Foreign body - + + 0 - + 0 0 0 0 0 Obstruct ion + a + -

Locat ion Upper 1/3 + + + + + + + Lower 1/3 ? + + +

Eso phagoscopy + + + + +

Time (hrs) 8 3 3 7 8

Remarks e,b e e c,a d d d e d d

LEGEND:

a) Air fluid level on plain x-ray b) Stricture (caustic) c) Myasthenia gravis d) Spontaneous passage into stomach e) Foreign body extracted with esophagoscope + Present, abnormal - Absent, normal

0 Not done ? Unknown

OBJECTS:

B = Bone BE = Beef T = Thumb tack C = Coin

groups according to the f inal diagnosis: group i - - those wi th a foreign body sensa t ion , b u t in which none was identif ied; group 2 - - those in

which a foreign body was identified. The seven pa t ien ts in group I (Table 2) w e r e a l l s e n t home w i t h o u t esophagoscopy or specific t r ea tment .

24/102 JACEP 8:3 (March) 1979

None developed any complicat ion indicat ive of res idua l foreign body on s h o r t - t e r m fol low-up. One p a t i e n t had s l ight pers i s ten t pain t ha t took a week to d isappear , but most pa t ien ts were a s y m p t o m a t i c a f te r 24 to 48 hours.

Of the 15 pa t i en t s in group 2, four had a foreign body lodged in the pharynx, visible on direct or indi rec t e x a m i n a t i o n , a~d t h e s e we re removed directly. The detai ls concern- ing the factors and outcomes of the 11 cases of esophageal foreign body (Table 3) are given.

DISCUSSION A l t h o u g h the smal l n u m b e r of

cases, s tudied retrospect ively, makes it d i f f icul t to d r aw ce r t a i n conclu- s ions, some p a t t e r n s a r e e v i d e n t . These m a y be usefu l to deve lop a s tandard inves t iga t ive and therapeu- tic protocol for a long- term prospec- t ive s tudy.

The c lass ical t r iad of hypersa l i - ra t ion, and local pain increased by swallowing appears to be a useful in- d ica tor of es~ophageal . foreign body, but could be reduced to the key factor of h y p e r s a l i v a t i o n . This fac tor always seems to be associated wi th an abnormal esophagoscopy as in cases 1 to 4. In case 5, the pa t i en t was no l o n g e r s y m p t o m a t i c w h e n t h e esophagoscopy was performed. Many p a t i e n t s ~ w i t h o u t d e m o n s t r a b l e fo re ign body h a v e loca l p a i n in- c reased by swa l lowing bu t no t accompanied by hypersa l iva t ion (group 1). P resumably , minor t r a u m a sec- ondary to the passage of the foreign body c a u s e s p a i n loca l i zed to the damaged region. The lacera t ions ap- pear to heal rap id ly in most cases. The acceptabi l i ty of m a n a g i n g these p a t i e n t s w i t h o u t e s o p h a g o s c o p y needs to be ver if ied by fu r the r ex- perience.

The absence of hype r sa l i va t i on does not , h o w e v e r , e x c l u d e an esophageal foreign body (case 9). Re- flex hype r sa l iva t ion occurs even in the absence of e sophagea l obst ruc- t ion (cases 2, 3), bu t b l u n t foreign bodies located in the d is ta l esophagus (cases 9 to 11) seem less l ike ly to act ivate th is reflex. I t should also be noted t ha t even pat ients wi th com- pletely obst ructed a i rways may only hypersa l iva te obviously af ter the effect of esophagea l pooling is e l imi- nated by thei r t ry ing to d r ink some- thing.

Of the three pa t ien ts in complete e sophagea l obs t ruc t ion , cases 1, 4, and 5, two had abnormal esophagi. One was known to have a s t r ic ture

Fig . 1. Foreign body above the crico- pharyngeal constriction (cash 7).

Fig. 3. Esophageal perforation - free air in the retropharyngeal space.

from a caust ic substance and had had previous s imi l a r episodes. The o ther was k n o w n to have m y a s t h e n i a gravis, but had never previously had esophagea l problems. This esophagus was atonic on examinat ion. Even i f the foreign body is a large piece of food, or o ther large object, the finding of a complete esophageal obstruc- t ion in such pa t ien ts is h ighy sugges- t i ve of u n d e r l y i n g e s o p h a g e a l pa thology, and this mus t be el imi- n a t e d or conf i rmed by s u b s e q u e n t examina t ion . 5

Radiologic Studies The resu l t s of radiologic s tudies

Fig. 2. Air-fluid level in the esophagus (case 4).

Fig. 4. Esophageal perforation - sub- cutaneous emphysema in the right supraclavicular region.

were a lways abnormal in the presence of an esophageal foreign body if a combinat ion of plain views of the neck and chest and of b a r i u m swallows was used, Foreign bodies will u sua l ly lodge in the na r rowes t par t of the esophagus, just above the con-. s t r ic t ion caused by the cr icopharyn- geus muscle. This a rea mus t be care- fully examined on the l a te ra l view of the neck (Figure 1, case 7) if smal l , ba re ly radioopaque, mea t bones are not to be missed. The p la in fi lms may also show an air-f luid level, indicat- ing obs t ruc t i on (F igure 2, case 4). Whi le not seen in this ser ies of cases, the presence of free a i r or edema in the soft t i ssues s t rongly sugges ts per- fora t ion and/or infection (Figures 3 to 5).

W h i l e p la in f i lms a re u s u a l l y adequa te to localize the foreign body (8 of our 11 cases), the b a r i u m swal : low wil l be necessary in some cases

8:3 (March) 1979 JACEP 103/25

~ ] --

Fig. 5. Retropharyngeal edema post foreign body ingestion ? perforation. Fig . 6. Barium swallow - obstruction (case 1).

• ? ~,,

Fig. 7. Barium swallow - foreign body outlined by residual barium (case 2). Fig. 8. Foreign body hidden in the vallecula.

to prove an o b s t r u c t i o n (F igu re 6, case 1) or more c lea r ly out l ine the foreign body (Figure 7, case 2). The re l i ab i l i ty of negat ive images, with- out fluoroscopic study, as indicators of a foreign body is quest ionable, as demons t ra ted by case 6.

The impor t ance of rad io log ica l studies even in the presence of min- imal symptoms was demons t r a t ed in a r e p o r t 4 of t h r e e cases of e x t r a - lumina l esophageal foreign bodies in children, found because of complica- t ions some t ime af ter the swal lowing episode, which in i t se l f had caused

few symptoms. This repor t also re- minds us of the typica l o r ien ta t ion of coins, coronal in the esophagus and sag i t ta l in the t rachea , and suggests t h a t a n y o t h e r o r i e n t a t i o n m i g h t signify an ex t r a - lumina l position.

Spontaneous Passage M a n y fore ign bodies wi l l pass

spontaneously into the s tomach after a shor t while, as in at leas t 5 of 11 cases in this series, especia l ly if they are a l ready pas t the cr icopharyngeal constr ict ion and i f the esophagus is normal . While the dangers of erosion

and esophagea l e d e m a make it dif- f icult to decide whe the r a period of observat ion is jus t i f ied for b lun t ob- j ec t s in the lower e sophagus , i t is clear t ha t spontaneous passage into the s tomach is u sua l ly accompanied by a rap id change in symptoms. If th is should occur while the pa t ien t is w a i t i n g for an e s o p h a g o s c o p i c examinat ion , the s i tua t ion should be reeva lua ted .

Direct Examination Examina t i on of the pha rynx and

h y p o p h a r y n x w i l l u s u a l l y p e r m i t

26/104 JACEP 8:3 (March) 1979

v i s u a l i z a t i o n and e x t r a c t i o n of pharyngeal foreign bodies, especially fish bones, which tend to lodge here. Par t icular a t tent ion should be paid to the pyriform fossae and the vallecula, where an object may be hidden (Figure 8). Other than foreign bodies, one may look for lacerations, which may account for the symptoms, or pooling of saliva which may indicate a t ru ly esophageal foreign body. This par t of the examina t ion requires some practice and is ot~en neglected, so tha t foreign bodies are not found unt i l a subsequent examination.

CONCLUSION

Pat ients with an esophageal or p h a r y n g e a l fo re ign body p r e s e n t w i th a f a i r l y c o n s t a n t g roup of symptoms and a b n o r m a l phys i ca l signs. The pat ient with a clear his- tory of foreign body ingestion should, in addition to. the clinical evaluation,

undergo a radiological examina t ion of the esophagus, even when only m i n i m a l symptoms are present . If the plain x-ray films do not demon- strate a foreign body, static views of the esophagus d u r i n g and af ter a ba r ium swallow should be done.

D i rec t e x a m i n a t i o n of the pharynx and hypopharynx is necessary to locate and remove foreign bodies in this location. For pat ients wi th poss ib le e s o p h a g e a l fo re ign bodies, the presence of hypersalivation, radiological visualization of the foreign body, or esophageal obstruc- t ion are ind ica t ions for esophagoscopy. Pat ients with no foreign body v is ib le on d i rec t and rad io logica l examina t i on , wi thou t hypersa l iva- tion, do not require esophagoscopy and can be observed as outpatients.

It may be permissible to observe b l u n t fore ign bodies in the lower esophagus for a short while before esophagoscopy, in the hope the abject

wi l l pass s p o n t a n e o u s l y in to the stomach. The possibility of underly- ing esophageal pathology should be considered in all cases.

REFERENCES

1. Norberg HP, Reyes HM: Complications of ornamental Christmas bulb ingestion - - case report and review of literature. Arch Surg 110:1494, 1975.

2. Marsh BR: The problem of the open safety pin. Ann Otol Rhinol Laryngol 84:624, 1975.

3. McNair TJ (ed): Hamilton-Bailey's Emergency Surgery, ed 8. Bristol, Eng- land, John Wright & Sons Publishers, 1967, chap 50.

4. Yee KF, Schild JA, Holinger PH: Ex- traluminal foreign body in the food and air passages. Ann Otol Rhinol Laryngol 84:619, 1975.

5. Warren R: Surgery. Philadelphia, WB Saunders, 1963, p 694.

CALL FOR ORIGINAL PAPERS FOR 1979 SCIENTIFIC ASSEMBLY The ACEP Section on Education has issued a call for abstracts of original scientific papers to be considered for presentation

at the 1979 Scientific Assembly in Atlanta, Georgia, October 1-4, 1979.

B. Ken Gray, MD, chairman of the Section on Education, has set May 1 as the deadline for submission of abstracts. Final papers must be in the Section's hands no later than July 31.

Submit &copies of the abstract. The abstract should be between 250 and 500 words in length. The presentation itself is limited to 10 minutes.

Papers submitted must be the original and unpublished work of the author, and must be related directly to some aspect of emergency medicine. Papers will be considered for publication in JACEP, and must be submitted in a form suitable for publication 30 days prior to the Assembly. Papers not received will not be presented.

Abstracts should be submitted to Frank J. Baker, II, MD, Scientific Assembly Abstracts, ACEP, 3900 Capital City Boulevard, Lansing, Michigan 48906.

SUGGESTIONS FOR WRITING ABSTRACTS

An abstract should be factual, clearly conveying the reason for the work, the methods, the results and their significance. To make your abstract more readable, fol low these guidelines:

1. A brief introduction stating why the work was done.

2. The methods used stated clearly, as well as whatever limitations the methods may have.

3. The results clearly stated in numerical form or tabular if appropriate. Has statistical significance been achieved?

4. Brief discussion of what the results indicate.

5. Conclusion, stating the relevance of these particular findings to emergency medicine.

Be sure to present the data in the abstracts. Avoid generalit ies such as "the significance of these results will be discussed," or "the management will be out- l ined."

SCIENTIFIC EXHIBITS

Scientific exhibits for display at the ACEP Scientific Assembly to be held in At- lanta, Georgia, October 1-4, 1979 are.currently being reviewed by the Scientific As- sembly Committee.

Individuals or organizations wishing to enter an exhibit should contact Edward P. Morgan, MD, Scientific Exhibits, ACEP, 3900 Capital City Boulevard, Lansing, Michi- gan 48906, with information about the proposed exhibit.

Check appropriate category:

[ ] Gastrointestinal [ ] Cardiovascular [ ] EMS [ ] Trauma [ ] Methods and Techniques [ ] Infections [ ] ED Administration [ ] Psychosocial [ ] Respiratory [ ] Burns [ ] Prehospital Care

Presenter:

Mailing Address of Principal Author

From (Institution)

8"3 (M arc h) 1979 JACEP 105/27

suspected esophageal foreign body — choosing appropriate management

Documents